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CLINICAL  MEDICINE. 


LECTURES 


DELIVER  HI)    AT    THE    HOTEL-DIE  U    PARIS 


A.    TROUSSEAU, 

LATE  PROFESSOR  OF  CLINICAL  MEDICINE  IN  THE  FACULTY  OF  MEDICINE,   PARIS; 

PHYSICIAN  TO  THE  HOTEL-DIEU  \    MEMBER  OF  THE  IMPERIAL 

ACADEMY  OF  MEDICINE,   ETC.,   ETC. 


TRANSLATED   FROM 


THE  THIRD   REVISED  AND  ENLARGED  EDITION, 


Sir  JOHN  ROSE  CORMACK,  M.D.,  F.R.S.E., 

FELLOW  OF  THE  ROYAL  COLLEGE  OF  PHYSICIANS  OF  EDINBURGH,  ETC.,  ETC. 


P.   VICTOR  BAZIRE,  M.D., 

ASSISTANT  PHYSICIAN  TO  THE  NATIONAL  HOSPITAL  FOR  THE  PARALYZED,   ETC.,   ETC. 

COMPLETE  IN  TWO  VOLUMES. 

Vol.  I. 

PHILADELPHIA: 

P.  BLAKISTON,  SON  &  CO., 

Successors  to  Lindsay  &  Blakiston. 
1882. 


~RCGI 
T? 
/ff2- 


PUBLISHERS'  NOTICE. 


This  American  edition  of  the  celebrated  Clinical  Lectures,  by  Professor 
Trousseau,  of  the  Hotel  Dieu,  Paris  (published  by  the  New  Sydenham  So- 
ciety, of  London),  in  five  volumes,  octavo,  is  complete  in  2  volumes,  and  is 
thus  furnished  at  less  than  one-half  the  price  that  was  charged  for  the 
original  translation. 

Lectures  39  to  51,  53  to  61,  and  66,  translated  by  Dr.  Bazire,  were  con- 
tained in  volume  one  of  the  Sydenham  edition.  In  the  American  edition 
they  are  arranged  in  their  regular  order  of  sequence,  along  with  those  con- 
tained in  the  remaining  four  volumes,  all  of  which  were  translated  by  Sir 
John  Rose  Cormack,  m.d.,  from  the  third  and  last  French  edition. 


ADVERTISEMENT. 


Ix  this  third  edition,  the  work  has  undergone  important  modifica- 
tions. For  the  accomplishment  of  this  editorial  labor,  M.  Trousseau 
selected  his  former  chef  de  clinique,  M.  Michel  Peter,  now  Professor 
Agrege  of  the  Faculty  of  Medicine,  and  Physician  to  the  Hospitals  of 
Paris.  The  first  and  second  volumes  were  revised  and  corrected  in 
accordance  with  the  suggestions  and  under  the  control  of  M.  Trous- 
seau. M.  Peter  modified  the  third  volume  in  conformity  with  the  sug- 
gestions of  his  master,  who  had  ceased  to  live  when  that  volume  was 
being  prepared  ;  he  had,  however,  left  instructions  regarding  it,  which 
were  scrupulously  followed.  As  the  interpreter  of  his  venerated  mas- 
ter, M.  Peter  has  striven  to  be  equal  to  his  task,  and  to  represent  faith- 
fully the  latest  sayings  of  that  profound  and  eloquent  man  whose  voice 
is  now  forever  silenced. 

Among  the  most  extensive  additions  may  be  mentioned,  researches 
regarding  temperature  in  diseases,  particularly  in  eruptive  fevers  and 
dothinenteritis ;  granular  and  waxy  degeneration  of  muscles ;  leueocv- 
tosis  in  typhoid  fever ;  the  spinal  and  cerebro-spinal  type  of  typhoid 
fever ;  the  application  of  the  sphygmograph  in  diseases  of  the  heart 
and  in  epilepsy ;  the  laryngoscope  in  lesions  of  the  lungs ;  and  the 
ophthalmoscope  in  cerebral  affections. 

Besides  additions,  of  which  only  the  most  important  have  been  men- 
tioned, a  great  number  of  lectures  have  been  retouched,  and  some  have 
even  been  rewritten.  For  example,  the  lecture  on  aphonia  and  cauter- 
ization of  the  larynx  has  been  entirely  recast,  in  consequence  of  the 
new  views  derived  from  the  use  of  the  laryngoscope;  the  lecture  on 
hydrophobia  has  been  recast;  also  that  on  alcoholism,  in  which  have 
been  incorporated   the  careful   researches  with  which  contemporary 


\ 
\ 

Xvi  ADVERTISEMENT. 

science  has  enriched  this  subject.  Next  to  the  lectures  now  enumerated 
may  be  specified  as  having  been  most  largely  modified,  those  on  pelvic 
hematocele,  puerperal  purulent  infection,  and  phlegmasia  alba  dolens. 
Cases  have  been  added  whenever  they  imparted  greater  perspicuity,  or 
contributed  new  views. 

In  the  advertisement  to  the  second  edition,  M.  Trousseau  recorded 
that  MM.  Leon  Blondeau,  Dumontpallier,  and  Peter,  had  "all  three 
done  more  than  merely  edit  his  work ;  they  had  assisted  him  in  his 
researches,  and  had  often  yielded  to  him  the  honor  of  very  interesting 
inquiries,  thereby  making  to  a  certain  extent,  a  sacrifice  on  his  account." 
It  would  have  been  unjust  not  to  have  here  reproduced  this  grateful 
testimony  of  a  deceased  master. 

Pakis,  4th  November,  1867. 


CONTENTS  OF  FIRST  VOLUME. 


PAGE 

Publishers'  Notice, . xiii 

Advertisement,  xv 

Introduction  :  "What  is  Clinical  Medicine  ? 33-61 


LECTURE  I. 

SMALL-POX. 


Distinct  Small-Pox. — Constipation. — Convulsions. — Eachialgia. — Paraplegia  of 
Small-pox. — Duration  of  the  Period  of  Invasion. — Eruption  with  Eeference 
to  its  Position  on  Pace,  Trunk,  and  Limbs. — Orchitis  of  Small-pox. — Desicca- 
tion,       63-73 

Confluent  Small-Pox. — Diarrhoea  chiefly  in  Children  at  the  Commencement  of 
the  Illness. — Salivation. — Swelling  of  the  Face. — Swelling  of  the  Hands,  and 
Nervous  Complications. — Boils. — Abscesses. — Purulent  Infection. — Albuminu- 
ria.— Anasarca. — Treatment, 73-90 


LECTURE  II. 

VARIOLOUS   INOCULATION. 

Advantages  of  Inoculation. — Experiments  on  Clavelization. — Dangers  of  Inocula- 
tion and  Means  of  diminishing  them. — Methods  of  Inoculating. — The  Mother- 
Pock  and  its  Satellites. — General  Symptoms, 90-96 


LECTURE  III. 

COW-POX. 

Grease  of  Horses. — Cow-pox  in  the  Cow. — Cow-pox  in  the  Human  Subject. — Cow- 
pox  and  Horse-pox  are  Analogous  to,  but  Not  Identical  with  Small-pox — 
Practical  Importance  of  this  Distinction. — Kegeneration  of  Cow-pox,  .     96-111 


XV111  CONTENTS    OF    FIRST    VOLUME. 

Transmission  of  Cow-pox  from  Man  to  Man. — Circumstances  Favorable  to  Success- 
ful Vaccination. — The  Lymph  ought  to  be  taken  between  the  Fifth  and  Seventh 
Days. — Selection  of  Subjects  from  whom  the  Lymph  ought  to  be  taken. — Health 
of  Persons  who  are  to  be  Vaccinated. — Transmission  of  Syphilis  in  Vaccina- 
tion.— Vaccinal  Eruptions. — Modified  Cow-pox. — Eegeneration  of  Lymph. — 
Revaccination. — Vaccination  at  the  Bar  of  Public  Opinion,        .         .     111-133 


LECTURE  IV. 

CHICKEN-POX. 

Chicken-pox  or  Varicella  essentially  different  from  Modified  Small-pox. — Unlike 
Small-pox,  it  does  not  protect  from  Variolous  Contagion. — Small-pox  does  not 
protect  from  Chicken-pox. — Course  and  Characteristics  of  the  Eruption,  133-136 


LECTURE  V. 

SCARLATINA. 

Variety  in  the  Characters  of  Epidemics. — Contagion. — Incubation. — Complica- 
tions at  the  Beginning  of  an  Attack. — Characters  of  the  Eruption. — Desqua- 
mation, ............     136-145 

Cerebral  and  Nervous  Complications. — Sore  Throat  complicated  with  Diphtheria. — 
Buboes. — Rheumatism,  .........     146-151 

Complications  occurring  during  the  Decline  of  the  Disease. — Anasarca. — Hematu- 
ria.— Albuminuria. — Convulsions. — (Edema  of  the  Glottis. — Pleurisy. — Pericar- 
ditis.— Endocarditis. — Rheumatism. — Scarlatina  without  Eruption. — Anasarca 
without   Eruption. — Treatment, 151-170 


LECTURE  VI. 

MEASLES  ;    AND    IN   PARTICULAR   ITS   UNFAVORABLE   SYMPTOMS   AND 

COMPLICATIONS. 

Normal  Measles. — Period  of  Invasion  is  longer  than  in  any  other  Eruptive  Fever. — 
Complications  of  the  Period  of  Invasion. — Convulsions  at  the  Beginning  of  the 
Attack. — False  Croup  — Suffocative  Catarrh. — Epistaxis. — Otitis. — Diarrhoea. — 
Complications  of  the  Eruptive  Stage,  and  of  the  Last  Stage,         .         .     170-185 


LECTURE  VII. 

RUBEOLA. 

Very  Different  Disease  from  biopsies. — Stands  in  the  same  Relation  to  Mea-les  a- 
Chicken-pox  to  Small-pox. — Does  not  produce  Catarrh  of  the  Mucous  Mem- 
brane.— No  Serious  Sequela.'.  —  May  attack  the  same  person  more  than  once,  and 
does  not  confer   Exemption  from    Measles 188  187 


CONTENTS    OF    FIRST    VOLUME.  XIX 

LECTURE  VIII. 

ERYTHEMA   NODOSUM. 

A  Specific  and  Separate  Disease. — Successive  Eruptions. — Articular  Pains. — 
General  Symptoms. — A  Possible  Manifestation  of  the  Eheumatic  Diathesis, 

187-190 

LECTURE  IX. 

ERYTHEMA   PAPULATUM. 

Differs  from  Erythema  Nodosum  in  the  Form  and  Seat  of  the  Eruption,  and  in 
the  Severity  of  the  Symptoms. — Rheumatic  Character,       .         .         .     191-195 

LECTURE  X. 

ERYSIPELAS  ;   AND   IN   PARTICULAR   ERYSIPELAS   OF   THE   FACE. 

Pathology  of  Erysipelas. — Almost  always  an  exciting  Cause  independent  of  Indi- 
vidual Predisposition  and  General  Cause. — May  Supervene  in  the  Course  of 
Epidemics. — Severity  increased  by  Traumatic  Influence. — General  Symptoms 
dependent  on  Inflammation  of  Wound  and  Lymphatic  Vessels. — Delirium  has 
not  the  Signification  attributed  to  it  in  Erysipelas. — Erysipelas  sometimes 
Contagious. — When  not  a  Complication  of  another  Disease  is  a  Mild  Affection 
which  subsides  spontaneously. — Treatment  ought  to  be  Expectant,    .     195-204 

ERYSIPELAS   OF   NEW-BORN   INFANTS. 

Affection  often  Puerperal. — Differs  Essentially  from  Ordinary  Erysipelas. — Gener- 
ally Eatal,    205-210 

LECTURE  XL 

MUMPS. 

A  Specific  and  Contagious  Disease. — Metastases. — Complications,     .         ,     210-214 

LECTURE  XII. 

URTICARIA. 

A  Distinct  Nosological  Species. — Sudoral  Nettlerash  \_V eruption  ortiee  sudorale~\  is 
no  more  Urticaria  than  Morbilliform  and  Scarlatiniform  Sudoral  Eruptions 
are  Measles  and  Scarlatina. — General  Precursory  Symptoms. — Exciting 
Causes, 215-218 


XX  CONTENTS    OF    FIRST    VOLUME. 

LECTURE  XIII. 

ZONA   OR   HERPES   ZOSTER. 

Characteristics. — Accompanying  Pains. — Inveterate  Consecutive  Neuralgic  Affec- 
tions,          218-223 

LECTURE  XIV. 

SUDORAL   EXANTHEMATA. 

Multiplicity  of  Forms. — Cutaneous  and  Mucous  Exanthemata. — ^Physiological 
Causes. — Antagonism  of  the  Secretions  of  the  Skin  and  the  Secretions  of  the 
Intestinal,  Respiratory,  and  Urinary  Mucous  Membranes.  —  Exanthemata 
produced  by  Medicinal  Agents — Sudoral  Exanthemata  becoming  Purulent  in 
Lying-in  "Women  and  Others. — -Analogies  between  Sudoral  Exanthemata  and 
Exanthemata  produced  by  a  Virus  or  Dependent  on  Diathesis,  .         .     224-233 

LECTURE  XV. 

DOTHINENTERIA,  OR  TYPHOID  FEVER. 

Specific  Lesion. — Furuncular  Eruption  of  th«  Intestine. — Intestinal#  Perforation. — 

Peritonitis  without  Perforation, 234-243 

Intestinal  Hemorrhage. — Hemorrhagic  Putrid  Fever,  ....  243-248 
Granular  and  Waxy  Degeneration  of  the  Striated  Muscles  in  Typhoid  Fever. — 
Nature  and  Consequences  of  this  Degeneration. — Special  Course  of  the  Rise 
and  Fall  of  Temperature  in  Typhoid  Fever  :  this  is  characteristic. — Parallelism 
between  the  Course  of  Temperature  and  the  Evolution  of  the  Intestinal  Le- 
sions,         248-255 

Rosy  Lenticular  Spots. — Successive  Eruptions. — Miliary  Eruption. — Blue  Spots, 

255-258 
Intestinal  Dothinenteric  Catarrh. ■. — Its  Specific  Character. — Predominance  of  Intes- 
tinal and  Pulmonary  Catarrhal  Affections  constitutes  the  Forms  of  the  Disi 

called  "Abdominal  "  and  "  Thoracic," 258-260 

Forms  of  Dothinenteria,  viz.,  the  Mucous,  Bilious,  Inflammatory,  Adynamic, 
Ataxic,  Spinal,  Cerebro-Spinal,  and  Malignant,  ....     261   267 

Parotitis  and  Deafness  as  Prognostic  Signs  of  Dothinenteria,    .         .         .     267 
Dothinenteria  may  at  first  simulate  Intermittent  Fever;  and  Marsh  [Intermittent] 
Fever  may  likewise  at  the  beginning  of  the  attack  simulate  Dothinenteria, 

268  272 
Contagion.— Conditions  under  which  Dothinenteria  occurs,       .  .     272  276 

Treatment  of  Dothinenteria. — Regimen  of  the  Patients '-'" 

Affections  which  occur  during  Convalescence.— Gastric  Disturbance.— Vomiting. 
—Diarrhoea. — Nervous  Symptoms. — Vertigo. — Delirium. — Impaired  Mental 
Power. — Paralysis. — Dropsical  Effusions^   ......    2€ 


CONTENTS    OF    FIRST    VOLUME.  XXI 

Local  Complications  which  Supervene  during,  and  at  the  Decline  of 
Dothinenteria. — Softening  of  the  Cornea,  Affections  of  the  Larynx,  Necrosis 
of  the  Cartilages  of  the  Nose. — (Edema  of  the  Glottis  supervening  during 
Dothinenteria,  and  necessitating  Tracheotomy. — Sloughs. — Erysipelas. — Col- 
liquative Suppurations. — Paraplegia  consecutive  to  Infiltration  of  Pus  into  the 
Spinal  Canal  producing  Inflammation  and  Suppuration  of  the  Spinal  Marrow. 
— Spontaneous  Gangrene  of  the  Limbs, 288-305 


LECTURE  XVL 

TYPHUS. 

An  Infectious  Disease  like  Dothinenteria. — Differs  from  Dothinenteria  in  the  Ab- 
sence of  Intestinal  Lesions. — The  two  Fevers  are  distinguished  from  each  other 
by  the  Aggregate  of  the  Symptoms,  and  their  Thermal  Variations,  .     305-315 


LECTURE  XVIL 

MEMBRANOUS   SORE  THROAT,   AND   IN   PARTICULAR   HERPES  OF   THE 
PHARYNX.      [COMMON   MEMBRANOUS   SORE   THROAT.] 

Many  Different  Kinds  of  Membranous  Sore  Throat. — Common  Membranous  Sore 
Throat  often  originates  in  Herpes  of  the  Pharynx. — Often  difficult,  especially 
during  an  epidemic,  to  form  a  good  Differential  Diagnosis  between  it  and 
Diphtheritic  Sore  Throat. — In  these  Doubtful  Cases  we  must  act  as  if  the  malady 
were  of  a  bad  character. — Recovery  from  Common  Membranous  Sore  Throat 
is  Spontaneous, 315-323 


LECTURE  XVIII. 

GANGRENOUS   SORE   THROAT. 

Gangrenous  Sore  Throat  from  Excess  of  Inflammation. — Gangrenous  Sore  Throat 
Supervening  as  a  Complication  of  severe  Diseases,  such  as  Dysentery,  Typhoid 
Eever,  &c. — Gangrenous  Sore  Throat  as  a  Complication  of  Scarlatinous  and 
Diphtheritic  Sore  Throat. — Primary  Gangrenous  Sore  Throat,  .         .     323-330 


LECTURE  XIX. 

INFLAMMATORY    SORE   THROAT. 

Recovery  is  Spontaneous. — Distinct  from  Rheumatic  Sore  Throat. — Distinct  also 
from  the  Sore  Throat  caused  by  the  Secretion  from  the  Tonsils,         .     330-335 


XX11  CONTENTS    OF    FIRST    VOLUME. 

LECTURE   XX. 

diphtheria. 

Diphtheritic  Sore  Throat  and  Croup.  [Pharyngeal  and  Laryngeal 
Diphtheria.] — Occurs  in  all  Climates  and  all  Seasons. — Chiefly  attacks  Chil- 
dren.— Manner  in  which  it  is  Propagated. — Glandular  Swellings. — The  Color 
of  the  False  Membranes  :  their  Smell  simulating  that  of  Gangrene. — Its  Prop- 
agation to  the  Larynx. — Croup. — Intermittence  of  Symptoms. — Generally 
proves  Fatal  when  its  Progress  is  not  Stopped,    .         .         .         .         .     335-352 

Malignant  Diphtheria. — A  much  more  Terrible  Form  of  the  Disease. — The 
Local  Affection  is  nothing  compared  to  the  Constitutional  Symptoms. — It  Kills, 
not  like  Croup  by  Asphyxiating  the  Patients  by  Suffocative  Paroxysms,  but  it 
Kills  by  General  Poisoning  after  the  manner  of  Septic  Diseases. — Glandular 
Engorgement  considerable. — Erysipelatous  Redness. — Membranous  Coryzaand 
Nasal  Diphtheria. — Diphtheritic  Ophthalmia. — Epistaxis. — Hemorrhages  of 
every  kind. — Ansemia, 352-361 

Diversity  or  Localization  in  Diphtheria. — Palpebral  Diphtheria. — Cutaneous, 
Vulvar,  Vaginal,  Anal,  and  Preputial  Diphtheria,     ....     361-372 

Diphtheria  of  the  Motjth. — Of  all  the  Manifestations  of  Diphtheria,  it  has  the 
greatest  Tendency  to  remain  confined  to  its  own  Locality. — May  be  Propagated 
to  the  Pharynx  and  Larynx,  and  produce  Croup. — May  lead  to  Gangrene. — 
May  be  a  Manifestation  of  Malignant  Diphtheria. — Exceedingly  Contagious. — 
Epidemic, 373-376 

Nature  of  Diphtheria:  Contagion:  Alteration  of  the  Blood:  Albu- 
minuria,          376-382 

Paralysis  in  Diphtheria. — Nota  new  disease. — The  Mild  Form. — Symptoms.— 
Paralysis  of  the  Veil  of  the  Palate,  of  the  Senses,  Limbs,  and  of  the  Muscles  of 
Organic  Life. — Death  by  Suffocation,  by  Strangling. — The  Aggravated  Form. 
— Ataxo-adynamie  Symptoms. — The  Gravity  of  the  Paralysis  bears  neither  any 
Relation  to  the  Intensity  or  Duration  of  the  Pseudo-membranous  Affection,  nor 
to  the  Albuminuria.  This  kind  of  Paralysis  is  the  Result  of  Poisoning. — 
Treatment, 382-402 

Treatment  of  Diphtheria  and  Croup. — The  Antiphlogistic  Treatment  ought 
to  be  absolutely  rejected. — Alterative  Treatment:  Mercurials  useful  as  Topical 
Agents:  their  inconveniences:  Alkalies,  particularly  Bicarbonate  of  Soda,  of 
very  doubtful  benefit.— Chlorate  of  Potash  useful  in  cases  of  average  severity. 
— Emetic  Treatment:  its  inconveniences  greater  than  its  advantages.— Serious 
Consequences  produced  by  Blisters.— Topical  Method  of  Treatmenl  by  Astrin- 
gents and  Caustics  is  best  treatment  of  Diphtheritic  Affections. — i  latheterism  of 
the  Larynx. — Indispensable  Necessity  of  sustaining  the  Vital  Powers  of  the 
Patients  by  Food  and  Tonic  Medicines M)2    Us 

Tracheotomy.— Its  Utility  and  Necessity.— Mode  of  Operating.— The  Dilator.— 
Operation  ought  to  be  very  slowly  Performed:  Dangers  of  rapid  performance. 


CONTENTS    OF    FIRST    VOLUME.  XX111 

— Dressing. — Cauterization  of  the  Wound. — The  Neckcloth. — General  Treat- 
ment.— The  chances  of  Success  are  the  greater,  the  less  energetic  the  anterior 
treatment  has  been. — Alimentation  of  the  Patients. — Kemoval  of  the  Canula. — 
Infected  Canula?. — A  Condition  Favorable  to  Success  is  to  Operate  as  soon  as 
possible.— Unfavorable  Conditions. — Death  is  certain  in  Malignant  Diphtheria: 
Death  is  almost  certain  in  Children  under  two  years,         .         .         .     419-434 


LECTURE  XXI. 

THRUSH. 

Synonyms. — Micrographers  regard  it  as  Mycelium. — Arises  from  Modification  of 
the  Secretion  produced  by  Inflammation  of  the  Mouth. — In  Adults  is  met  with 
in  advanced  stage  of  nearly  all  Chronic  Diseases. — Accompanying  Intestinal 
Derangement. — In  Children,  supervenes  also  in  Diseases,  which,  regard  being 
had  to  the  Age  of  the  Subject,  may  be  considered  Chronic. — Indicates,  irrespec- 
tive of  the  cause,  a  general  state  of  Inanition. — When  purely  local  is  not  a  seri- 
ous affection. — Mixed  Thrush. — The  Mouldy  Eruption  of  Thrush  may  become 
developed  on  any  mucous  membrane  covered  with  Epithelium,  and  having  the 
Secretion  altered. — The  Different  Erythematous  Affections  which  accompany 
it  depend  upon  a  general  state  of  the  System. — Treatment :  The  Local  Lesion 
is  easily  destroyed. — Necessary  to  continue  the  Use  of  Topical  Agents  for 
some  days  after  the  disappearance  of  Thrush,  to  modify  the  inflamed  state 
of  the  Mucous  Membrane. — The  same  treatment  applicable  to  the  Cutaneous 
Lesions. — When  Thrush  depends  on  a  General  Condition  of  the  System, 
the  Treatment  must  be  directed  to  the  removal  of  the  Causes  of  that  Con- 
dition,       434-442. 


LECTURE  XXII. 

SPECIFIC   ELEMENT   IN   DISEASE. 

The  Specific  Element  is  Dominant  throughout  the  whole  of  Medicine. — Dichotomic 
Doctrines  of  Brown  and  Broussais. — Diseases  have  Certain  Characters  in  Com- 
mon; and  also  Individual  or  Specific  Characters. — Specific  Causes. — Specific 
Symptoms. — Knowledge  of  Specific  Character  applied  to  Diagnosis,  Prognosis, 
and  Treatment, .    ..   442-457 


LECTURE  XXIII. 

CONTAGION. 

Definition. — Parasitical  Diseases  are  not  included. — Spontaneous  Development  of 
Morbid  Germs. — Infection. — Infectious  Diseases  may  become  Contagious.— 
Dormant  State  of  Germs. — Difference  between  Infection  and  Contagion. — 
Morbific  Matter. — Conditions  of  Contagion :  Inherent  in  Individuals  and  in 
Germs. — Immunity,  Temporary  and  Absolute. — Conditions  as  to  Age,  and 
Previous  Contamination. — Acclimation  and  Habit. — Apparent  Immunity. — 
Modes  of  Transmission. — Contact. — Direct  Inoculation. — Inhalation,  457-479 


XXIV  CONTENTS    OF    FIRST    VOLUME. 

LECTURE  XXIV. 

OZiENA. 

A  very  Common  Affection. — Must  not  be  confounded  with  Foetor  of  the  Mouth  or 
Throat. — Fetor  of  Ozsena  is  altogether  Peculiar. — Sometimes  Dependent  on 
Alteration  of  the  Secretions. — Fetor  of  Inflammatory  Secretions  in  some  per- 
sons.— Constitutional  Ozsena. — Symptoms. — Syphilitic  Ozsena  very  frequent. — 
Ulceration  of  the  Mucous  Membrane  :  Necrosis. — Diseases  of  the  Maxillary 
Sinus. — Topical  Treatment  is  the  most  usual. — Constitutional  Treatment  is  very 
useful  in  Syphilitic  Ozsena :  also  of  considerable  benefit  in  Herpetic  and  Scrof- 
ulous Ozsena. — Powder  for  snuffing  up  the  Nose. — Injections. — Treatment  must 
be  very  patient  and  very  varied, 480-488 

LECTURE  XXV. 

STRIDULOUS   LARYNGITIS,   OR   FALSE   CROUP. 

Long  confounded  with  Pseudo-membranous  Croup. — Differs  essentially  from  that 
disease  in  its  Nature,  Manner  of  Invasion,  Progress,  and  Complications. — 
Croupy  [Croupale]  Cough  presents  characters  very  different  from  those  of  True 
Croup. — False  Croup  is  not  a  dangerous  disease ;  but  still,  in  some  very  rare 
cases,  it  causes  death. — The  Prognosis  is  serious  when  the  laryngeal  affection  is 
the  forerunner  of  peripneumonic  catarrh. — In  the  majority  of  cases,  the  Treat- 
ment ought  to  be  Expectant, 488-495 

LECTURE  XXVI. 

CEDEMA   OF   THE   LARYNX. 

(Edema  of  the  Larynx  is  Not  in  itself  a  Disease  :  it  is  a  Complication  of  Diseases  of 
the  Larynx. — Improperly  named  QMema  of  the  Glottis. — Sometimes,  but  not 
often,  independent  of  Inflammation. — Predisposing  Causes. — Exciting  Causes. 
— Frequently  supervenes  in  Chronic  Laryngitis. — Common  Termination  of 
what  is  called  Laryngeal  Phthisis. — Treatment :  Topical  Medication  is  import- 
ant.— Often  necessary  to  resort  to  Tracheotomy,         ....     495-509 

LECTURE  XXVII. 

APHONIA:    CAUTERIZATION   OF   THE    LARYNX. 

Different  Causes  of  Aphonia. — From  Lesion,  or  without  Lesion  of  the  Larynx. — 
Nervous  Aphonia. — Good  Effects  resulting  from  Cauterization,  and  sometimes 
even  from  the  mere  Introduction  of  tho  Laryngoscope,      .         .         .     509-515 


CONTENTS    OF    FIRST    VOLUME.  XXV 

LECTURE  XXVIII. 

DILATATION   OF   THE   BRONCHI   AND   BRONCKORRHCEA. 

Extreme  Difficulty  of  Diagnosis. — Dilatation  of  the  Bronchi  may  be  mistaken  for 
Pulmonary  Phthisis — or  for  Pleurisy  with  Perforation  of  the  Lung. — Dif- 
ferential Diagnosis. — Important  Signification  of  Abundant  and  Fetid  Expecto- 
ration.— Causes  of  the  Fetor. — Dilatation  of  the  Bronchi,  unless  it  be  to  a  very 
great  degree,  is  not  a  Serious  Affection. — Treatment  of  Bronchorrhcea,  or  Pul- 
monary Blenorrhagia. — Balsams. — Arsenical  Inhalation,  .         .         .     516-530 

LECTURE  XXIX. 

HAEMOPTYSIS. 

Haemoptysis. — Supplementary  Haemoptysis. — The  Differential  Diagnosis  between 
the  Haemoptysis  symptomatic  of  Pulmonary  Phthisis,  and  the  Haemoptysis  of 
Hemorrhagic  Pneumonia,  is  by  no  means  so  easy  as  some  physicians  allege, 

530-541 

LECTURE  XXX. 

PULMONARY   PHTHISIS. 

Kapid  Phthisis,  or  Galloping  Consumption. — Eapid  Phthisis  is  simply  Ordi- 
nary Phthisis  accomplishing  its  course  in  a  very  Short  Period  of  Time. — Acute 
Phthisis  is  a  Distinct  Morbid  Species,  of  which  there  are  Two  Forms,  the  Catar- 
rhal and  the  Typhoid, 541-547 

Pulmonary  Tuberculization,  and  Chronic  Peripneumonic  Catarrh  in 
Children, 547-551 

LECTURE  XXXI. 

GANGRENE   OF   THE   LUNG. 

Difficulties  of  Diagnosis. — Several  Species  of  Gangrene  of  the  Lung  :  One  of  them, 
the  Species  here  more  particularly  considered,  is  Curable,  .         .         .     551-556 

LECTURE  XXXII. 

pleurisy:  paracentesis  of  the  chest. 

Pleurisy. — Ordinary  Signs. — Skoda's  Bruit. — Interpretation  of  the  Kubbing 
Sound. — Crepitant  Kales  of  Pleurisy. — Persistence  of  Blowing  Sound  in  Cases 
of  Excessive  Effusion. — Blowing  Sound,  and  Amphoric  Voice,  are  Signs  of 
Pleurisy. — Mistakes  in  Diagnosis  may  sometimes  occur. — Intercostal  Fluctua- 
tion,              ....     556-565 

vol.  I. — 2 


XXvi  CONTENTS    OF    FIRST    VOLUME. 

Paracentesis  of  the  Chest. — Cases. — Historical  Sketch  of  the  Operation  for 
Effusion  into  the  Cavity  of  the  Pleura, 565-580 

Circumstances  which  render  Paracentesis  of  the  Chest  necessary. — Pleurisy  may  be 
Fatal. — Profuse  Effusion  may  cause  Sudden  Death. — It  may  occasion  Death  by 
Asphyxia. — On  the  other  hand,  Paracentesis  may  accomplish  an  Immediate 
Cure:  when  this  takes  place,  the  Temperature  of  the  Body  at  once  becomes 
normal. — The  Continuance  of  the  Effusion  in  the  Chest  may  occasion  Hectic 
Fever. — The  Effusion  may  become  Purulent. — Traumatic  Pleurisy. — Pleurisy 
may  occasion  development  of  the  Tubercular  Diathesis. — Latent  Pleurisy  is  a 
frequent  manifestation  of  this  Diathesis,  whether  the  Effusion  remain  Serous, 
or  become  Purulent,  as  usually  occurs. — Paracentesis  is  also  useful  when  there 
exists  Hydro-pneumothorax. — Cancerous  Pleurisy,     ....     580-611 

The  Quantity  of  the  Effusion  regulates  the  time  at  which  Paracentesis  is  indicated. 
— The  General  Symptoms  and  Oppression  of  Breathing  are  Fallacious  Indica- 
tions.— The  only  Trustworthy  Signs  are  those  furnished  by  Auscultation  and 
Percussion. — The  Manner  of  Operating.— Certain  Phenomena  which  supervene 
during  the  Flow  of  the  Fluid.— Coughing  Fits.— Flow  of  Blood  from  the  Wound. 
— The  Serosity  jellies  in  cooling,  and  sometimes  assumes  a  rosy  color. — Circum- 
scribed Pleurisies. — Objections  to  Paracentesis. — Paracentesis  in  Empyema. — 
Injections  of  Iodine  ;  and  the  Permanent  Canula,       ....     612-631 


LECTURE  XXXIII. 

TRAUMATIC   EFFUSION   OF   BLOOD   INTO   THE   PLEURA:    PARACENTESIS  OF 

THE   CHEST. 

Effusion  of  Blood  into  the  Cavity  of  the  Pleura  mechanically  arrests  Traumatic 
Hemorrhage. — In  such  cases,  Paracentesis  is  not  only  useless,  but  may  even 
prove  injurious. — The  Blood  coagulates  immediately. — It  scarcely  irritates  the 
Pleura. — Reabsorption  takes  place  very  rapidly,  ....     631-638 


LECTURE  XXXIV. 

HYDATIDS   OF   THE   LUNG. 

Hydatids  of  the  Lung  though  rare  are  not  so  rare  as  Hydatids  of  the  Pleura. — Diag- 
nosis is  exceedingly  difficult. — Resemblance  to  Pulmonary  Phthisis. — Possi- 
bility of  Cure  by  Spontaneous  Evacuation  by  the  Bronchial  Tubes. — Reserve 
required  both  in  respect  of  the  Prognosis  and  Treatment,  .         .         .     638-649 


LECTURE  XXXV. 

PULMONARY   ABSCESSES  AND   PERIPNEUMONIC   VOMICiE. 

Rare  Affections,  if  we  exclude  from  the  category  Tubercular  Vomicae  and  Metas- 
tatic Abscesses. — Most  frequent  in  Children,  in  whom  they  are  the  resull  of 
Lobular  Pneumonia. — Diagnosis  of  Peripneumonia  Vomica)  is  Difficult. — They 
may  be  confounded  with  Pleural  Abscesses, 641 


CONTENTS    OF    FIRST    VOLUME.  XXV11 

LECTURE  XXXVI. 

TREATMENT   OF   PNEUMONIA. 

Simple  Pneumonia  without  any  Complication. — Expectant  Medicine. — Local  and 
General  Bleeding. — Blisters. — Antimonial  Preparations,  particularly  the  Pre- 
cipitated Sulphuret  [Kermes]  in  large  doses  according  to  Easori's  Method, 

660-670 

Erysipelato-phlegmonous  Pneumonia,         ....  .         .     670-671 


TREATMENT   OF    PNEUMONIA    COMPLICATED    WITH    DELIRIUM,    BY 
PREPARATIONS   OF   MUSK. 

Musk  not  indicated  in  all  cases  of  Pneumonia  accompanied  by  Delirium. — Distinc- 
tions Essential  to  establish  in  relation  to  tbis  point,    ....     671-676 


PNEUMONIA   OF   THE   SUMMIT. 

Not  necessarily  accompanied  with  Delirium. — Delirium  may  also  occur  in  Pneu- 
monia situated  in  the  Centre  or  Base  of  a  Lobe. — Pneumonia  of  the  Summit  is 
not  necessarily  more  dangerous  or  more  tedious ;  but  this  statement  requires 
limitation  in  respect  of  Tuberculous  Patients,      ..        .         676-677 


LECTURE  XXXVII. 

PARACENTESIS   OF   THE   PERICARDIUM. 

Cases. — Historical  Summary. — Harmlessness  of  Tapping  the  Pericardium  and  In- 
jecting Solutions  of  Iodine. — Better  to  make  the  opening  with  the  Bistoury 
than  with  the  Trocar. — Dropsy  of  the  Pericardium  almost  always  associated 
with  some  other  diseased  state,  particularly  with  the  Tuberculous  Diathesis. — 
Paracentesis  affords  relief  and  prolongs  life  placed  in  immediate  jeopardy, 

678-699 


LECTURE  XXXVIII. 

ORGANIC   AFFECTIONS   OF   THE   HEART. 

General  Considerations. — Insufficiency  of  the  Aortic  Valves  is  the  most  serious  of 
all  the  Lesions  of  the  Cardiac  Orifices. — Dropsy  treated  by  Purgatives. — Diar- 
rhoea sometimes  requires  to  be  arrested  :  at  other  times  it  constitutes  a  natural 
crisis  which  ought  not  to  be  interfered  with. — Diagnosis  of  Affections  of  the 
Heart  is  often  difficult. — Embolism  and  its  Consequences,  .         .         .     699-715 


XXV111  CONTENTS    OF    FIRST    VOLUME. 

LECTURE  XXXIX. 

ON  VENESECTION   IN   CEREBRAL   HEMORRHAGE   AND   APOPLEXY. 

Apoplexy  is  not  to  be  confounded  with  Hemorrhage. — Cerebral  Hemorrhage  rarely 
sets  in  with  Apoplectiform  Phenomena,  properly  so  called. — Apoplexy  may  be 
the  expression  of  various  Grave  Lesions  of  the  Encephalon.— Value  of  Facial 
Hemiplegia  in  Hemorrhage. — Inutility  of  Venesection,  of  Bloodletting  in  gen- 
eral, of  Purgatives  and  Emetics  in  Hemorrhages  and  Apoplexy. — Differential 
Diagnosis  between  Softening  and  Hemorrhage. — Value  of  Certain  Signs  with 
regard  to  Prognosis, 715-726 

LECTURE  XL. 

ON   APOPLECTIFORM   CEREBRAL   CONGESTION,  AND   ITS   RELATIONS  TO 
EPILEPSY   AND   ECLAMPSIA. 

g  1 .  The  Existence  of  Cerebral  Congestion  is  not  contested ;  but  it  has  been  singu- 
larly Abused,  in  order  to  explain  Cerebral  Phenomena  in  the  Production  of 
which  Congestion  plays  no  part  whatever. — Sudden  and  transient  Fits  of  Apo- 
plexy are  among  these,  and  the  so-called  Apoplectiform  Cerebral  Congestions 
are  oftener  connected  with  Epilepsy  than  is  generally  believed. — A  few  Con- 
siderations on  the  sudden  and  irresistible  Impulses  of  Epileptics  in  general, 
and  on  the  inferences  to  be  drawn  from  them  in  a  medico-legal  point  of  view, 

726-732 

\  2.  Apart  from  Epilepsy,  a  great  many  Cases  of  so-called  Cerebral  Congestion,  in 
what  is  popularly  known  as  the  coup  de  sang  {ictus  sanguinis),  belong  to  the 
Class  of  Internal  Convulsions,  of  Vertigo  occurring  in  connection  with  Disease 
of  the  Internal  Ear,  and  with  Dyspepsia. — What  happens  in  the  Brain  in  these 
Attacks  is  much  more  nearly  allied  to  Syncope  than  to  Congestion. — The  Apo- 
plectic Stupor  of  Cerebral  Hemorrhage,  of  Epilepsy,  and  Eclampsia,  is  due  to 
what  I  have  called  "  Cerebral  Surprise." — Epilepsy  and  Eclampsia  present  re- 
markable analogies. — The  condition  of  the  Cerebro-spinal  Axis,  of  which  they 
az-e  both  an  expression  (a  condition  unknown  in  its  essence),  suffices  for  Pro- 
ducing Stupor. — The  Cerebral  Congestion,  which  in  Attacks  of  Epilepsy  and 
Eclampsiamay  be  pushed  as  far  as  Hemorrhage,  is  a  Secondary  Phenomenon, 

733-740 

LECTURE  XLI. 

ON  EPILEPSY. 

\  1.  Cases  of  Epilepsy. — Description  of  a  Fit. — Bow  to  recognize  the  Feigned  Dis- 
ease.— Three  Stages:  Tonic  Convulsions,  Clonic  Convulsions,  and  Stupor. — 
Synonyms:  Morbus  Major.  Morbus  Comitialis,  Morhu.-  Berculeus,  Falling 
Sickness,  Eaut-mal,  &c,  &c— Sequelae:  Subcutaneous  Bcchymoses,  Cerebral 
Hemorrhages,  &c. — Cerebral  and  Spinal  Lesions  are  Effects,  nol  a  Cause  of 
Epilepsy. — Exciting  Causes. — Statu-  Epilepticus. — Petit-mal,    .         .     741-752 


CONTENTS    OF    FIRST    VOLUME.  XXIX 

\  2.  Epileptic  Vertigo. — Aura  Epiloptica. — Partial  Epilepsy. — Angina  Pectoris. — 
Painful  Spasm  of  the  Face, 752-700 

§  3.  On  the  Eelations  of  Epilepsy  to  Insanity, 760-769 

\  4.  On  Hereditary  Taint  as  a  predisposing  Cause  of  Epilepsy. — Influence  of  Mar- 
riages of  Consanguinity, 769-775 

\  5.  Diagnosis  between  Epilepsy  and  Eclampsia. — Transformation  of  Eclampsia  into 
Epilepsy. — Differential  Diagnosis  from  Hysteria. — Symptomatic  Epilepsy. — 
Treatment  of  Epilepsy, 775-783 

LECTURE  XLII. 

ON    EPILEPTIFORM   NEURALGIA. 

The  Branches  of  the  Trigeminal  or  Fifth  Cranial  Nerve  are  those  generally 
Affected. — The  Neuralgia  is  in  most  cases  Accompanied  by  Partial  Convul- 
sions.— Is  nearly  Incurable. — Analogy  between  it  and  the  Aura  Epileptica. — 
Differs  from  Epilepsy,  although  sometimes  Observed  in  Epileptics. — Is  Be- 
lieved by  Section  of  the  Nerve  and  by  large  doses  of  Opium,     .         .     783-791 


LECTURE  XLIII. 

INFANTILE    CONVULSIONS. 

/ 
The  Organic  Alterations  are  an  Effect,  and  not  the  Cause,  of  the  Convulsions. — 

Yet  those  Secondary  Anatomical  Lesions  should  be  taken  into  consideration. — 
Predisposing,  Hereditary,  and  Acquired  Causes. — Exciting  Causes. — The  Con- 
vulsive Paroxysm  comprises  Two  Stages,  one  of  Tonic  Contraction,  and  the 
other  of  Clonic  Movements. — A  Third  Stage,  that  of  Collapsus,  is  an  Effect  of 
the  Convulsion  itself. — Convulsions  present  Infinite  Varieties. — General  Con- 
vulsions.— Partial  Convulsions. — Status  Convulsivus. — Inward  Convulsions. — 
Thymic  Asthma. — Sequela}. — When  Death  occurs,  it  is  by  Asphyxia,  or  by 
Nervous  Syncope. — Prognosis. — Treatment, 791-809 


LECTURE  XLIV. 

ECLAMPSIA   OF   PREGNANT  AND   PARTURIENT  WOMEN,  .     809-813 

LECTURE  XLV. 

ON  TETANY. 

Causes  :  the  most  frequent  are  Nursing  and  the  Puerperal  State ;  Influence  of  An- 
tecedent Diarrhoea  ;  Effect  of  Cold. — Description  of  the  Disease  :  Three  Arbi- 
trary Forms. — Mild  Form:  Local  Manifestations  are  alone  present,  and  the 
Symptoms  are  very  Slight. — Intermediate  Form  :  the  Contractions  become 
general,  and  Spread  from  the  Extremities  to  the  Muscles  of  the  Trunk  and 
Face,  while  General  Symptoms  are  superadded  to  them. — Grave  Form  :  Vio- 
lence of  the  Convulsions. — A  Fatal  Case. — Prognosis  generally  not  Grave. — 
Pathological  Anatomy  very  little  known. — Nature  of  the  Disease. — Differen- 
tial Diagnosis.— Treatment,        .        .         .        .    '    .         .         .         .     814-825 


XXX  CONTENTS    OF    FIRST    VOLUME. 


LECTURE  XLVI. 

ON  CHOREA, 825-827 

ST.    VITUS'S   DANCE. 

Eeason  why  the  term  St.  Vitus's  Dance  appears  to  me  better  than  that  of  Chorea. 
— Predisposing  Causes:  Age,  Sex,  Hereditary  Influence. — Pathological  Condi- 
tions: Chlorosis,  Tubercular  and  Strumous  Diathesis,  Piheumatism. — Exciting 
Causes  :  Emotions,  Fright. — Description  of  the  Disease. — Antecedent  Phe- 
nomena.—  Convulsive  Phenomena. — Their  Specific  Character. — Paralysis. — 
Disorders  of  Sensibility. — Impairment  of  the  Intellectual  Faculties. — The 
Complaint  is  usually  Curable. — Its  Mean  Duration. — It  may  Terminate  in 
Death,  and  How. — Pathological  Anatomy  throws  no  light  on  it. — Influence 
of  Intercurrent  Eebrile  Diseases  on  the  Course  of  the  Complaint. — Relapses 
and  Recurrences  :  their  Duration  is  Less  than  that  of  the  Previous  Attacks. — 
Treatment :  Cold  and  Warm  Baths,  Sulphur  Baths,  Gymnastics. — Internal 
Remedies  :  Tartar  Emetic,  Strychnine,  Opium  in  Large  Doses  in  Grave  Cases, 
Hygienic  Measures, 827-853 

OF   THE    DIFFERENT   FORMS   OF   CHOREA. 

Chorea  Saltatoria. — Methodical  or  Rhythmic  Chorea. — Tic-douloureux  (Chorea 
Neuralgica). — Tic  Non-douloureux. — "Writer's  Cramp  (Cliorea  Scriptorwm, 
Functional  Spasm  of  Dr.  Duchenne,  de  Boulogne),      ....     853-863 


LECTURE  XL VII. 

SENILE   TREMBLING  AND   PARALYSIS  AGITANS,  .     863-S70 


LECTURE  XLVIII. 

CEREBRAL  FEVER. 

Instances  of   Different  Forms  of   Cerebral  Fever. — Description  of  the  Difi 

Three  Stages  which  are  generally  Distinct. — I'mnonijuri/  Stai/e,  Characterized 
by  a  Group  of  general  Phenomena,  which  may  be  seen  in  other  Diseases,  but 
which  arc  never  so  Marked  and  never  so  Prolonged  as  in  this  Complaint. — 
Second  Stage :  Absence  of  Fever  ;  the  Pulse  becomes  remarkably  Slow,  and  the 
Breathing  peculiarly  Irregular. — This  Irregularity  of  the  Respiratory  Move- 
ments is  a  Sign  of  Great  Value. — Differential  Diagnosis  between  Cerebral 
Fever  and  Typhoid  Fever. — Third  Period:  the  Pulse  quickens  again,  and 
often  to  an  Extraordinary  Degree.  —  Prostration,  Delirium:  Convulsion 
first  Partial,  then  General  ;  Paralysis. — Cerebral  Fever  is  nearly  always,  not 
to  Bay  always,  Fatal,  whatever  be  the  Treatment  adopted. — The  post-mortem 
Appearances  are  more  indicative  of  Oerebro-meningitis  than  of  Meningitis. — 
Whether  Tubercular  or  not,  the  Oomplainl  run-  the  Bame  Course. — Chronic 
Hydrocephalus. — It  is  not  a  consequence  of  Cerebral  Paver,      .        .    871   B90 


CONTENTS    OF    FIRST    VOLUME.  XXXI 

LECTURE  XLIX. 

CROSS-PARALYSIS,   OR   ALTERNATE   HEMIPLEGIA. 

In  most  Cases  it  is  owing  to  a  Lesion  of  the  Pons  Varolii,  but  it  is  not  an  Absolute 
Sign  of  such  Lesion.  It  should  not  be  confounded  with  Glosso-laryngeal 
Paralysis, 891-895 

LECTURE  L. 

FACIAL   PARALYSIS,   OR   BELL'S   PARALYSIS. 

Facial  Hemiplegia  :  its  Causes  and  Symptoms.— Contraction  of  the  Muscles  con- 
secutive to  Paralysis  of  one  side  of  the  Face  may  be  mistaken  for  Paralysis  of 
the  opposite  side  — Treatment. — Double  Facial  Paralysis,    .         .         .     895-907 

LECTURE  LI. 

ON   GLOSSO-LARYNGEAL   PARALYSIS,  .  .  .     908-925 


INTRODUCTION. 


"WHAT  IS  CLINICAL  MEDICINE  ? 

Gentlemen  :  Before  speaking  to  you  about  the  patients  in  the  wards,  I 
require  to  tell  you  what  I  mean  by  "  clinical  instruction,"  both  in  respect 
of  the  teacher  and  the  taught.  To  me  it  is  no  doubt  pleasant  to  see  numer- 
ous pupils  crowding  round  the  beds,  and  filling  the  benches  of  the  theatre, 
but  it  is  very  much  more  pleasant  to  have  the  consciousness  of  discharging 
a  useful  mission,  and  of  leaving  on  the  youthful  mind  impressions  which 
will  by  and  by  yield  fruit.  Professor  and  pupils  must  conform  to  certain 
conditions,  without  attention  to  which  clinical  instruction  will  necessarily 
be  sterile. 

Although  the  clinic  is  the  copestone  of  medical  study,  I  would  not  wish 
you  to  suppose  that  it  ought  to  be  deferred  till  you  have  nearly  reached  the 
close  of  your  curriculum  as  students.  From  the  day  on  which  a  young 
man  wishes  to  be  a  physician,  he  ought  to  attend  the  hospitals.  It  is  essen- 
tial to  see — to  be  always  seeing — sick  persons.  The  heterogeneous  materials, 
though  amassed  without  order  or  method,  are  nevertheless  excellent  ma- 
terials ;  they  are  for  the  present  useless,  but  you  will,  at  a  later  date,  find 
them  stored  in  the  treasure-house  of  your  memories.  I  am  now  an  old  man, 
yet  I  remember  the  patients  whom  I  saw  forty  years  ago,  when  on  the 
threshold  of  my  career.  I  recollect  their  principal  symptoms,  their  anatom- 
ical lesions,  and  the  numbers  of  their  beds ;  and  sometimes  the  names 
even  of  the  patients  come  into  my  mind,  after  that  long  interval  of  time. 
These  recollections  are  of  service  to  me ;  they  still  afford  me  instruction, 
and  you  sometimes  hear  me  appeal  to  them  at  our  clinical  meetings. 

For  these  reasons,  then,  I  ask  the  young  student  to  atteud  every  day  an 
hospital  visit.     I  care  little  whether  he  commence  with  medicine  or  surgery. 

Still,  it  appears  to  me  more  profitable  at  first  to  frequent  the  medical 
than  the  surgical  wards.  The  young  man  is  attracted  by  the  display  of 
surgical  operations;  the  pomp  of  preparation,  the  dexterity  of  the  surgeon, 
the  immediate  conquests  which  he  achieves,  combine  to  strike  and  bewitch 
the  youthful  imagination  ;  but,  so  far  as  instruction  is  concerned,  the  per- 
formance which  he  has  witnessed  is  barren.  Before  one  can  understand  the 
mechanism  of  the  reduction  of  a  fracture  or  dislocation,  a  considerable 
knowledge  of  anatomy  and  physiology  must  be  acquired  ;  but  the  pupil 
who  is  present  at  those  delicate  operations,  in  which  the  performer  does  not 
make  the  slightest  cut  without  bearing  in  mind  the  minutest  anatomical 
details,  cannot  understand  the  amount  of  skill,  coolness,  and  intelligence 
required  to  attain  results,  which,  to  the  operator  are  immense,  but  which 
are  inappreciable  by  one  who  has  everything  to  learn.  I  have  always  ob- 
served that  young  men  were  more  delighted  by  those  operations  which  de- 


64  INTRODUCTION. 

mand  no  more  intelligence  than  is  required  by  a  butcher's  lad  to  cut  up  an 
ox,  than  by  those  wonderful  proceedings,  those  delicate  and  thoughtful 
manipulations,  the  ability  to  perforin  which  constitute  the  real  surgeon, 
and  which  strike  with  admiration  the  thoroughly  informed  who  can  under- 
stand and  appreciate  them.  You  will  not,  then,  derive  real  benefit  from 
frequenting  the  surgical  wards  till  you  have  been  initiated  in  anatomy, 
while,  for  studying  the  rudiments  of  medicine,  it  will  suffice  to  have  ac- 
quired some  superficial  acquaintance  with  physiology. 

You  will  soon  become  accustomed  to  see  patients,  to  read  in  their  coun- 
tenance the  gravity  of  their  diseases,  to  feel  the  pulse  and  appreciate  its 
character,  and  you  will  learn  the  first  elements  of  auscultation  and  percussion. 
You  will  soon  become  acquainted  with  the  chief  functional  disorders,  and 
be  able  to  recognize  the  modifications  of  the  secretions  and  the  excretions. 
You  will  see  in  the  dead-house  some  of  the  relations  between  the  lesions 
found  on  dissection,  and  the  symptoms  or  signs  observed  during  life.  At 
the  end  of  some  months  you  will  have  learned  many  things  which,  if  not 
then  acquired,  you  would  be  obliged  to  learn  at  a  subsequent  stage  of  your 
studies.  Let  me  repeat  that  these  ideas  will,  in  truth,  be  only  confused  ; 
but  still  you  will  find  as  you  go  on  that  the  lessons,  and  particularly  the 
familiar  conversations  of  your  masters  and  fellow-students,  will  have  helped 
you  to  arrange  some  of  the  disorderly  materials ;  in  any  case,  you  will 
have  learned  enough  to  render  attractive  your  future  studies. 

The  public  think  it  strange  to  hear  physicians  speak  of  the  fascination 
which  accompanies  the  study  of  our  art.  Literature,  painting,  and  music, 
do  not  yield  an  enjoyment  more  keen  than  that  which  is  afforded  by  the 
study  of  medicine,  and  whoever  does  not  find  in  it,  from  the  commencement 
of  his  career,  an  almost  irresistible  attraction,  ought  to  renounce  the  inten- 
tion of  following  our  profession. 

But  the  very  attractiveness  of  medicine  when  studied  at  the  bedside,  has, 
nevertheless,  sometimes  slight  drawbacks.  The  young  student  who  passes 
an  hour  or  two  every  morning  in  the  wards  of  an  hospital,  experiences  no 
great  pleasure  in  resuming  his  place  at  the  dissection-table.  I  admit  that, 
for  the  novice,  the  study  of  anatomy  is  often  irksome.  It  is  a  study  which 
forms  an  essential  part  of  the  education  of  the  physician  and  surgeon  :  but 
its  utility  is  not  at  once  perceived,  and  the  toilsome,  disgusting  nature  of  the 
occupation,  combined  with  the  sustained  attention  which  is  necessary,  fatigue 
the  student;  in  fact,  it  is  only  the  inflexible  requirements  of  the  examiners 
which  prevent.-  the  majority  of  our  young  recruits  from  deserting  the  dfe- 
secting-room  ;  the  facility  and  the  charm,  then,  of  hospital  study  may 
become  a  danger,  by  leading  students  to  neglect  necessary  and  laborious 
branches  of  their  education. 

The  short  time  which  you  can  devote  to  medicine,  makes  it  very  diffi- 
cult for  you  to  study  the  accessory  sciences.  It  is  important,  therefore,  thai 
before  entering  upon  the  medical  curriculum,  you  should  possess  a  knowl- 
edge of  chemistry  and  physics  sufficient  to  enable  you  to  understand  their 
applications  to  medicine;  Imt  I  would  deeply  deplore  your  losing  time  in  ac- 
quiring too  extensive  a  knowledge  of  chemistry.  A  Ithough  chemistry  renders 
,-ei'v  restricted  services  to  medicine  properly  so  called,  although  in  general 

the  iiio-I  eminent  chemists  have  been  i r  physician-,  and  sterling  practi- 
tioners have  always  been  sorry  chemists,  I  would  not  the  less  admit  the  desira- 
bility of  tin'  physician  having  a  very  extensive  knowledge  of  chemistry,  were 
t  only  for  the  purpose  of  convincing  him  of  the  vanity  of  the  pretensions  of 

the  chemists,  who  believe  that  they  can  explain  the  law-  of  life  and  of  the- 
rapeutics, because,  forsooth,  they  know  the  natun  ofsoiue  of  the  reactions 
which  take  place  in  the  living  body.      A-  the  lifetime  ofan  intelligent   man 


WHAT    IS    CLINICAL    MEDICINE?  35 

is  hardly  long  enough  to  enable  him  to  make  himself  acquainted  with 
medico-chirurgical  pathology  and  therapeutics,  why  should  the  student  be 
asked  to  distract  his  attention  with  accessory  studies,  which,  without  being 
wholly  useless,  are  nevertheless  too  unimportant  to  be  pursued  at  the  sacrifice 
of  physiology,  clinical  instruction,  and  therapeutics,  the  subjects  without  a 
knowledge  of  which  no  man  can  be  a  physician? 

Gentlemen,  far  from  me  be  the  thought  of  instituting  a  suit  against  the 
accessory  sciences,  and  against  chemistry  in  particular.  I  only  condemn 
an  exaggeration  of  their  importance,  their  pretentiousness,  their  being 
mixed  up  with  our  art  in  an  inappropriate  and  impertinent  manner.  I  do 
not  know  any  one  who  denies  that  all  the  compositions  and  decompositions, 
all  the  molecular  movements,  all  the  manifestations  of  force  belonging  to 
vegetative  life  are  physico-chemical ;  but  if  among  these  manifestations 
there  be  some  which  are  governed  by  laws  similar  to  the  laws  which  govern 
dead  matter,  there  are  others  (and  they  are  the  most  numerous,  the  most 
important,  the  most  essential  to  living  matter),  which  obey  quite  different 
laws — laws  which  perhaps  chemistry  may  some  day  discover,  but  which  for 
the  present  remain  autonomous,  special,  unexplained,  inexplicable,  and 
when  confronted  by  which,  the  vanquished  chemists  and  natural  philoso- 
phers ought  to  pause.  I  have  no  objection  to  their  holding  the  opinion 
that,  in  a  future,  more  or  less  remote,  they  may  be  able  to  subordinate  vital 
to  chejnical  laws,  but  in  the  meantime,  I  wish  them  to  be  modest,  and  not 
to  pass  off  their  hopes  for  ascertained  truths.  I  am  quite  willing  to  con- 
fess my  ignorance  as  a  chemist,  but  only  on  condition  that  chemists  admit 
their  ignorance  as  physiologists  and  physicians. 

I  should  be  sorry  to  have  to  repeat  to  you  discussions  which,  leaving 
every  one  in  possession  of  his  own  opinions,  have  hitherto  led  to  no  result. 
I  agree  with  the  majority  of  physiologists  and  physicians  in  believing  that 
the  acts  of  organic  life,  and  a  fortiori,  those  of  animal  life,  are  subject  to 
laws  which  in  the  meantime,  ought  to  be  regarded  as  essentially  different 
from  those  which  govern  inorganic  matter.  Take  two  eggs,  laid  by  the  same 
hen,  with  an  interval  of  some  days  between  them,  the  one  having  received, 
and  the  other  not  having  received  the  fecundating  influence  of  the  male.  I 
beg  the  ablest  chemist  to  tell  me  what  analysis  will  tell  him  about  the  differ- 
ence between  these  two  eggs.  In  both  there  is  albumen,  fat,  earthy  phos- 
phates, chlorides,  and  a  little  iron.  Has  the  chemist  discovered  wherein  con- 
sists the  chemical  and  physical  difference  between  these  two  eggs?  Will  he 
admit  with  me,  and  with  everybody  else,  that  their  composition  is  identical? 
There  is,  however,  a  very  small  difference,  quite  insignificant,  the  chemist 
tells  us :  they  say  that  one  is  organic  matter  without  vitality,  while  the  other 
is  absolutely  identical  organic  matter,  endowed  with  a  property  which,  for 
want  of  a  better  name,  we  call  life.  Let  us,  nevertheless,  see  how  each  egg 
is  affected  by  the  same  influences.  We  place  them  below  a  hen,  under  ex- 
actly the  same  conditions  as  to  light,  temperature,  and  moisture.  In  a  few 
days,  the  non-fecundated  egg,  obeying  the  laws  of  dead  organic  matter, 
will  be  putrescent,  while  the  other  will  contain  a  contractile  tube  filled  with 
blood :  in  a  few  days  later,  this  minute  vessel  will  consist  of  four  compart- 
ments separated  by  valves,  and  will  become  a  heart  receiving  and  sending 
forth  blood  through  separate  channels.  The  calcareous  phosphates  will 
take  their  appointed  places,  lengthening  out  as  jointed  levers,  moulded  as 
cavities,  or  extended  as  plates.  The  albumen  will  be  distributed  in  the 
blood,  muscles,  parenchyma,  and  membranes:  the  iron  and  the  salts  will 
take  their  own  special  and  predetermined  places. 

"  The  retort  has  its  mysteries,"  say  chemists,  but  it  appears  to  me  that 
the  fecundated  egg  has  other  and  somewhat  stranger  mysteries.     The  talis- 


36  INTRODUCTION. 

man  which  exists  in  it,  but  not  in  the  chemist's  retort,  is  life;  the  singular 
properties  of  living  matter  are  vital  properties,  and  say  what  you  will  in 
opposition  to  them,  you  will  be  obliged  to  admit  their  existence. 

If  you  kill  the  living  matter,  before  incubation,  by  a  violent  shake,  by 
elevating  or  lowering  the  temperature  a  little  too  much,  or  by  the  electric 
spark,  and  treat  the  non-fecundated  egg  in  the  same  manner,  the  condition 
of  both  will  become  identical  from  that  time,  and  the  course  which  each 
will  follow  will  thenceforth  be  similar.  There  will,  however,  be  nothing 
less  than  there  was  before,  except  that  trifle,  which  it  is  not  worth  while  to 
take  account  of,  life,  or — if  you  like  the  term  better — vital  properties. 

But  the  evolution-power  of  the  embryo,  in  which  the  vital  force  appears 
so  marvellous,  continues  to  exist,  perhaps,  in  a  more  simple  but  in  a  not 
less  evident  form.  When  the  animal  is  fully  formed,  it  is  no  longer  from 
an  amorphous  material  that  the  tissues  select  their  constituent  elements, 
but  from  a  liquid  of  determinate  composition — from  the  blood.  Hence- 
forth, it  is  this  liquid  which  provides  for  all  the  aggregations,  all  the  de- 
compositions, and  for  that  incessant  movement  constituting,  in  point  of  fact, 
one  continuous  evolution,  which  is,  to  the  observer,  less  extraordinary  than 
the  first  evolution,  only  because  it  is  accomplished  by  completely  formed 
instruments. 

Is  it  possible  that  there  exists  one  man  so  insane  as  to  deny  that  all  the 
movements  of  composition  and  decomposition  are  something  more  than 
mere  chemical  manifestations.  Combinations  may  be  ternary  or  quater- 
nary, but  they  are  not  the  less  only  chemical  combinations ;  and  I  do  not 
know  that  any  one  has  ever  denied  this  statement.  From  this  poiut  of 
view  we  are  all  iatro-chemists,  with  this  distinction,  that  the  worshippers  of 
chemistry  hold  that  the  changes  in  living  plants  and  animals  take  place  in 
accordance  with  the  laws  of  inorganic  chemistry,  while  we  maintain  that 
the  laws  which  preside  over  organic  chemical  action  are  of  a  special  char- 
acter, and  in  particular,  that  in  living  organisms  chemistry  is  controlled 
by  special  powers,  which  give  it  a  special  direction,  placing  it  under  con- 
ditions wholly  different  from  those  observed  in  matter  destitute  of  life. 

That  which  strikes  me  as  most  remarkable  in  the  fecundated  egg.  as  well 
as  in  the  fully  formed  animal,  is  not  so  much  the  complex  chemical  com- 
binations which  take  place  at  so  small  a  cost  of  effort,  as  the  elective  affini- 
ties which  manifest  themselves,  if  I  may  be  permitted  so  to  express  myself. 
In  the  amorphous  albuminous  mass  which  we  call  the  egg,  each  principle, 
without  any  straying,  takes  its  proper  place:  here,  we  have  the  calcareous 
phosphates,  and  there,  the  phosphorus,  the  fatty  matters,  the  fibrin,  the 
hair  and  nails,  each  finding  their  places  with  an  order  and  method  which 
clearly  demonstrate  the  existence  of  properties  different  from  those  of  inor- 
ganic matter  or  dead  organic  matter.  Again,  in  that  living  organism,  the 
fecundated  egg,  chemical  actions  which  are  all  decreed,  regular  and  of  un- 
erring perfection,  concur  in  promoting  one  object  ;  but  in  the  non-fecundated 
egg,  there  is  chance,  and  that  chaos  of  chemical  reactions  which  manifests 
itself  in  dead  organic  matter.  Chemistry  plays  its  pail  in  both  instances, 
but  that  part  is  very  different  in  each:  and  we  must  admit  that  there  are 
special  properties  in  the  one  case,  because  in  it  there  are  special  results. 

Gentlemen,  forgive  me  for  having  made  a  digression  which,  perhaps,  you 
have  found  out-  of  place,  and  loo  long.  Hie  excessive  admixture  of  physico- 
chemical  science  with  our  ar(  has  produced  so  much  evil,  and    is  calculated 

to  had  astray  so  disastrously  young  men  commencing  the  study  of  medi- 
cine, that,  in  spile  ofmyeelf,  I  h'^\  that  1  am  exaggerating  the  danger, and 

withdrawing  you  from  studies  to  which  you  are  indebted  for  useful  infor- 
mation. 


WHAT    IS    CLINICAL    MEDICINE?  37 

Let  us,  then,  return  to  our  clinical  inquiries. 

The  living  organism,  both  in  animals  and  vegetables,  has  properties,  in 
virtue  of  which  it  accomplishes  the  functions  of  nutrition.  Besides,  there 
exist,  especially  in  animals,  organs  which  incontestably  establish  a  co-ope- 
rative purpose  in  the  different  parts  of  the  living  economy.  In  health,  the 
different  functions  are  performed  with  regularity;  but  in  disease,  the  func- 
tions of  nutrition  and  relation  are  modified.  Whatever  the  nature  of  these, 
modifications  may  be,  they  do  not  fundamentally  change  the  properties  of 
living  matter  ;  they  only  change  its  modifications.  The  properties  remain 
unaltered  ;  "  Q.ure  faciunt,  in  homine  sano,  actiones  sanas,  eadem  in  segroto, 
morbosas." 

When  a  morbific  element  is  introduced  into  the  economy,  when  it  circu- 
lates with  the  blood,  it  there  behaves  itself  like  the  different  principles 
which  are  daily  received  into  the  system  by  digestion,  absorption,  and  res- 
piration. Some  of  these  principles  are  wholly  assimilated,  and,  conse- 
quently, are  of  the  nature  of  food,  while'  others  contain  materials  which 
rebel  against  assimilation,  and  which,  if  absorbed,  have  to  be  eliminated  by 
the  different  emunctory  channels,  and  rejected  by  the  stomach  or  intestinal 
canal,  if  they  have  been  swallowed.  You  perceive  that  things  proceed  in 
natural  order  up  to  that  point;  that  is  to  say^all  goes  on  naturally  in  re- 
spect of  alimentary  substances  containing  non-assimilable  principles  which 
are  necessarily  expelled.  But  if  among  these  non-assimilable  principles 
there  be  anything  which  produces  an  active  topical  irritation,  there  will 
follow  local  inflammation,  exercising  an  immediate  or  remote  influence 
upon  different  functions,  according  to  the  more  or  less  intimate  degree  in 
which  the  part  affected  is  connected  by  sympathetic  relations  with  other 
parts.  If  the  agent,  in  addition  to  its  irritant  properties,  possess  the  power 
of  vitiating  or  altering  the  quality  of  the  blood,  or  of  acting  directly  or  in- 
directly on  the  regulating  power  of  the  nervous  system,  you  can  conceive 
the  greatness  of  the  perturbations  which  will  be  produced. 

But  let  us  return  to  physiology.  To  sum  up  the  preceding  remarks,  be- 
lieve me  that  the  relative  vital  processes,  whether  more  or  less  complicated, 
ceaselessly  demand  organic  modifications  which  have  their  counterparts  in 
pathology,  just  as  pathological  phenomena  have  their  correlatives  in  physio- 
logical functions.  What  is  the  difference  between  the  therapeutic  stimulant 
and  the  alcohol  or  coffee  which  we  imbibe  daily  at  meals  ?  What  is  the 
difference  between  the  dulling  drugs  prescribed  by  the  physician,  and  the 
enervating  fumes  of  tobacco  which  constitute  in  the  present  day  a  part,  so 
to  speak,  of  the  life  of  the  majority  of  the  male  population  ?  Wherein  con- 
sists the  difference  between  food  charged  with  spices,  incorporated  with 
highly  stimulating  condiments — between  meat  which  the  epicure  esteems, 
because  it  is  in  an  advanced  stage  of  putrescence — and  the  morbific  causes 
which  excite  and  shatter  the  nervous  system,  or  alter  the  constitution  of  the 
blood  ? 

Animals  and  plants,  however,  are  constituted  with  the  power  of  selecting 
from  food  that  which  is  suitable,  and  rejecting  that  which  is  injurious  to 
them.  This  effort  of  selection  is  accomplished  at  the  cost  of  an  only  tran- 
sient inconvenience.  The  feverishness  which  accompanies  digestion,  is 
indeed,  within  certain  limits,  a  pathological  condition.  It  occurs  several 
times  a  day  without  injury  or  lasting  disturbance  of  the  economy  ;  but  if 
there  be  an  alteration  in  the  functional  instruments,  the  duration  and  vio- 
lence of  the  disturbance  reaches  a  state  of  disease  ;  and  likewise,  if  the  in- 
struments be  perfect,  but  the  work  which  they  have  to  perform  be  beyond 
their  organic  power,  an  analogous  disturbance  supervenes,  which  is  disease. 

We  can  imagine  that,  in  that  condition  which  we  designate  inflammation 


38  INTRODUCTION. 

(la  fluxion),  and  inflammatory  engorgement,  as  well  as  in  the  formation  of 
all  kinds  of  plastic  deposits,  each  organic  cell  is  in  its  ultimate  analysis  an 
animal  in  the  most  elementary  form,  with  a  mouth  represented  by  the 
artery,  an  anus  represented  by  the  vein,  and  an  amorphous  mass  represented 
by  the  parenchyma  of  the  ceil;  the  blood,  the  nutritive  element,  is  its  food. 
In  the  physiological  state  that  which  takes  place  is  simply  composition  and 
decomposition,  the  tissue,  at  the  same  time,  preserving  its  integrity,  and 
undergoing  no  changes  which  are  not  purely  physiological ;  but  if  the  blood 
carries  vitiated  materials,  or  materials  which  are  too  actively  nutritious,  it 
is  evident  that  something  will  take  place  in  it  analogous  to  that  which  I 
described  as  occurring  in  the  alimentary  canal  under  similar  circumstances. 
The  unsuitable  materials  will  be  badly  received  by  the  organic  cell,  and 
will  produce  within  it  morbid  disturbances  ;  they  may  either  remain  in  it 
too  long,  or  be  expelled  from  it  too  quickly  ;  or  they  may  develop  within  it 
new  phenomena  of  anomalous  secretion.  The  duration  of  the  disturbance 
set  up  is  in  proportion  to  the  degree  in  which  the  materials  are  antipatheti- 
cal to  the  living  cell,  in  proportion  to  the  degree  in  which  they  are  irritat- 
ing or  too  abundant.  When  the  extraordinary  afflux  ceases,  the  properties 
of  the  tissue,  for  a  time  oppressed  and  disturbed,  return  to  their  normal 
state,  the  cure  being  accomplished  in  the  same  way  that  a  return  to  health 
takes  place  after  a  fit  of  indigestion.  It  is  in  this  sense  that  we  ought  to 
understand  the  famous  Hippocratic  theory  of  the  coction  of  humors  in  dis- 
ease ;  to  the  mind  of  Hippocrates,  normal  digestion  was  nothing  more  than  a 
"  coction  ;"  and  he  regarded  the  coction  which  takes  place  in  disease  p  <i 
process  analogous  to  healthy  digestion. 

I  am  perfectly  aware,  gentlemen,  that  here  theories  leave  much  to  be 
desired  ;  and  I  know  that  they  are  not  more  acceptable,  when  the  subject 
under  discussion  is  the  great  class  of  nervous  diseases  which  holds  so  large 
a  place  in  pathology;  but,  as  I  have  already  had  the  honor  of  telling  you, 
in  studying  the  physiological  processes  assigned  to  the  nervous  system,  and 
the  hygienical  causes  which  act  more  particularly  on  that  system,  one  soon 
perceives  that  ultimately  the  laws  are  the  same  which,  in  the  circumstances 
specified,  preside  over  physiological  and  pathological  processes.  What  I 
have  said  to  you  in  respect  of  diseases  cum  materia,  of  diseases  in  their 
relations  to  the  phenomena  of  digestion  and  nutrition,  also  apply  to  ner- 
vous diseases  in  their  relations  to  the  senses  and  the  different  manifesta- 
tions more  particularly  originating  in  the  nervous  system. 

We  have  just  seen  that,  in  accordance  with  the  laws  of  physiology, 
nutrition  cannot  be  accomplished  in  a  certain  time  and  manner  without 
giving  rise  to  transient  perturbation.  We  have  seen  that  the  functional 
aptitudes  suffice  for  the  restoration  of  order.  If  we  go  a  little  higher,  we 
arrive  at  the  state  of  disease )  the  functional  aptitudes  remain  the  same: 
but  a  little  more,  work,  or  some  more  toilsome  exertion,  are  required  to 
accomplish  the  pathological  than  the  physiological  function.  Though  the 
apparatus  be  sufficient  for  the  work,  though  it  does  not  the  less  possess  the 
fitness  and  power  bestowed  upon  it  by  nature,  it  requires  more  time  for 
performing  the  pathological  function,  and  meets  with  more  difficulties  in 
accomplishing  it.  I  f  these  difficulties  are  not  insurmountable,  a  cure  takes 
place  a  cure  wrought  out  in  virtue1  of  the  innate  properties  of  the  matter 
aggregated  and  constituted  in  organs;  if,  as  unfortunately  too  often  hap- 
pens, i  he  difficulties  are  Insurmountable,  the  result  is  the  destruction  of  the 
function  or  the  organ,  or  the  destruction  of  both.  It  is  not  the  less  true 
that,  to  living  tissues,  to  organs,  i"  apparatus,  certain  powers  are  allotted, 
which  survive  the  most  violent  shocks,  and  by  the  instrumentality  of  which 
powers,  physiological  and  pathological  processes  are  accomplished.     It  is 


WHAT    IS    CLINICAL    MEDICINE?  39 

correct,  therefore,  in  a  figurative  sense,  to  say  that  nature  has  a  tendency 
to  effect  a  cure;  but  this  statement  <!<><'>  not  imply  thai  the  tendency  may 
not  be  met  within  the  living  body  by  the  insurmountable  obstacles  of  a 
worn-oul  state  or  a  destruction  of  organs  :  and  external  to  the  body,  by  a 
violent  and  malignant  operation  of  morbific  causes.  He  who  is  a  thorough 
believer  in  this  inherent  power  of  tissues,  will  be  less  disposed  to  act,  more 
circumspect  in  his  therapeutic  assaults,  and  will  better  understand  that  the 
physician  sometimes  discharges  his  duty  best  by  restricting  himself  to 
observing  and  directing  the  vital  forces.  We  have  too  much  faith  in  our- 
selves, and  are  too  distrustful  of  that  which  I  metaphorically  call  nature. 
We  do  not  sufficiently  recognize  the  fact  that,  when  once  the  stir-up  is 
given — pardon  the  vulgarity  of  the  expression — things  resume  their  normal 
style,  and  that  there  is  nothing  which  the  physician  ought  more  to  respect 
than  the  return  of  the  natural  functions  to  activity,  as  that  will  do  more 
to  bring  about  a  cure,  than  all  the  agents  of  the  materia  medica. 

When  under  the  influence  of  that  particular  modification  of  the  economy, 
which  (for  want  of  a  better  name)  we  call  inflammation,  an  effusion  of 
serosity  and  plastic  products  takes  place  into  the  pleural  cavity,  we  try  to 
interfere,  and — we  will  say  it — we  interfere  usefully  in  a  tolerably  large 
number  of  cases;  but  it  is  as  to  the  limits  within  which  successful  interven- 
tion is  practicable  that  the  majority  of  physicians  are  most  ignorant.  To 
look  at  the  pertinacity  of  our  medications,  the  incessant  and  tumultuous 
activity  of  our  therapeutics,  one  wTould  suppose  that  it  is  our  duty  to  dis- 
trust nature,  that  we  are  jealously  desirous  of  doing  all  ourselves  and  with- 
out her  aid.  When  inflammation  of  the  pleura  is  at  an  end,  there  remains 
a  something,  and  that  something  very  plainly  appreciable  by  ausculta- 
tion and  percussion — I  mean  effusion  :  this  will  occupy  our  minds,  both  be- 
fore and  after  it  occurs,  more  than  the  local  lesion  which  gives  rise  to  it.  We 
are  slow  to  believe,  that  when  the  inflammatory  orgasm  has  ceased,  the  great 
organic  cell,  which  we  term  the  pleura,  can  return  to  its  normal  aptitudes, 
and  perform  that  function  which  elementary  organic  cells  are  constantly 
performing  in  the  process  of  nutrition.  -From  that  time,  the  pleura  proceeds 
to  absorb  and  digest  the  morbid  products  which  it  contains ;  and  this  it  is 
generally  able  to  accomplish,  though  in  most  cases  the  work  is  slowly  done. 
I  at  once  admit  that  paracentesis  of  the  chest  will  save  the  pleura  a  great 
deal  of  work,  just  as  I  grant  that  copious  vomiting  is  the  best  and  most 
salutary  of  remedies  when  the  stomach  is  surcharged;  nevertheless,  when 
the  effusion  is  not  excessive,  when  there  is  no  irremediable  tubercular 
deposit  in  the  lungs  or  on  the  surface  of  the  serous  membrane,  the  natural 
innate  functions  of  the  pleura  suffice  for  the  absorption  of  the  effused  fluid 
and  the  accomplishment  of  a  complete  cure. 

In  the  same  category,  there  is  a  multitude  of  chronic  diseases.  When 
an  exostosis  supervenes  under  the  influence  of  the  syphilitic  poison,  beware 
of  supposing  that  the  lesion  ought  to  be  pertinaciously  pursued  as  long  as 
the  bone  and  periosteum  remain  swollen.  The  venereal  virus  has  been 
long  ago  Conquered,  and  the  exostosis,  or  other  lesions  which  remain,  are 
only  evidences  of  its  past  action.  If  the  practitioner  discontinue  his  treat- 
ment, the  functions  of  assimilation,  distributed  to  all  the  tissues,  will  prove 
sufficient  to  cause  the  disappearance  of  that  which  a  too  protracted  medi- 
cation would,  perhaps,  have  allowed  to  remain.  Homoeopaths,  very  unin- 
tentionally and  unwittingly,  I  admit,  came  opportunely  to  teach  us  to 
recognize  the  inherent  forces  of  the  living  economy.  Their  successes,  based 
with  precision  upon  cures  which  they  attribute  to  themselves,  but  winch 
belong  exclusively  to  nature,  have  been  useful  lessons  to  us.  They  have 
taught  us  to  rely  a  little  less  on  ourselves  and  a  little  more  on  the  wonder- 


40  INTRODUCTION. 

ful  aptitude  of  the  tissues  and  apparatus  which  constitute  the  animal 
machine. 

Again,  gentlemen,  do  not  forget  that,  in  acute  diseases,  the  time  for  use- 
ful treatment  passes  away  rapidly,  and  that  the  expectant  system  soon  finds 
its  opportunity ;  and  while  we  admit  that  in  chronic  diseases,  the  active, 
patient,  reiterated  interference  of  the  physician  may  be  advantageously 
continued  over  a  long  period,  it  is  nevertheless  sometimes  very  necessary  to 
stay  the  hand,  though  full  of  medicaments,  and  wait  for  a  few  days.  It 
often  happens  that,  when  thus  waiting,  we  see  the  awaking  of  the  normal 
functions  from  a  state  of  slumber,  suffocation,  and  perversion,  and  have 
the  good  fortune  to  witness  powerful  manifestations  of  that  which  is  called, 
without  a  sufficient  comprehension  of  the  term,  the  vis  medicatrisc  natures. 

After  a  few  months  of  study,  the  student  ought  to  collect  and  write  out 
cases  ;  he  will  thus  acquire  the  habit  of  examining  patients — of  scrutinizing 
appliances  and  proceedings,  of  discriminating  the  symptoms  which  are  of 
most  importance  and  significance ;  in  particular,  he  will  learn  to  know  the 
usual  course  of  diseases — a  kind  of  knowledge  the  most  valuable  which  the 
practitioner  can  possess.  I  would  fail  in  my  duty  if  I  did  not  lay  strong 
emphasis  on  the  words  I  am  now  going  to  utter — to  know  the  natural  progress 
of  diseases  is  to  know  more  than  the  half  of  medicine. 

But  do  not  imagine,  gentlemen,  that  it  is  easy  to  acquire  this  knowl- 
edge. There  are  many  causes  which  place  almost  insurmountable  obsta- 
cles in  the  way  of  this  essential  study.  Most  physicians  entertain  so  exalted 
an  opinion  of  the  power  of  their  art,  as  to  believe  it  to  be  a  dereliction  of 
duty  to  abstain  from  treatment  when  they  have  before  them  an  acute  or 
chronic  case.  They  institute  active  treatment,  which  of  necessity  disturbs 
the  normal  evolution  of  the  disease;  and  even  when  this  treatment  is  use- 
ful, it  prevents  them  from  ascertaining  what  would  have  taken  place  if 
matters  had  been  let  alone;  when  the  treatment  proves  injurious  the 
observer  is  left  in  a  similar  kind  of  perplexity.  It  must  be  granted  that 
if  we  who  have  grown  old  in  hospital  and  private  practice,  experience  so 
much  embarrassment  in  ascertaining  the  natural  course  of  diseases,  your 
difficulty  will  be  much  greater.  You  may  well  ask:  Where  is  the  thread 
to  guide  us  through  the  inextricable  labyrinth? 

There  is,  however,  a  sufficiently  easy  method  of  acquiring  this  knowl- 
edge so  important  to  the  practitioner.  Observe  the  practice  of  many  physi- 
cians ;  do  not  implicitly  believe  the  mere  assertion  of  your  master;  be 
somethiug  better  than  servile  learners;  go  forth  yourselves  to  see  and  to 
compare!  If,  in  spite  of  treatment  the  most  varied  and  opposite,  you 
perceive  that  a  particular  malady  generally  proves  mild,  you  may  come  to 
the  conclusion  that,  in  respect  of  it,  physicians  are  impotent,  and  that  the 
mildness  depends  less  on  the  treatment  than  on  the  inherent  nature  of  the 
disease.  Having  made  good  this  point,  look  about  in  the  hospitals,  and 
you  will  quickly  rind  a  great  many  individuals  who  enter  our  wards  after 
having  spenl  the  first  days  of  their  illnesses  at  their  homes  without  any 

treatment,   and   you    will   discover   thai    a    large    number  of    the86  patients 

have  come    into    hospital   just  when    vale-ceiiee  was   beginning.      These 

are  among  the  most  important  which  you  can  observe.  Compare 
them  with  those  which  you  have  seen  treated  in  hospital.  Doting,  in  both 
classes,  the  duration  of  the  disease  and  the  rapidity  of  convalescence ;  if  it 
become  evident  to  you  thai  the  advantage  is  on  the  side  of  those  who  had 
no  treatment,  or  that  the  influence  of  treatmenl  of  the  most  various  kinds 
ua-  null,  nearly  null,  or  absolutely  hurtful,  you  have  already  learned  thai 
the  disease  in  question  is  an  acute  one, in  which  nature  is  more  powerful 
than  the  physician.     Knowing,  henceforth,  the  physiognomy  ofthedh 


WHAT    IS    CLINICAL    MEDICINE?  41 

when  allowed  to  run  its  own  course,  you  can,  without  risk  of  error,  estimate 
the  value  of  the  different  medications  which  have  heen  employed.  You 
will  discover  which  remedies  have  done  no  harm,  and  which  have  notably 
curtailed  the  duration  of  the  disease;  and  thus  for  the  future  you  will  have 
a  standard  by  which  to  measure  the  value  of  the  medicines  which  you  see 
employed  to  counteract  the  malady  in  question.  What  you  have  done  in 
respect  of  one  disease,  you  will  he  able  to  do  in  respect  of  many  ;  and  by 
proceeding  in  this  way  you  will  be  able,  oil  sure  data,  to  pass  judgment  on 
the  treatment  pursued  by  your  masters. 

But  it  is  evident  that,  to  arrive  at  the  point  which  I  have  now  indicated 
you  require  daily  attention,  great  love  of  truth,  and  much  disinterestedness ; 
and  these  are  difficult  requirements.  Affection  for  a  teacher  to  whom  you 
have  long  been  in  the  habit  of  listening,  may  lead  you  too  readily  to  be- 
lieve his  assertions.  I  do  my  utmost  to  instruct  you  in  what  I  believe  to 
be  the  truth.  Many  of  you,  through  a  very  natural  feeling  of  deference 
(for  which  I  am  grateful),  swear  by  the  master's  word,  but  I  adjure  you  to 
seek  yet  other  sources  of  instruction.  I  cannot  do  this  as  easily  as  you  can  ; 
it  is  only  by  reading  that  I  can  become  enlightened  as  to  my  faults,  and 
correct  my  erroneous  opinions.  In  addition  to  reading,  you  have  to  guide 
you  the  observation  of  the  practice  of  twenty  hospital  physicians,  carried 
out  in  wards  freely  open  to  you,  and  by  men  whose  advice  is  affectionately 
tendered.  I  am  grateful  when  you  bring  under  my  notice  observations 
which  enable  me  to  correct  a  mistake.  Every  year  I  am  indebted  to 
active,  devoted  young  men  for  the  opportunity  of  learning  facts  with  which 
I  was  unacquainted,  and  reviewing  erroneous  views  which  I  had  long  been 
teaching.  In  such  opportunities  I  find  a  very  agreeable  reward  for  my 
efforts  to  be  useful,  and  for  the  love  I  bear  to  my  pupils. 

An  understanding  of  the  natural  course  of  diseases  is,  then,  as  I  have  just 
said,  the  most  important  kind  of  knowledge  which  a  young  physician  can 
seek  after.  It  is  with  the  aid  of  this  compass  that  he  steers  with  certainty 
through  the  difficult  study  of  therapeutics,  and  is  enabled  to  gauge  the  value 
of  systems  which  succeed  each  other,  only  that  they  may  in  turn  be  speedily 
crushed  by  those  which  arise  in  their  stead. 

There  is  no  kind  of  practice,  not  even  the  fooleries  of  amulets  and  homoe- 
opathy, which  may  not  yield  you  very  useful  instruction.  As  enlightened 
observers  of  the  wonders  attributed  to  secret  remedies  handed  down  in 
families,  and  fervently  propagated  by  the  believers  in  all  religions  (even 
by  those  who  pretend  that  they  are  above  such  prejudices),  you  will  see 
morbid  phenomena  defile  before  you  in  regular  order,  and  without  having 
anything  wherewith  to  reproach  your  consciences,  you  will  get  ideas  from 
what  is  passing,  which  you  could  not  derive  from  your  own  researches. 
In  point  of  fact,  gentlemen,  the  physician,  worthy  of  the  priesthood  to 
which  he  has  devoted  himself,  has  no  right  to  place  on  one  side  his  beliefs, 
even  though  they  be  false,  that  he  may  experiment  upon  his  patients,  and 
wait  with  curiosity  to  see  what  "expectation"  can  do  for  them. 

I  have  long  been  disposed  to  doubt  the  efficacy  of  medicine  in  acute 
pneumonia.  Long  ago  I  was  tempted  to  leave  nature  to  bring  to  a  favor- 
able issue  this  disease,  against  which  we  are  all  disposed  to  act  so  vigor- 
ously ;  but  I  have  not  yet  dared  so  to  act.  Antimonials,  emetics,  and  digi- 
talis, are  my  chosen  weapons ;  and  I  should  consider  that  I  failed  in  my 
duty  if,  convinced  as  I  am  (perhaps  erroneously)  of  their  great  utility,  I 
did  not  employ  them,  that  I  might  see  in  what  manner  nature  would  bring 
the  disease  to  a  conclusion. 

Abstinence  from  treatment  answers  admirably  in  mild  diseases,  and  one 
may,  without  dereliction  of  duty,  study  their  natural  characters  left  undis- 


42  INTRODUCTION. 

turbed  by  the  intervention  of  art;  but  when  there  is  danger,  and  we  believe 
that  we  possess  a  remedy  capable  of  removing  that  danger,  conscience  calls 
out  to  us  to  be  doing,  and  brings  us  back  to  active  treatment,  even  when, 
for  a  moment,  we  were  about  to  yield  to  the  seductive  influence  of  a  culpa- 
ble curiosity. 

This  abstinence  from  interference  which  I  have  now  censured,  I,  how- 
ever, entirely  approve,  nay,  I  proclaim  its  opportunity,  when  we  have  to 
deal  with  diseases  against  which  all  treatment  has  proved  useless.  In  such 
cases,  waiting  teaches  us  at  least  one  thing — that  there  are  remedies  which 
are  hurtful,  and  that  it  is  better  to  do  nothing  than  to  do  mischief.  But, 
in  these  very  cases,  if  it  be  incumbent  on  us  to  refrain  from  treatment,  that 
Ave  may  understand  the  natural  course  of  the  disease,  we  must  not  too  abso- 
lutely act  in  this  way,  and  it  is  our  duty  to  yield  to  those  who,  rightly  or 
wrongly,  believe  that  they  have  found  a  useful  remedy.  In  incurable  affec- 
tions, in  affections  which,  though  often  curable,  are  grave,  only  yielding 
slowly,  and  after  leading  the  patient  through  the  greatest  perils,  therapeutic 
attempts  are  allowable,  if  they  are  corollaries  from  facts  acquired  under 
analogous  circumstances,  or  from  the  successful  experiments  of  others. 
When  a  patient  runs  an  imminent  and  certain  risk,  it  is  justifiable,  or  at 
least  it  is  excusable,  to  use  every  remedy,  as  in  such  a  case  we  cannot  make 
bad  worse.  Still,  even  in  such  cases,  our  therapeutic  action  must  be  defen- 
sible in  theory  and  by  an  appeal  to  analogy. 

In  presence  of  a  child  dying  from  suffocation  in  croup,  it  is  intelligent, 
and  accordant  with  powerful  analogy,  to  act  surgically,  by  affording  an 
exit  to  the  foreign  body,  and  allowing  air  to  enter  below  the  obstruction  in 
the  larynx.  Even  when  in  such  a  case  success  does  not  crown  the  daring 
of  the  operator,  his  conscience  will  be  absolved — and  that  is  the  great 
point.  For  centuries,  paracentesis  of  the  abdomen  has  been  practiced  for 
the  evacuation  of  serous  effusions.  Why  limit  the  employment  of  paracen- 
tesis of  the  chest  to  purulent  effusions,  as  has  till  lately  been  the  practice? 
Have  I  not  been  justified  in  acute  pleurisy,  with  suffocation  impending, 
when  I  plunged  my  trocar  into  the  pleura?  Tracheotomy  and  puncturing 
the  thoracic  walls  may  prove  useless,  but  still,  if  experiments  be  allowable 
under  any  circumstances,  they  are  alloAvable  in  cases  such  as  I  have  now 
indicated. 

So  long  as  the  man  of  art  only  makes  experiments  of  this  kind,  he  will 
be  forthwith  absolved  by  his  own  conscience  (and  that  is  the  most  impor- 
tant matter),  and  he  will  likewise  be  acquitted  by  his  peers,  who  sil  in  judg- 
ment on  his  conduct ;  while,  on  the  other  hand,  he  will  be  condemned,  and 
justly  branded,  if  the  experiment  has  been  performed  merely  to  gratify 
curiosity.  But  how  much  more  blameworthy  is  the  man  who  experiments 
in  such  a  fashion  in  an  hospital,  where  there  is  not  that  feeling  of  responsi- 
bility which  often  makes  the  private  practitioner  tremble;  where  there  is 
no  necessity  to  guard  against  a  compromising  of  position;  where  patients 
are  under  absolute  authority,  and  may  for  disobedience  lie  dismissed  from 
hospital,  and  turned  adrift  without  asylum  or  succor. 

Strive,  gentlemen,  if  you  become  witnesses  of  such  misdeeds,  misdeeds 
very  rare,  thank  God!  strive  not  to  imitate  them,  lest  you  lay  up  tor  your- 
selves remorse  to  follow  you  to  the  end  of  your  career.  The  physician  has 
the  righl  to  experiment,  bul  within  certain  limits,  and  under  certain  con- 
ditions which  I  have  in  part  indicated,  and  which  1  desire  still  farther  to 
explain.     To  understand   properly  the  nature  of  this  right,  it  is  necessary 

to  know  the  way  in  which  practical  and  therapeutical  views  are  acquired. 
I  have  already  told  you  that  mosl  of  the  ascertained  facts  in  therapeutics 
have  proceeded  from  empiricism  ;  hut  I  have  taken  care  to  let  you  under- 


WHAT    IS    CLINICAL    MEDICINE?  43 

stand  that,  although  tlic  primitive  fact  he  purely  empirical,  its  applications 
pertain  to  the  intelligence  of  the  physician  who  has  discovered  them.     I 

have  already  told  you  that  the  intelligent  physician  perceives  in  a  fad 
something  which  others  do  not  sec  in  it,  and  that  it  is  in  consequence  of 
this  that  the  fact  enlarges  his  horizon.     The  inferences,  however,  from  an 

elementary  fact,  will  only  have  value  in  proportion  to  the  extent  to  which 
experience  is  developed ;  and  experience  can  only  be  acquired  by  experi- 
menting. There  is  not  a  physician  in  the  world,  unless  he  be  stupid  and 
dishonest,  who  experiments  without  some  other  motive  than  merely  to  state 
results.  He  is  led  on  by  one  or  several  facts  already  ascertained,  and  his 
tentative  proceedings  are  in  reality  legitimized  as  he  proceeds,  either  by 
anterior  ideas  supplied  by  chance  or  a  combination  of  chance  with  atten- 
tive observation  of  facts. 

When  the  women  employed  in  picking  the  stigmata  of  saffron  have 
frequently  had  to  complain  of  an  excessive  menstrual  flow,  the  fact,  one 
of  common  notoriety,  could  not  but  make  an  impression  on  the  minds 
of  physicians  even  the  least  intelligent ;  and  from  that  point  there  was 
but  one  step  to  the  discovery  of  the  therapeutic  action  of  saffron  as  an 
emmenagogue,  and  to  a  recognition  of  its  power  of  frequently  producing 
abortion. 

How  did  we  come  to  try  to  repress  the  fleshy  granulations  of  a  wound 
by  the  use  of  fused  nitrate  of  silver?  I  do  not  know.  But  this  practice, 
now  so  very  common  as  to  be  left  in  the  hands  of  medical  novices  and 
complete  strangers  to  our  art,  has  conducted  practitioners  to  a  course  of 
experiment  most  prolific  in  results.  Perceiving  the  resemblance  between 
the  catarrhal  affections  of  mucous  membranes  and  the  granulating  surfaces 
of  wounds,  they  asked  themselves  whether  it  might  not  be  opportune  to 
apply  the  same  caustic  to  mucous  surfaces  in  such  affections ;  trials,  a-t  first 
cautious,  gave  such  encouraging  results  that  the  experimenters  became 
bold,  and  solutions  of  nitrate  of  silver,  at  first  applied  to  the  pharynx  and 
mucous  lining  of  the  mouth,  have  passed  into  everyday  use  in  the  treat- 
ment of  inflammations  of  the  mucous  membrane  of  the  nose,  eyes,  urethra, 
vagina,  and  even  of  the  intestine. 

But  if  the  most  energetic  of  caustics  was  so  evidently  useful,  might  not 
one  expect  the  same  results  from  other  substances  of  the  same  class  as 
nitrate  of  silver?  The  sulphates  of  copper  and  zinc,  corrosive  sublimate, 
and  solutions  of  potassa,  soda,  and  ammonia,  tried  in  succession  by  different 
practitioners  have  responded  favorably  and  every  day  this  field  of  experi- 
ment is  becoming  enlarged.  It  was  soon  perceived  that  the  primary  effect 
of  these  different  agents  w^as  analogous  to  that  produced  by  inflammation, 
and  it  was  easy  to  understand  that  inflammation  artificially  induced  in 
tissues  already  the  seat  of  inflammation,  led  to  a  cure  of  the  original  in- 
flammatory attack.  When  this  view  was  once  acquired — a  view,  as  you 
have  seen,  wholly  due  to  experiment — there  flowed  from  it  the  great  thera- 
peutic principle  of  substitution,  which,  at  present,  rules  supreme  in  medical 
practice. 

Thus  it  is  that,  step  by  step,  therapeutics  have  become  enriched  ;  it  is 
thus-  that,  day  by  day,  experiment  has  added  one  fact  after  another  to  our 
store.  When  facts  were  seen  to  present  analogies,  and  when  their  relations 
to  each  other  became  understood,  groups  of  systems  were  formed,  which 
afterwards  expanded,  and  constituted  a  sort  of  body  of  therapeutic  doctrine, 
doubtless  leaving  beyond  its  limits  many  unexplained  facts,  which  must 
remain  provisionally  within  the  domain  of  empiricism,  until  they  can,  at  a 
later  date,  be  placed  in  a  special  category,  and  in  a  general  system. 

Since  the  time  of  Svdenham  there  has  assuredlv  been  no  advance  in  the 


44  INTRODUCTION. 

treatment  of  intermittent  fever,  but  the  empirical  opinion  as  to  the  powerful 
influence  of  the  Peruvian  bark  is  for  all  that  not  a  crude  notion,  which  it 
is  sufficient  to  announce  to  give  currency  to  with  the  general  public. 
When  the  Countess  del  Cinchon,  in  the  enthusiasm  of  her  thankfulness, 
sent  to  Rome  and  Madrid  the  miraculous  powder  which  had  cured  her 
of  fever,  the  proceeding  was  only  empirical ;  but  Peruvian  bark,  when 
adopted  and  tested  by  Torti  and  .Sydenham,  became  a  remedy  administered 
according  to  methods  which  it  was  the  province  of  great  physicians  to 
determine.  It  is  thus  that  even  when  a  remedy  is  only  applicable  to  a 
special  disease,  when  no  theory,  no  process  of  inductive  reasoning  has  led 
to  its  employment,  when,  in  consequence,  it  seems  to  belong  exclusively  to 
empiricism,  the  physician  may  still  intervene  with  his  intelligence,  and 
institute  a  plan  of  treatment  with  a  single  medicine.  He  will  not  attempt 
to  systematize,  he  will  not  be  able  to  try  even  the  smallest  series  of  remedies, 
but  he  will  form  opinions  as  to  the  fitting  time  for  using  the  special  remedy, 
and  as  to  the  nature  and  duration  of  its  influence  in  individual  cases.  He 
will  regulate  the  doses  as  to  their  amount  and  frequency  of  administration. 
He  will  inquire  into  the  means  of  rendering  the  remedy  as  inoffensive  as 
possible,  and  he  will  study  to  discover,  in  the  special  symptoms  of  the  case, 
whether  there  be  any  other  indications  which  experience  has  already 
taught  him  to  appreciate  and  fulfil.  He  will  see  that  the  ansemia  which 
accompanies  marsh  poisoning  yields  with  ease  and  certainty  to  the  same 
remedies  which  succeed  so  well  in  chlorotic  cachexia,  and  in  such  cases 
iron  will  become,  in  the  hands  of  the  physician,  a  useful  adjuvant  unknown 
to  the  empiric.  The  empiric  can  cure  a  paroxysm  of  fever;  but  it  is  the 
physician  who  cures  the  fever  in  the  totality  of  its  phenomena.  It  is  the 
physician  who  makes  a  diagnosis,  which  it  is  impossible  for  the  empiric  to 
accomplish.  To  know  that  a  patient  has  daily  a  paroxysm  of  fever  com- 
mencing with  rigors,  and  followed  by  heat  and  sweating,  is  knowledge  of 
the  commonest  possible  description — it  is  not  diagnosis;  but  to  know  that 
the  paroxysm  of  fever  is  unconnected  with  concealed  inflammation,  deep- 
seated  suppuration,  or  an  idiosyncrasy  of  the  nervous  system  so  common 
in  some  women — to  knowthat  it  really  is  the  manifestation  of  the  influence 
of  marsh  miasmata — is  a  complex  conception  which  can  only  exist  within 
the  domain  of  the  physician.  To  appreciate  the  present  influence  of  that 
poisoning,  the  influence  which  it  has  exerted  and  is  destined  to  exerl  on 
the  patient,  and  so  to  be  enabled  to  adapt  the  duration  and  activity  of  the 
treatment,  in  accordance  with  the  seriousness  of  the  case,  is  beyond  the 
resources  of  the  empiric. 

When  it  is  necessary  in  simple  or  pernicious  fevers  to  find  the  thread 
which  leads  up  to  a  knowledge  of  the  cause  and  essential  nature  of  the 
disease;   when    it    is   necessary   in   a  man   who    has   a    cough,  .|:'i:..,,i,  v   of 

breathing  in  the  horizontal  position,  bloodstained  expectoration,  ;i.,.. 

in  the  side,  to  lift  the  deceitful  mask  and  identify  the  intermittent  fever 
which  demands,  imperiously  and  immediately,  large  doses  of  cinchona  ; 
when  it  is  necessary  to  search  out  and  discover  the  same  indication  of  treat- 
ment amid  a  turmoil  of  violenl  symptoms  in  a  protracted  paroxysm  of 
intermittent,  which  assumes  the  form  of  continued  fever:  when  such  con- 
tingencies arise,  it  is  the  physician  who  can  alone  usefully  interfere,  and 
the  vulgar  empiric,  who  ha-  by  chance  stopped  a  lit  of  intermittent  fever, 

is    incapable   of  skilfully    wielding   the    therapeutic    weapon,   even    in    the 

simplest  cases,  and  if  he  ha-  to  do  with  forms  of  intermittent  fever,  in  any 
degree  complicated,  he  is  unaware  thai  he  ought  to  employ  the  hark. 

Though  empiricism,  therefore,  has  furnished  the  original  suggestion  of 
the  employment  of  cinchona,  although  up  to  this  day  we  are  quite  unable 


WHAT    IS    CLINICAL    MEDICINE?  4") 

to  explain  the  action  of  this  powerful  drug,  physicians  have  taken  posses- 
sion of  its  unexplained  action,  have  extended  it-  beneficial  sphere,  and 

have,  with  a  medicine  which  is  empirical,  instituted  a  system  of  treat  incut 
which  is  not  empirical. 

The  mission  of  the  clinical  professor  is  quite  different  from  that  of  the 
professor  of  pathology.  It  is  the  province  of  the  latter  to  trace  system- 
atically the  history  of  diseases — to  point  out  their  causes,  nature,  symp- 
toms, and  treatment.  He  ought,  as  much  as  possible,  to  classify  them  in 
nosological  order,  and  to  present,  as  far  as  in  him  lies,  an  exact,  well-defined 
picture,  with  which  all  the  facts  ought  to  correspond.  The  duty  of  the 
clinical  teacher  is  not  of  the  same  kind.  If  a  series  of  patients  suffering 
from  a  similar  affection  present  themselves  in  the  wards,  he  will,  no  doubt, 
profiting  by  the  occurrence,  sketch  a  picture  of  the  disease;  but  the  descrip- 
tion given  will  be  to  a  certain  extent  the  recapitulation,  the  corollary,  of 
facts  observed;  he  -will  much  more  frequently  have  to  study  with  his  pupils 
the  forms  which  the  malady  takes  in  virtue  of  particular  medical  constitu- 
tions of  the  atmosphere,  and  the  idiosyncrasy  of  each  patient,  than  to  give 
a  general  picture.  It  will  be  specially  incumbent  upon  him  to  show  in 
what  respect,  and  in  what  degree,  the  case  under  observation  varies  from 
classical  descriptions :  to  point  out  the  innumerable  modifications  in  respect 
of  the  form,  general  character,  and  treatment  of  diseases  clue  to  the  differ- 
ent conditions  under  which  the  patients  are  placed.  In  a  word,  while 
indicating  the  points  in  which  the  case  conforms  to  classical  models,  he  will 
describe  with  the  most  minute  care  the  points  in  which  it  differs  from  them, 
endeavoring  at  the  same  time  to  show  upon  wThat  these  differences  depend. 
It  is  precisely  this  kind  of  fundamental  study  which  makes  the  prac- 
titioner. 

When  the  pupil  has  finished  reading  a  treatise  on  medical  pathology, 
he  fancies  himself  already  a  physician  ;  but  when  confronted  with  a  patient, 
he  experiences  the  strangest  embarrassment,  and  soon  finds  out  that  he  has 
no  ground  to  stand  on.  I  do  not  speak  only  of  embarrassment  resulting 
from  not  being  accustomed  to  the  task — that  he  feels,  and  it  is  comprehen- 
sible that  he  should — but  what  I  wish  to  tell  you  is,  that  the  signs  and 
symptoms  have  to  him  an  air  of  utter  strangeness.  In  his  pathological 
treatises,  the  student  has  seen  pulmonary  tubercular  phthisis  delineated  in 
striking  features,  the  signs  furnished  by  auscultation  and  percussion  have 
been  clearly  and  methodically  laid  down  ;  the  author  has  insisted  on  deli- 
cate shades  of  variation,  and  on  numerous  exceptional  circumstances;  but 
these  variations  and  exceptions  have  made  little  impression  on  the  young 
man,  though  they  are  the  very  things  which  most  frequently  strike  the 
true  clinical  observer  as  noteworthy  in  the  incipient  stage,  and  during  the 
course  of  phthisis.  He  only  who,  during  many  months,  and  in  the  wards 
of  an  hospital,  has  studied  tubercular  phthisis  in  all  its  forms  and  in  all  its 
symptoms,  can  comprehend  the  immense  difficulties  wdiich  occasionally 
encompass  its  diagnosis. 

Gentlemen,  I  grieve  to  see  beginners  pressing  round  the  beds,  during  the 
visits  which  immediately  precede  the  lectures  in  the  theatre,  and  absenting 
themselves  from  the  wards  on  the  days  on  which  no  public  lectures  are 
given.  Let  me  tell  you  that  such  a  course  of  proceeding  is  most  unprofit- 
able. F'-oni  the  crowding,  it  is  with  difficulty,  if  at  all,  that  you  have  been 
»»V1  feel  the  patient's  pulse  or  judge  of  the  expression  of  his  countenance ; 
v  au  have  not  ventured  to  fatigue  him  with  an  examination  not  to  be  re- 
peated without  danger ;  whereas,  in  the  services  where  there  are  few  pupils, 
and  even  in  the  clinical  wards  on  the  days  when  there  are  no  lectures,  you 
have  abundant  leisure  to  interrogate  and  examine  the  patients,  to  ask 


46  INTRODUCTION. 

explanations  from  your  teacher  and  fellow-students :  from  examinations 
made  in  this  way,  you  will  carry  away  much  most  useful  information,  and 
it  will  he  exactly  such  information  as  will  enable  you  to  understand  the 
public  discussions  upon  which  the  professors  enter. 

I  know  how  much  room  there  is  for  improvement  in  the  clinical  teaching 
of  the  Faculty  of  Medicine  of  Paris.  I  know  that  young  men  are  not 
sufficiently  exercised  in  the  examination  of  patients  ;  but  whatever  is  waul- 
ing in  the  official  teaching,  you  can  supplement  by  private  instruction. 
Most  of  our  young  hospital  physicians  and  surgeons — the  agreges  of  the 
Faculty — who  have  nearly  all  obtained  hospital  appointments  by  competi- 
tive examination,  are  most  anxious  to  direct  students  in  the  difficult  study 
of  diseases ;  and  I  must  say  that  there  is  not  a  town  in  the  world  where 
this  kind  of  instruction  is  given  with  greater  zeal  and  liberality  than  in 
Paris.  The  immense  hospitals  of  this  capital  are  open  gratuitously  to 
Frenchmen  and  foreigners ;  every  morning  more  than  fifty  services  offer  to 
industrious  young  men  the  most  fertile  and  varied  elements  of  study,  and 
when  students  who  have  taken  advantage  of  their  opportunities  come  to 
attend  the  lectures  of  the  clinical  professors,  they  do  so  with  profit. 

You  must  perceive  that  it  ls  physically  impossible  for  the  clinical  pro- 
fessor to  exercise  his  pupils  in  auscultation  and  percussion,  without  a  knowl- 
edge of  which,  however,  they  must  remain  unaccpuainted  with  a  great  many 
diseases.  It  is  impossible  for  the  clinical  professor,  when  surrounded  by  a 
hundred  and  fifty  or  two  hundred  students,  to  teach  them  by  methodically 
interrogating  the  patient,  by  discussing  diagnosis,  and  pointing  out  treat- 
ment ;  that  can  only  be  done  in  the  private  services,  and  in  the  clinical 
wards  upon  occasions  when  the  professor  is  not  obliged  to  enter  the  theatre 
at  a  stated  hour,  when  he  is  not  surrounded  by  a  crowd  of  pupils  desirous 
to  listen  to  the  master's  authoritative  words,  rather  than  to  the  hesitating 
talk  of  the  timid  scholar  making  his  first  professional  attempts  with  patients. 

I  cannot,  gentlemen,  sufficiently  impress  upon  you  that  anatomy  is  never 
learned  in  a  course  of  lectures;  you  must  have  the  dead  body,  and  it  must, 
moreover,  be  a  dead  body  surrounded  by  two  or  three  students  dissecting 
along  with  you,  and  one  of  whom  is  sufficiently  intelligent  to  direct  your 
proceeding-; ;  the  clinic  stands  in  the  same  category,  and  can  only  be  learned 
in  the  hospital,  with  the  aid  of  an  interne,  or  chef  de  service,  to  teach  you 
the  art  of  putting  questions,  and  of  conducting  methodically  the  examina- 
tion of  a  patient. 

I  do  not  wish  to  speak  to  you  here  about  the  particular  methods  of  in- 
terrogating patients;  the  methods  are  very  useful,  but  tiny  arc  described  in 
all  your  manuals.  When  I  say  that  they  are  very  useful,  I  wish,  at  the 
same  time,  to  warn  you  against  certain  excesses  in  their  employment,  which 
always  wound  me  deeply,  and  which  you  will  never  see  me  commit.  Ybu 
must  remember,  gentlemen,  thai  hospital  patients  are  poor  creatures  forced 
into  our  wards  by  distress  ami  want.  Tins  fact  ought  of  itself  to  be  enough 
to  conciliate  our  esteem  and  inspire  our  respect  for  them.  With  r<  gard  to 
men,  I  admit  that  we  may  act  with  Less  reserve  than  with  women.  Upon 
the  whole,  there  is  no  great  inconvenience,  on  the  score  of  modesty  or  pro- 
priety, in  uncovering  a  man  to  examine  the  Surface  of  his  body:  but  this 
examination  is  not  permissible  if  it  involve  any  risk  to  health;  and  here  I 
musi  remark,  that  young  men,  when  they  strip  patients  for  examination, 
too  often  forget  that  if  the  skin  be  covered  with  perspiration,  il  cannot, 
without  greal  danger,  be  exposed  to  the  contacl  of  cold  air.  It  is  m>i  per- 
missible to  any  one,  not  even  for  the  sake  of  soience,  to  prolong  an  exami- 
nation by  auscultation  and  percussion  to  auch  a  point  as  to  exhaust  the 
strength  of  the  poor  patient,  and  it  is  preferable,  except  in  cases  of  impe- 


WHAT    IS    CLINICAL    MEDICINE?  47 

rious  necessity,  to  leave  an  investigation  incomplete,  or  to  discontinue  it 
till  the  evening  or  next  morning,  than  to  shatter  a  patient  already  pro- 
foundly prostrated. 

What  I  have  just  said  applies  to  both  sexes;  but  when  the  patients  are 
women,  the  physician  ought  to  remember  that  he  has  daughters  and  sisters 
to  deal  with,  and  never  to  allow  his  examination  to  assume  the  appearance 
of  a  culpable  curiosity.  The  fallen  women  who  enter  the  hospitals  (and 
they  are  a  very  numerous  class  of  patients)  respect  us  only  when  we  respect 
them.  They  judge  us  favorably  from  a  reserved  manner,  for  which,  per- 
haps, they  would  elsewhere  banter  us;  and  I  rather  think  that  they  carry 
away  with  them  from  hospital  better  feelings  when  they  have  been  treated 
with  as  much  consideration  as  the  poor  virtuous  girls  who  occupy  the  ad- 
joining beds. 

It  is  quite  possible  to  make,  with  the  most  perfect  chastity,  investigations, 
which  seem  to  be  the  reverse  of  chaste;  and,  provided  they  are  useful,  espe- 
cially when  they  are  so  regarded  by  the  patients,  they  are  acceded  to,  and 
often  even  with  gratitude.  This  is  not  a  question  of  prudery,  but  simply 
one  of  good  breeding.  Bear  in  mind  that  the  physician's  chance  of  success 
in  his  difficult  career  is  all  the  greater,  the  less  he  forgets,  in  his  intercourse 
with  patients,  those  rules  of  propriety  which  constitute  the  appanage  of  a 
good  education. 

When  your  clinical  studies  are  more  advanced,  when  you  can  with  real 
advantage  make  a  digest  of  the  knowledge  you  have  acquired  by  systema- 
tizing your  facts  and  cases,  you  will  estimate  more  correctly  than  you  now 
can,  the  value  of  the  different  nosologies  and  nomenclatures  which  so  un- 
fortunately incumber  our  art.  All  nosologists  have  believed  themselves  to 
be  in  the  right,  all  have  pitied  their  predecessors,  and  all  have  been  thor- 
oughly convinced  that  the  classes,  orders,  genera,  and  species  of  diseases, 
were  never  grouped  upon  principles  more  legitimate  and  natural  than  those 
they  have  adopted.  They  have  all  been  convinced  that  the  new  names 
which  they  have  imposed  on  diseases  form  an  imperishable  nomenclature. 
What  remains  of  nosologies  and  names?  Nothing  which  has  not  been  con- 
secrated by  the  assent  of  all  ages,  nothing  which  has  not  been  adopted  by 
the  generality  of  physicians — nothing  save  the  debris  of  all  nosological 
systems  and  nomenclatures. 

People  give  themselves  a  great  deal  of  trouble  to  torture  the  Gi'eek  lan- 
guage, and  to  heap  up  learned t  solecisms;  they  labor  long  to  collect  the 
most  preposterous  and  fantastic  names ;  but  the  good  sense  of  the  public 
executes  prompt  justice  upon  all  these  absurdities,  and  every  one  remains 
faithful  to  the  old  names,  every  one  is  satisfied  with  them,  and  every  one 
understands  them  infinitely  better  than  the  barbarous  words  which  it  was 
wished  to  substitute  for  them. 

The  manufacturers  of  nomenclature  ought  to  look  well  about  them,  to 
see  what  are  the  terms  which  have  survived,  and  which  will  survive  for 
ages  to  come,  continuing  fresh,  intelligible,  and  triumphant,  in  spite  of  the 
attacks  of  which  they  have  been  the  object.  I  have  no  desire  to  defend 
such  names  as  St.  Vitus's  dance  [clause  de  Saint  Guy],  epilepsy,  hysteria, 
variola,  scarlatina,  hooping-cough  [coquelache],  mumps  [ourles],  cholera, 
dysentery,  and  many  others  of  the  same  sort  which  it  would  be  tedious  to 
enumerate ;  but  tell  me,  gentlemen,  whether  it  be  not  true  that  the  term 
"  dame  de  Saint  Guy,"  although  originally  applied  to  another  nervous  affec- 
tion, has  been  used  by  all  physicians,  without  a  single  exception,  from  the 
time  of  Sydenham  downwards,  to  designate  chorea,  that  fantastic  neurosis 
which  we  so  often  see,  in  infancy  and  adolescence  ?  I  admit  with  you  that 
the  word  "  coqueiuche"  has,  in  a  nosological  sense,  no  meaning;  but  if  it  be 


48  INTRODUCTION. 

a  fact  that,  in  the  middle  ages,  this  name  was  given  to  an  odd  sort  of  epi- 
demic pulmonary  catarrh  which  made  it  obligatory  on  the  sufferers  to  cover 
their  heads  with  a  kind  of  cowl  called  coqueluchon,  it  is  equally  true,  that 
there  is  not  a  medical  practitioner  in  the  world,  nor  even  a  person  com- 
pletely ignorant  of  our  profession,  who  could  make  a  mistake  as  to  the 
meaning  of  the  word  "  coqueluche."  With  you,  I  admit,  that  it  is  singular 
to  have  given  pox  the  name  of  mutual  love,  invented  by  the  shepherd  of 
Fra castor:  but  nevertheless,  we  know  what  is  meant  by  syphilis,  and  no 
name,  were  it  ever  so  Grecian  or  barbarian,  could  be  as  good  as  that  which 
all  have  adopted.  Generally,  people  speak  and  write  with  a  desire  to  be 
understood,  and  words  which  are  applied  with  precision  and  exclusiveness 
to  the  things  which  it  is  wished  to  designate,  are  necessarily  the  best:  and 
they  are  all  the  better  the  less  they  possess  a  nosological  signification.  The 
names  which  I  have  just  cited  are  perfect,  precisely  because  they  imply  no 
adhesion  to  a  medical  doctrine ;  that  is  the  reason  why  they  are  excellent ; 
and  it  is  because  their  adoption  does  not  constitute  an  article  of  pathological 
faith,  that  they  have  been  universally  adopted. 

We  are,  in  the  existing  state  of  matters,  at  liberty  to  place  diseases  where 
we  please  in  our  list ;  but  their  nosological  position  implies  neither  the  ne- 
cessity nor  the  propriety  of  changing  names.  We  ought  to  be  sufficiently 
modest  and  sensible  to  feel  that  we  know  nothing  to  the  foundation,  and 
that  a  synthetic,  purely  conventional  term,  is  better  than  a  descriptive  one, 
which  will  always  have  the  inconvenience  of  being  too  short  to  suffice  for 
the  requirements  of  description. 

When  the  immortal  Jussieu  classified  plants,  he  was  careful  not  to  change 
the  names  of  those  which  had  been  known  for  ages  by  the  same  names  ;  he 
did  not  change  names  given  by  Tournefort  and  Linnseus  ;  he  accepted  those 
bestowed  by  Virgil,  Theophrastus,  and  Dioscorides,  as  well  as  the  popular 
appellations  of  flowers  and  trees.  The  apple  remained  the  apple,  belladonna 
kept  its  elegant  name,  mandragora  retained  the  appellation  which  had 
made  it  so  celebrated  and  formidable;  he  allowed  the  hemlock  of  Socrates 
to  keep  its  ancient  name,  and  was  satisfied  to  classify  vegetables  according 
to  affinities  of  structure  and  organization,  always,  when  it  was  possible, 
respecting  not  only  the  names  but  even  the  epithets  of  Linmeus.  Where 
should  we  have  been  in  the  study  of  botany,  if  Linmeus  had  refused  to 
accept  the  names  of  Tournefort  ?  or  if  Jussieu  had  superseded  those  of  Lin- 
nseus,  and  if  Lamarck  and  Richard  had  conceived  the  idea  of  making  them- 
selves celebrated,  by  substituting  for  the  nomenclature  of  Jussieu  one  more 
to  their  own  liking? 

It  is  evident  that  for  new  diseases  new  names  must  be  found;  bu1  even  in 
such  cases,  it  is  important  to  avoid  nosological  appellations.  I  much  prefer 
the  name  of  Bright's  disease  [md/adir  <!<•  liriglif]  to  that  of  albuminous 
nephritis  {nephrite  album i in -it-v],  not  only  because  it  is  a  homage  to  the 
illustrious  English  practitioner  who  was  the  first  to  give  a  good  description 
of  the  disease,  hut  still  more  because  it  imposes  on  me  no  doctrine  nor  opinion. 

Scarcely  forty  years  have  elapsed  since  the  publication  of  the  beautiful 
researches  of  Bright,  yet  in  thai  time  they  have  been  followed  by  twenty 
theories  in  relation  to  the  disease  in  question.  Let  diabetes  mellitus  [diabMt 
sti<-rr\  retain  the  name  it  has  bo  long  possessed,  and  do  nol  be  in  a  hurry. 

after  reading  the  ingenious  experiments  of  Claude  Bernard,  to  give  B  name 
suggestive  of  irritation  of  the  fourth  ventricle  or  irritation  of  the  liver;  wait, 
and  even  when    voii   are  well    informed  regarding   the   cause  and  nature  of 

diabetes,  abide  by  the  old  name,  which  proclaims  no  foregone  conclusion. 
Vulgar,  universally  received  names  are  a  sort  of  current  coin,  the  denomina- 
tion of  which  one  cannot  alter,  without  introducing  confusion  into  the  com- 


WHAT    IS    CLINICAL    MEDICINE?  49 

merce  of  science.  Resl  assured,  that  systems  of  nomenclature  (of  which 
absurdity  is  the  least  fault-  are  doI  worth  tainting  the  memory  with;  and 
earnest  physicians  ought  to  abstain  from  employing  them,  quite  as  much  from 
respect  to  philology,  as  from  a  true  desire  to  promote  the  progress  of  our  art. 

It  would  no  doubt  be  desirable  that  in  medicine,  nosology,  that  is  to  say 
the  systematic  arrangement  of  diseases,  preceded  clinical  study  and  thera- 
peutics. If  the  system  was  true,  the  results  would  be  necessary,  and  con- 
sequently, easy  ;  but  unfortunately,  many  systems  of  nosology  have  been 
tried,  and  not  one  of  them  has  survived  its  author.  Clinical  studies,  par- 
ticularly therapeutics,  are  every  day  giving  the  lie  most  cruelly  to  the  fun- 
damental propositions  of  these  artificial  sciences,  and  there  is  not  a  physician, 
who,  even  after  a  short  practical  experience,  would  not  execute  summary 
justice  on  all  nosologies  and  nomenclatures. 

I  admit  that  nosologies  are  an  assistance  to  the  student,  at  the  commence- 
ment of  his  medical  studies,  just  as  the  very  false  system  of  Linnaeus  may 
greatly  aid  one  in  his  botanical  novitiate ;  but,  gentlemen,  when  you  know 
enough  to  be  able  to  observe  for  yourselves  [lorsque  vous  connaissez  assez  pour 
pouvoir  reconnoitre],  allow  me  this  sort  of  play  of  words — hasten  to  forget 
nosology,  keep  beside  the  bed  of  sickness,  studying ;  studying  each  patient, 
each  disease  in  each  patient,  proceed  like  the  naturalist  who  studies  the 
plant  in  its  individuality,  in  all  its  elementary  parts,  and  in  all  its  varieties, 
ignoring  classes,  families,  genera,  and  species,  till  his  knowledge  is  sufficient 
to  enable  him  to  systematize,  that  is,  till  he  can  understand  and  discover 
sufficiently  to  establish  analogies. 

I  recognize  the  fact  that  you  bring  into  the  clinical  wards  your  noso- 
logical theories  ;  I  even  grant  that  they  assist  you  at  the  commencement  of 
your  study  of  diseases ;  but  still,  I  say,  that  in  proportion  to  the  extent  to 
which  facts  become  unravelled  before  you,  in  proportion  to  the  degree  in 
which  you  have  examined  them,  and  acquired  an  aptitude  for  comparing 
them,  you  must  hasten  to  get  rid  of  your  scholastic  trammels.  Hasten  to 
shake  off  the  master's  yoke ;  exercise  your  mind  and  judgment,  and  compel 
yourselves  to  systematize  for  yourselves !  By  pursuing  this  course,  you 
will  by  study  either  arrive  at  the  same  results  as  your  predecessors,  or  you 
will  form  opinions  from  a  different  point  of  view  :  in  either  case  your  views 
will  have  become  a  personal  acquisition.  I  do  not  wish  you  to  efface  from 
your  memories  all  that  you  have  heard  in  lectures  nor  to  withhold  belief 
from  everything  which  you  have  not  tested,  but  you  must  gauge  by  your 
own  personal  observation  every  doctrine  which  you  are  taught ;  you  must 
collect  and  classify  facts  from  your  private  practice,  and  afterwards  systema- 
tize them.  Though  the  systems  which  you  thus  construct  will  be  far  from 
embracing  all  the  facts  of  medicine — not  even  all  those  which  you  your- 
selves have  studied — the  work  of  construction  will  teach  you  to  perceive 
immediate  and  remote  relations,  and  will  furnish  you  with  a  sort  of  step- 
ping-stone, by  the  help  of  which  you  will  be  able  to  add  other  facts  in  suc- 
cession. It  is  by  intellectual  gymnastics  such  as  I  have  now  recommended, 
that  you  will  attain  a  power  of  inductive  reasoning  unknown  to  those  who, 
less  through  respect  to  those  who  have  opened  to  them  the  gates  of  science, 
than  through  laziness  or  incapacity,  servilely  remain  in  ruts  hollowed  out 
for  them  by  their  masters. 

I  like  much  to  see  in  youth  an  independent,  somewhat  adventurous 
mind — a  kind  of  mind  which  might  in  later  years  be  a  source  of  danger, 
when  it  was  necessary  to  apply  practically  to  patients  the  opinions  formed 
by  hospital  study. 

The  time  for  subordination  comes  apace ;  the  pupil  is  about  to  become 
the  physician !     It  is  then  that  reading — the  written  experience  of  others — 

VOL.    I. — 4 


50  INTRODUCTION. 

ought  to  come  in  aid  of  personal  observation  ;  it  is  then  that  we  form  judg- 
ments upon  the  rules  laid  down  by  our  predecessors  and  masters ;  it  is  then 
especially  that  we  become  modest,  for  we  then  very  quickly  perceive  that 
all  we  have  seen  and  estimated,  has  been  seen  and  estimated  by  others,  and 
by  others  more  eminent  than  ourselves:  we  perceive  that  their  generaliza- 
tions are  of  a  higher  and  more  prolific  character  than  our  own,  and  their 
systems  better  compacted ;  and  when  questions  of  medical  or  surgical  the- 
rapeutics are  under  discussion,  we  soon  discover  that  the  plans  which  they 
recommend  have  been  ripened  and  regulated  by  experience  deserving  the 
highest  respect. 

But  our  reading  and  the  lessons  of  our  masters  profit  us  in  proportion  as 
we  have  personal  knowledge  and  ideas  of  our  own  at  command.  The  de- 
ductions which  eminent  physicians  have  drawn  from  the  facts  they  have 
observed  appear  quite  natural,  and  we  recognize  in  them  opinions  with 
which  we  ai*e  familiar,  because  they  had  arisen  in  our  own  minds,  and  the 
views  which  are  new  to  us  have  less  of  novelty,  from  the  fact  that  we  are  more 
naturally  led  up  to  them.  A  pupil  feels  pride  in  having  arrived  at  con- 
clusions similar  to  those  previously  adopted  by  masters  of  the  art,  at  having 
devised  a  therapeutic  proceeding,  or  an  operation  already  long  known  in 
practice.  He  then  understands  better  how  worthy  of  respect  are  his  pre- 
decessors who  have  done  so  much  for  the  healing  art,  and  his  confidence  in 
them  increases  in  proportion  to  the  number  of  ideas  which  he  finds  he  has 
in  common  with  them.  The  man  who  has  always  responded  to  the  sugges- 
tion of  another,  and  has  not  acted  from  his  own  promptings,  will  never  be 
so  eminent  a  physician,  nor  so  ardent  an  admirer  of  our  great  predecessors, 
as  he  who  has  been  educated  almost  up  to  their  level,  or  who,  though  still 
young,  has  at  least  like  them,  sought  out  new  paths. 

Between  pupils  and  teacher,  there  ought  to  exist  a  species  of  reciprocity, 
in  which  the  former  receive  the  largest  share  of  benefit,  but  in  which  the 
latter  is  also,  to  a  certain  extent,  a  gainer.  Much  have  I  congratulated 
myself  that  I  had  encouraged  the  young  men  by  whom  I  was  surrounded 
to  think  for  themselves,  to  communicate  their  ideas  to  me,  and  to  converse 
with  me  on  what  they  believed  to  be  their  discoveries.  How  often  have 
these  ardent  spirits  reanimated  my  senescent  mind,  and  shown  me  new 
horizons!'  How  much  have  I  learned  in  the  familiar  chats  which  take 
place  in  the  wards!  I  have  always  felt  pleasure  in  promoting  and  assist- 
ing the  researches  of  my  students  ;  and  while  my  experience  has  not  been 
useless  to  them,  their  enthusiasm  has  stimulated  me,  and  has  prevented  me 
from  rusting  with  that  self-conceit  of  teachers,  who  are  apt  to  fancy  that 
they  have  nothing  more  to  learn  in  the  very  difficult  art  of  medicine. 

The  man  who  is  convinced  that  there  is  something  to  be  gained,  will 
always  gain  something ;  and  in  the  most  beaten  paths  something  new  can 
always  be  found,  provided  it  be  sought  for  with  ardor  and  intelligence. 
Hence  is  it  that  when  a  man, ardent  and  young,  yokes  himself  to  an  idea — 
permit  me  to  use  this  vulgar  expression — lie  makes  discoveries,  arrives  at 
new  views,  and  teaches  his  masters  things  of  which  they  were  either  igno- 
rant, or  which  they  had  only  dimly  seen.  Doubtless,  gentlemen,  the  young 
physician  who  takes  this  adventurous  road,  often  loses  his  way.  and  is 
obliged,  after  long  efforts,  to  retrace  his  steps;  but  rest  assured  he  has 
gained  something  by  the  mental  discipline  undergone,  and  he  will  be  the 

more  apt    to  harn,  the   more   frequently  be  has  exercised   his  mind  and  ap- 
plied his  attention  to  original  researches. 

Let  as  inquire,  then,  whether  the  plans  of  study  have  always  been  bad, 
whether  those  pursued  at  the  present  day  are  the  best,  and  whether  they 
are  adequate  to  establish  medicine  as  a  science. 


WHAT    IS    CLINICAL    MEDICINE?  51 

In  considering  these  questions,  I  shall  at  once  leave  on  one  side  t<he 
preparatory  sciences,  which  bear  the  same  relation  to  the  medical  art  as 
the  laws  of'  light  bear  to  painting,  or  stone-cutting  to  architecture;  I  shall, 
therefore,  say  nothing  here  of  physics,  chemistry,  or  natural  history,  which 
are  unquestionably  useful  in  medicine,  but  no  more  make  the  physician 
than  the  science  of  perspective  makes  the  landscape-painter. 

Medicine  is  the  art  of  curing,  and  it  is  nothing  more  than  that ;  to  cure  is 
its  object,  and  all  our  plans  culminate  in  medico-chirurgical  therapeutics. 
I  willingly  admit  that  some  branches  of  accessory  knowledge  are  good  in 
themselves ;  but  when  the  student  has  acquired  them,  I  ask,  how  is  he  to 
become  a  physician  ?  Several  methods  of  proceeding  present  themselves, 
but,  without  exception  all  of  them,  in  all  periods,  and  in  all  schools,  have 
been  based  on  previous  observation  of  facts.  So  far  as  I  know,  it  has  never 
entered  into  the  mind  of  any  reasonable  man  to  suppose  that  we  can  know 
without  looking,  or  look  without  seeing.  People,  therefore,  have  always 
seen  and  always  looked,  when  they  wished  to  acquire  information  upon  any 
point,  or  desired  to  systematize  their  knowledge. 

Attention  necessarily  implies  comparing;  and  when  comparison  is  not 
explicitly,  it  is  virtually  instituted.  Thus,  every  physician  has  seen,  looked 
at,  and  compared.  It  matters  little  to  say  that  there  is  nothing  to  pre- 
vent him  from  seeing  badly,  from  seeing  with  bad  eyes,  or  with  the  eyes 
of  other  people,  from  looking  at,  and  comparing  things  badly.  What 
I  here  wish  to  establish  is  simply  the  fact  that,  everywhere  and  with 
all  persons,  the  elementary  procedure  is  the  same.  The  subject,  then,  of 
methods  of  observation  resolves  itself  into  a  consideration  of  how  we  ought 
to  observe,  how  we  ought  to  compare  our  observations,  and  how  we  ought 
to  form  our  opinions. 

A  conception  of  the  nature  of  tangible  objects  is  acquired  by  a  simple 
perception  of  all  the  phenomena  by  which  objects  manifest  themselves. 
This  perception  demands  no  intellectual  effort ;  it  requires  attention  and 
memory,  and — as  memory  may  prove  treacherous — registration  of  the 
observed  phenomena. 

When  the  blind  man  of  Geneva  made  his  marvellous  researches  into  the 
habits  of  bees,  he  used  the  eyes  of  the  most  ordinary  peasants,  whose  atten- 
tion he  guided  ;  and  these  most  ordinary  peasants,  the  material  instruments 
of  his  intelligence,  enabled  him  to  ascertain  facts,  and  acquire  general  con- 
ceptions. 

All  of  you,  after  some  months'  experience,  by  adopting  a  formula  of 
examination  for  each  structure,  function  and  organ,  can  fill  up  a  sheet  of 
observations  in  as  complete  a  manner  as  your  masters  can  ;  to  enable  you  to 
do  this,  the  only  requisites  are  patience,  and  the  amount  of  intelligence  re- 
quired for  the  drawing  up  of  an  inventory.  Do  not  at  that  stage  of  your 
progress  be  too  proud  of  your  achievements,  for  you  are  then  no  better  than 
the  peasants  w7ho  saw  for  Hubert  of  Geneva  ;  your  eyes  have  seen,  as  it 
were,  the  industrious  bee  return  charged  with  honey  and  pollen  to  build 
the  hexagonal  cells ;  they  have  seen  a  bee  larger  than  the  rest  surrounded 
by  general  solicitude,  and  followed  by  a  crowd  of  lazy  bees  of  a  different 
shape  and  color,  ultimately  undergo  copulation,  and  observed  that  this  was 
a  signal  for  the  massacre  of  all  the  non-working  bees  in  the  hive  ;  they 
have  seen  the  sides  of  the  respected  bee  swell  out ;  they  have  seen  this  bee 
reposing  in  the  cells  which  the  working  bees  have  constructed  of  different 
sorts  ;  they  have  seen  the  workers  deposit  honey  in  cells  where  something 
like  a  worm  is  moving ;  they  have  seen  certain  larger  cells  receive  a  richer 
tribute,  and  they  have  seen  the  worm  contained  in  the  latter  become  bigger 
than  the  others  ;  they  have  seen  these  worms  all  at  once  assume  new  shapes,. 


52  INTRODUCTION. 

the  larger  becoming  a  cloud  of  bees  of  two  very  different  form?,  live  together 
amicably  till  the  smallest  sized,  which  are  armed,  utterly  exterminated  the 
others  ;  in  a  word,  they  have  seen  what  is  to  be  seen  by  paying  attention. 
But  the  blind  man  understood  what  was  seen  ;  nature  refused  him  instru- 
ments, so  he  made  them  for  himself,  just  as  Galileo  made  a  telescope.  He 
fructified  the  crude,  meaningless  notions  of  those  whom  he  employed,  and 
traced  with  admirable  sagacity  the  curious  habits  of  those  precious  insects 
— habits  of  which  hardly  the  slightest  knowledge  had  been  previously 
attained. 

God  forbid,  gentlemen,  that  I  should  here  depreciate  the  value  of  the 
knowledge  acquired  by  attentive  and  minute  observation  ;  the  value  of  the 
results  of  such  observation  is  immense ;  but  I  wish  to  point  out  that  it  has 
scarcely  any  claim  to  be  considered  an  intellectual  process.  Without  hewers 
of  marble  St.  Peter's  of  Borne  had  never  been  built,  but  it  would  make  me 
indignant  to  see  a  hewer  of  marble  fancying  himself  almost  a  Michael 
Angelo. 

Since  attention  alone  is  necessary  for  the  acquisition  of  facts  in  the  rough, 
as  the  most  commonplace  minds  are  as  well,  or  sometimes  even  better  fitted 
for  this  kind  of  work,  does  it  follow,  gentlemen,  that,  scorning  a  modest  oc- 
cupation, you  should  leave  to  others  the  collection  of  facts,  contenting  your- 
selves with  their  arrangement,  interpretation  and  systematization  ?  Even 
in  a  man  grown  old  in  harness,  that  would  involve  such  an  amount  of  aris- 
tocratic assumption  as  to  be  hardly  credible,  but  which,  to  say  the  least  of 
it,  would  be  quite  unparalleled  in  one  who  was  only  treading  the  first  steps 
of  his  career.  The  sculptor  does  not  take  up  his  chisel  to  produce  a  Laocoon 
till  after  he  has  for  a  long  time  kneaded  the  clay,  dashed  out  elementary 
forms  in  the  rough,  laboriously  modelled  shapes,  and  broken  many  a  grav- 
ing-tool  on  coarse  marble.  Persons  who  have  despised  laborious  beginnings, 
be  they  never  so  gifted  and  intelligent,  are  only  spurious  and  imperfect 
artists.  See,  then,  and  observe  for  yourselves,  for  you  cannot  understand 
and  utilize  knowledge  acquired  by  others,  unless  you  possess  some  which 
is  of  your  own  personal  acquisition. 

To  the  honor  of  all  the  great  men  who  have  rendered  our  art  illustrious, 
it  must  be  stated,  that  they  have  proclaimed  the  observation  of  facts  to  be 
an  absolute  necessity,  and  in  the  present  day  this  necessity  is  more  than 
over  admitted  by  those  who  preside  over  medical  teaching.  But  if  there 
be  unanimity  of  opinion  on  that  point,  there  is  certainly  no  such  concord 
as  to  the  manner  in  which  we  ought  to  proceed  to  the  interpretation  of  the 
facts  observed. 

At  present,  there  are  two  principal  methods  employed  for  the  interpre- 
tation of  medical  facts,  viz.,  the  numerical,  called  the  new  method,  and  the 
inductive,  called  the  old  method. 

The  former — the  numerical  method — has  taken  for  its  motto  the  celebra- 
ted sentence  of  J.  J.  Rousseau  :  "I  know  that  the  truth  is  in  the  facts,  and 
not  in  my  mind,  which  interprets  them;  and  that  the  less  1  introduce  my 
own  views  into  my  interpretations  the  more  8Ure  shall  1  be  of  approaching 
the  truth."1  The  second — the  inductive  method — is  that  which  lias  till 
now  been  followed  byall  greal  practitioners,  whatever  may  have  been  their 
other  doctrines;  and  it  is  adhered  to  by  the  majority  of  the  professors  of 
our  faculty. 

The  numerical  method,  which  took  statistics  for  its  basis,  and  which  bad 


*  "  Je  Bats  que  la  vcrit6  ol  <l:ui>  Ii>-  dieses  ct  non  dims  num  esprit  <|iii  les  juj 
que,  moina  je  meta  du  mien  duns  lea  jugementa  que  j'en  porta,  plus  je  bum  Bur 
a'approcher  de  la  v.'riuS." 


WHAT    IS    CLINICAL    MEDICINE?  53 

already  been  introduced  into  hygienics  by  Parent-Duchatelet,  was  applied 
to  the  study  of  pathology  and  therapeutics  by  a  man  of  undoubted  scien- 
tific honesty,  one  endowed  with  an  invincible  patience,  an  ardent  lover  of 
truth — truth  which  he  expected  to  attain  with  certainty.  This  method 
recognized  the  sovereign  power  of  figures.  Its  advocates  said  "The  phy- 
sician ought  to  restrain  the  flights  of  his  imagination  :  it  is  his  province 
severely  to  analyze,  reckon  up,  and  register  results  :  this,  and  neither  less 
nor  more  than  this,  is  his  duty.  He  must  be  actuated  by  the  inflexibility 
of  t1  e  just  judge,  who  applies  the  law  uninfluenced  by  passion  or  private 
feel'  ags  ;  by  the  rigor  of  the  statist,  who,  in  drawing  up  a  table  of  mortality, 
pays  no  attentiou  to  causes  of  death,  and  confines  himself  to  the  computa- 
tion of  the  chances  of  life  in  an  entire  population."  Finally,  the  numeri- 
cal method  applies,  in  all  its  rigor,  the  calculation  of  probabilities  to  medi- 
cine. 

The  inductive  method  is  a  totally  different  procedure :  it  collects  and 
analyzes  facts ;  but  it  likewise  compares  them,  and  does  not  always  sum  up 
their  number.  In  place  of  the  necessary  result  obtained  from  statistics,  it 
seeks  for  something  else,  viz.,  the  systematic  relation  and  connection  of 
facts  :  it  interrogates  facts,  comments  upon  them,  sevmrates  them,  groups 
them,  examines  them  in  every  aspect,  with  a  view  to  eliminate  from  them 
something  new  and  aiyplicable.  In  a  word,  in  opposition  to  the  numerical 
method,  it  puts  as  much  of  its  own  as  it  possibly  can  into  its  interpretation 
of  facts,  well  assured  that  by  so  doing  it  will  approach  more  nearly  to  the 
truth. 

The  first  part  of  the  sentence  of  J.  J.  Rousseau,  which  I  have  just  quoted, 
is  nonsense.  It  is  evident  that  facts,  just  because  they  are  facts,  are,  of 
necessity,  true :  in  this  sense,  to  affirm  their  existence,  points  out  what  they 
are ;  and  it  is  neither  correct  to  say  that  facts  are  true  nor  that  they  are 
false,  but  simply  that  they  are.  The  estimate  of  facts  may  be  either  true  or 
false,  but  the  estimate  belongs  to  the  mind  of  him  who  forms  it,  and  in  no 
degree  whatever  to  the  facts  themselves  :  it  is  absurd,  therefore,  to  say  that 
"  the  truth  is  in  the  facts,  and  not  in  the  mind  which  interprets  them." 
The  second  part  of  the  sentence  has  only  a  false  appearance  of  truth  :  it  is 
clear  that  if,  in  respect  of  two  given  facts,  we  confine  our  judgment  to 
pointing  out  the  immediate  link  by  which  they  are  united,  we  put  into 
that  judgment  the  least  possible  amount  of  our  own,  and  that,  if  we  have 
not  given  much  of  a  judgment,  we  have  at  least  given  one  which  is  suffi- 
ciently sound.  Nevertheless,  even  in  forming  judgments  upon  the  most 
general  relationships  of  facts,  it  becomes  necessary  to  put  in  somethiug  of 
our  own,  because  judgments  are  mental  acts,  and  are  essentially  outside  the 
facts.  The  question,  therefore,  to  be  determined  is,  whether  we  ought  to 
put  into  our  judgments  as  much  of  our  own  as  we  can,  or  whether,  as  seems 
to  be  the  wish  of  J.  J.  Rousseau,  as  little  as  possible  of  our  own.  For 
myself,  I  can  give  an  unhesitating  answer  to  this  inquiry.  The  more  we  lay 
hold  of  and  point  out  numerous  ways  in  which  facts  are  related  to  each 
other,  the  nearer  do  we  get  to  the  complete  truth,  and  the  less  complete  the 
truth  is,  the  less  truth  does  it  contain. 

I  do  not  reproach  the  numerical  method  because  it  numerates,  but  I 
reproach  it  because  it  only  numerates :  in  a  word,  because  it  depends,  like 
the  mathematician,  upon  an  absolutely  exact  result.  I  reproach  it  for 
counting  too  much,  for  counting  too  long,  for  counting  always,  and  for 
declining  to  put  any  mind  into  the  facts.  This  method  is  the  scourge  of  in- 
tellect :  it  transforms  the  physician  into  a  calculating  machine,  making  him 
the  passive  slave  of  the  figures  which  he  has  massed  up :  the  greatest 
reproach  which  I  cast  upon  it  is  that  it  stifles  medical  intellect.     Those  who 


54  INTRODUCTION. 

admire  the  numerical  method,  applaud  consequences  which  I  deplore ; 
they  do  not  wish  for  the  intervention  of  intellect;  I  do — I  wish  to  see  intel- 
lect exercising  itself  in  all  its  power. 

I  am  anxious  to  make  myself  clearly  understood ;  I  employ  statistics,  I 
even  employ,  if  you  like,  the  numerical  method,  provided  it  be  only 
regarded  as  a  means  sometimes  preparatory,  and  most  frequently  comple- 
mentary ;  but  I  spurn  it  with  all  my  energy  when  it  pretends  to  be  a 
method'  complete  in  itself,  and  capable  of  conducting  us,  as  a  matter  of 
necessity,  to  the  truth. 

The  numerical  method  leads  to  results  which  are,  and  can  be,  nothing 
more  than  crude  facts  and  elementary  ideas.  These  facts  and  ideas  are 
fond  for  the  intellect  which  elaborates  them.  This  method,  moreover,  pre- 
sents but  a  very  slight  fundamental  difference  from  that  which  has  hitherto 
been  universally  employed.  A  practitioner  of  the  past,  who  was  studying 
measles,  perceived,  I  presume,  a  primary  fever,  a  rash,  desquamation,  and 
complications,  of  which  he  took  account — he  registered  his  observations, 
and  then  he  noted  which  facts  were  general  and  common,  and  which  were 
accidental  and  special.  Practitioners,  then,  of  past  ages  acted  in  no  differ- 
ent way  from  that  I  have  now  described,  and  so  likewise  proceeded  in  our 
own  time,  before  the  numerical  method  was  invented,  Corvisart,  Bayle, 
Laennec,  Rostan,  Lallemand,  Andral,  Bouillaud,  Calmeil,  and  many 
others.  "When  they  had  examined  in  the  closet  the  observations  collected 
at  the  beds  of  their  patients,  they  noted  results,  and  then  drew  conclusions. 
What  more  does  the  numerical  method  do  ?  It  calculates  rigorously.  In 
place  of  saying  "one  hundred"  patients,  it  says  "ninety-nine,"  or  "one 
hundred  and  four"  patients ;  in  place  of  saying  (as  Bretonneau  first  said) 
"  in  putrid  fever,  intestinal  perforations  occur  in  the  ulcerated  Peyerian 
and  Brunnerian  glands,  and  are  seen  rather  frequently,"  it  says  "  intestinal 
perforations  are  observed  so  many  times  in  a  hundred  cases  ;"  in  place  of 
saying  "  softening  generally  accompanies  cerebral  hemorrhage,"  it  says,  for 
instance,  "softening  accompanies  cerebral  hemorrhage  sixteen  time.-  in 
twenty."  The  common  method  said,  and  still  says,  lobular  pneumonia  is 
a  very  frequent  complication  of  measles,  while  the  numerical  method  will 
tell  you  the  relative  proportion  of  cases  which  are,  and  which  are  not. 
complicated  in  that  manner.  It  is,  then,  you  see,  a  method  of  proceeding 
which  has  the  appearance  of  being  more  exact ;  but,  in  reality,  it  does  not 
differ  from  the  other  method. 

If  you  observe  with  attention,  you  will  arrive  at  the  same  principal  con- 
clusions by  the  inductive  as  by  the  numerical  method.  When  I  set  myself 
to  study  hooping-cough,  I  quickly  perceive  that  the  fits  of  spasmodic  cough 
almost  alwavs  cease,  or  at  least  become  much  less  frequent,  when  the  patient 
has,  than  when  he  has  not,  had  an  accession  of  fever.  I  pointed  out  this 
observed  fact  in  my  clinical  lectures  before  I  employed  arithmetic — by  and 
by  I  made  use  of  statistics,  and  then,  in  place  of  saying  almost  always,  I  said 
so  many  times  in  so  many  cases  observed,  which  is  just  another  way  of  saying 
almost  always. 

Do  not  imagine,  gentlemen,  that  there  is  any  reality  in  this  mathematical 
exactitude;  it  La  only  a  relative  precision,  for  it  changes  under  the  observa- 
tion of  the  same  man,  according  to  tin-  year,  the  season,  and  the  reigning 
medical  constitution.  Thus,  it  happens,  that  the  same  fact  which  was  ob- 
served lasl  vear  once  in  live  limes,  occur.-  this  year  only  once  in  ten  times, 
and  next  year,  perhaps,  it  will  only  happen  once  in  twenty  time-:  BO  that 
TOUT  law,  your  true  truth  \r/rilr  vraie)  neither  is,  nor  can  he.  absolute.      1 1 

the  pathologist  endeavors  to  formulate  the  facts  which  twenty  partisans  of 
the  Dumerical  method  have  given,  each  as  the  utmosl  expression  of  exact- 


WHAT    IS    CLINICAL    MEDICINE?  55 

iiess,  he  is  obliged  cither  to  strike  an  average  which  will  not  he  a  true  aver- 
age to-morrow,  or  to  return  to  those  odious  and  detestable  formulae  which 
it  is  desired  to  banish  from  medical  phraseology — sometimes,  often,  most  fre- 
quently, generally. 

Of  what  use  is  this  semblance  of  precision?  When  one  of  our  colleagues 
showed  the  medical  world  the  coincidence  which  exists  between  diseases  of 
the  heart  and  acute  articular  rheumatism,  was  that  beautiful  discovery  re- 
ceived the  less  favorably  because  the  discoverer  said  "very  often"  in  place 
of  " forty-four  times  in  the  hundred?"  Was  the  influence  of  sulphate  of 
quinine  on  miasmatic  hypertrophy  of  the  spleen  less  surely  established  when 
Bailly  said  "  almost  always"  than  if  he  had  said"  ninety  times  in  a  Jiundred?" 

But  it  will  be  alleged  that  the  numerical  method  allows  us  to  verify  the 
assertions  of  a  physician.  Do  you  think,  gentlemen,  that  if  one  wished  to 
make  m  false  statement,  it  would  be  less  easy  to  do  so  by  the  use  of  exact 
figures  than  by  the  employment  of  the  "sometimes"  and  "almost"  phrase- 
ology? Do  you  think  that  the  impudent,  lying  physician,  if  such  there  be, 
could  not  concoct  a  numerical  result  as  easily  as  a  general  assertion?  The 
one  method  would  only  give  him  the  trouble  of  lying  sooner  than  the  other; 
it  will  oblige  him  to  begin  by  fabricating  historical  details  so  that  he  may 
announce  an  exact  result :  while  in  the  other  case  he  will,  with  less  labor 
and  hypocrisy,  lie  only  in  the  false  conclusion  which  he  puts  forth. 

Thus  it  is  that,  although  I  concede  to  the  numerical  method,  as  now 
practiced,  a  very  minute  degree  of  importance  as  a  means  of  study,  I  recom- 
mend its  employment,  because  it  accustoms  the  student  of  medicine  to  pay 
attention,  and  enables  him  to  appreciate  better  certain  details  which,  though 
they  do  not  escape  a  trained  and  intelligent  observer,  might  remain  unper- 
ceived  by  one  less  familiar  with  the  sick. 

The  physician  who  popularized  the  numerical  method  at  the  same  time 
introduced  statistical  analysis  into  the  study  of  pathology,  and  the  minute 
dissection  of  the  facts  observed  sometimes  led  him  to  new  information,  not 
the  less  worthy  of  being  known  and  recorded  that  it  was  of  a  collateral 
character.  Rigorous  analysis,  then,  is  not  useless,  and  although  it  presents 
the  very  grave  inconvenience  of  crumbling  facts  (d'emietter  lesfaits),  to  use 
the  happy  expression  of  M.  Bretonneau,  in  such  a  way  as  to  disfigure  them 
completely,  it  nevertheless  makes  us  acquainted  with  some  subordinate 
truths  which  will,  sooner  or  later,  acquire  a  certain  scientific  value. 

If  the  application  of  statistics  to  medicine  was  not  rated  too  high,  if  it 
were  not  considered  as  the  very  keystone  of  the  arch  of  all  science,  and  if 
it  were  -simply  regarded  as  a  method  of  proceeding  a  little  less  imperfect 
than  the  majority  of  those  hitherto  adopted,  I  should  only  praise  it  and 
recommend  it  to  you,  because  I  really  believe  it  to  be  useful ;  but  there  is 
so  much  noise  made  about  such  poor  results,  that  I  cannot  conscientiously 
assist  in  deceiving  young  men  by  countenancing  a  charlatanic  parade  of 
exactitude  and  truth. 

The  statist  desires  too  many  facts ;  he  is  well  aware  that  statistics  are 
valuable  only  through  multitude  of  facts,  and  he  seeks  everywhere  for  the 
means  of  increasing  their  number.  There  is  nothing  of  this  kind  in  the 
inductive  method,  of  which  I  am  now  going  to  speak  to  you. 

Bacon's  "forest  of  facts,"  taken  literally,  has  no  great  value,  and  as  the 
expression  is  understood  nowadays,  it  has  no  value  at  all.  Undoubtedly 
two  facts  justify  a  conclusion  better  than  one  fact,  one  hundred  facts  better 
than  two  facts,  and  a  hundred  facts  better  than  a  thousand ;  that  is  to  say, 
one  isolated  fact  does  not  convey  its  lesson.  People  say  to  you,  Bring  to- 
gether facts;  do  your  best  to  collect  cases  in  as  complete  a  form  as  possible; 
collect  them  passively,  without  exercising  your  intellect  upon  them ;  so  far 


56  INTRODUCTION. 

from  permitting  thought,  till  you  receive  fresh  orders,  repress  every  mental 
impulse  ;  be  the  accountant  who  marshals  figures,  and  thinks  nothing  about 
results  till  he  has  added  up  all  the  columns.    I  also  tell  you  to  gather  facts, 
and  to  do  your  best  to  collect  cases  in  the  completest  form  possible  ;  but  from 
the  moment  that  you  have  got  one  fact,  apply  to  it  all  the  intelligence  i 
which  you  possess,  seek  its  salient  features,  look  at  the  points  which  are 
clear,  allow  yourselves  to  indulge  in  hypotheses,  and,  if  necessary,  go  i 
ahead ;  scrutinize  every  word  in  the  phrase,  strive  to  understand  the  un-  f 
known  tongue,  try  to  stammer  it  out,  and  do  not  delay  speaking  it  till  the 
hundred  thousand  words  of  the  dictionary  are  graven  on  your  memory. 
On  the  morrow,  a  new  fact  will  be  added  to  the  first;  this  will  suggest  new 
points  of  comparison,  all  the  more  obvious  to  you,  the  better  you  have  ) 
studied  and  understood  the  original  fact.     Then  you  will  proceed  to  the 
verification  of  your  hypotheses,  bringing  together  some  things  and«eparat- 
ing  others — for  when  two  notions  confront  each  other  within  one  intelli- 
gent head,  the  mind  must  find  out  what  they  have  in  common,  and  what 
they  possess  foreign  to  each  other. 

Proceeding  thus,  you  will  soon  be  in  possession  of  the  Baconian  "  forest 
of  facts."  In  the  course  of  your  progress,  a  thousand  ideas  will  germinate 
in  your  heads,  a  thousand  hypotheses,  a  thousand  systems,  will  be  con- 
structed and  destroyed.  You  will  no  longer  be  the  slaves  of  facts ;  you 
will  hold  them  enchained,  ready,  summoned  to  respond  to  your  interroga- 
tions ;  they  will  not  thrust  an  idea  upon  you,  but  you  will  call  upon  them 
to  verify  your  ideas ;  as  the  submissive  slaves  of  intellect,  they  will  have  to 
obey  you,  but  they  will  require  you  to  have  an  understanding  with  them, 
and  this  is  the  point  at  which  the  numerical  method  and  statistics  inter- 
vene. 

It  is  better,  said  Gaubius,  to  stand  still,  than  to  walk  on  in  darkness — 
"melius  est  sistere  gradum,  quam progredi per  tenebras."  But  in  what  man- 
ner has  the  human  mind  progressed  from  the  beginning  of  time  ?  I  ask 
you,  if  it  has  not  always  proceeded  to  verify  an  hypothesis  after  the  fashion 
of  the  daring  navigator  who,  with  prow  to  the  west,  trusts  to  unknown  seas 
his  genius,  his  glory,  and  the  lives  of  himself  and  his  adventurous  com- 
rades? What  ideas  germinated  in  the  head  of  Galileo  before  he  discovered 
the  movement  of  the  pendulum  !  and  do  you  believe  that  he  required  to 
see  a  thousand  candelabra  oscillating  under  the  dome  of  Pisa  to  enable 
him  to  create  that  splendid  hypothesis  which  soon  became  part  of  the  domain 
of  science?  Toricelli  formed  an  hypothesis;  he  put  mercury  and  water  into 
tubes,  and  thus  he  discovered  a  law!  Lavoisier  weighed  the  peroxide  of 
mercury,  and  thus  was  modern  chemistry  discovered!  In  one  fact,  the 
whole  science  was  revealed  to  him.  How  many  millions  had  seen  the  steam 
raise  the  lid  of  a  tea-kettle.  Watt  saw  it  once.  The  fact  was  fecundated, 
ami  the  man  of  genius  who  invented  the  .-team-engine  at  once  made  himself 
and  his  country  illustrious. 

The  propositioD  of  Gaubius,  adopted  by  one  of  the  most  eminent  practi- 
tioners of  our  day,  is  true,  provided  its  application  !><■  restricted  to  the  in- 
credible vagaries  of  minds  unguided  by  a  single  fact,  h  is  obvious  that 
if  v,e  proceed  without  either  premises  or  induction  to  create  a  system  which, 
sooner  or  later,  we  .-hall  he  asked  to  submit  to  the  test  of  experiment,  we 
do  what  is  useless  and  absurd;  hut  the  proposition  of  Gaubius  ceases  to  he 
true,  and  it  especially  ceases  to  he  scientific,  if  we  possess  any  facts,  how- 
ever few  in  Dumber  they  may  he,  and  however  insufficient  as  materials  for 
Bystematization,  to  guide  our  firsl  steps  amid  the  darkness.  These  facts 
bear  a  certain  analogy  to  tin-  thread  of  Theseus  and  the  blind  man's  staff; 

and  though,  a  — undly,  it'  we  have  no  other  aid,  we  arc    walking  in  darkn.  -- 


WHAT    IS    CLINICAL    MEDICINE?  57 

and  running  towards  the  unknown,  we  are,  nevertheless,  not  without  a  guide  ; 
»:*nd  even  if  we  find  the  road  shut  up,  we  shall  have  well  merited  the  grati- 
tude of  our  successors  for  showing  them  that  the  way  was  not  open,  ami  so 
.-paring  them  laborious  research  in  a  wrong  direction.  But  the  oftener  we 
accomplish  something  better  than  this,  we  put  up  signposts  in  unknown  defiles. 
s-  I  maintain,  then,  that  it  is  better  to  ivalk  in  darkness  than  to  stand  still,  if 
t  iv  darkness  you  mean  primary  facts  and  mental  processes  which  precede 
secondary  facts.  Why  should  God  have  given  us  minds  unceasingly  yearn- 
ing towards  progress  and  always  devouring  the  future  ?  Why  has  he  given 
us  intellects  ever  active,  eager  to  compare,  to  form  conclusions,  to  abstract, 
and  to  systematize,  were  it  not  that  the  intellectual  faculties  might  be  con- 
stantly at  work  with  the  primitive  materials  called  facts  ?  And  are  not 
the  products  of  this  mental  work,  ideas,  inductions,  hypotheses,  and  systems, 
to  be  tested  by  the  numerical  method  and  statistics  ? 

I  hear  you  ask  me,  Why  begin  with  induction  and  systematization,  if  you 
have  ultimately  to  come  to  a  matter  of  accountancy  with  facts  and  of  facts  ? 
ilt  is  very  easy  for  you  to  say  to  me,  Shut  the  eyes  of  your  understanding; 
here  is  an  object  which  presents  itself  with  color,  form,  weight,  and  density; 
state  its  modalities,  but  I  prohibit  you  from  forming  a  concrete.  Is  it  possi- 
ble for  me  to  refuse  an  attribute  to  the  subject,  to  disjoin  violently  what  my 
mind  has  strongly  united  and  combined  ?  Can  I  see,  hear,  and  feel,  with- 
out judging — judge  without  forming  conclusions — form  conclusions  without 
systematizing  ?  What  is  it  you  wish  ?  Shall  I  make  a  repertorium  of 
ideas?  Shall  I  bridle  my  understanding,  and  wait  for  the  signal  to  start 
on  my  intellectual  race?  You  say,  "  Off!"  But,  I  ask,  how  am  I  to  equip 
myself  for  the  course  ?  Do  you  suppose  that  the  rust  of  inactivity  can  be 
rubbed  off  at  your  word  of  command  ?  You  wish  the  pupil  to  see  only 
crude  facts,  and  to  stifle  his  intellect :  and  when,  by  means  of  this  dismal 
labor,  his  mind  has  been  to  some  extent  mutilated,  you  will  ask  him  to 
show  mental  vigor,  and  will  dare  to  hope  for  his  manifesting  prolific  thought. 

We  must  allow  the  luxuriant  intellect  of  youth  to  grow  up  in  freedom. 
We  must  take  care  not  to  stop  the  flow  of  that  generous  sap  which  seeks 
to  spread  forth  only  in  blossom  and  branches ;  so  long  as  the  vital  juice 
is  drawn  from  a  soil  fertile  in  clinical  observation  you  need  not  fear  that 
the  growth  will  stretch  too  far.  The  members  of  the  Faculty  whose  duty 
it  is  to  guide  pupils  in  their  practical  studies  will  moderate  their  impetuous 
ardor.  They  also  have  some  accounts  to  settle  with  hypotheses ;  but  they 
have  attained  an  age  which  has  whitened  their  hair  and  ripened  their  expe- 
rience, and,  having  become  accomplished  practitioners,  they  place  at  your 
service,  for  your  instruction,  their  disappointments,  their  knowledge,  and 
as  much  of  that  which  constitutes  individuality  in  their  art  as  it  is  possible 
to  transmit. 

What  I  have  said  regarding  philosophical  methods  is  only  applicable  to 
the  science,  and  in  no  degree  to  the  art  of  medicine.  In  point  of  fact, 
methods  belong  to  the  sciences;  in  the  arts  they  neither  have,  nor  ought  to 
have,  any  existence.     Method  and  art  reciprocally  exclude  each  other. 

Every  science  touches  art  at  some  points — every  art  has  its  scientific  side ; 
the  wTorst  man  of  science  is  he  who  is  never  an  artist,  and  the  worst  artist 
is  he  wrho  is  never  a  man  of  science.  In  early  times,  medicine  was  an  art, 
which  took  its  place  at  the  side  of  poetry  and  painting;  to-day,  they  try 
to  make  a  science  of  it,  placing  it  beside  mathematics,  astronomy,  and 
physics. 

In  my  opinion,  a  science  deals  with  concrete  elements  or  calculable  ab- 
stracts ;  it  implies  the  possibility  of  formulae,  and  excludes  individuality : 
an  art  creates  manifestations  without  having  calculated  their  connection 


58  INTRODUCTION. 

with  causes,  thus  implying  the  impossibility  of  formula?  and  proclaiming 
the  idea  of  individuality. 

A  Newton  would  be  the  most  stupid  of  mathematicians  if  he  only  occv,  l- 
pied  himself  with  the  calculus;  a  painter  is  a  painter,  and  nothing  mon'e 
than  a  painter.  Scientific  results  are,  we  may  say,  stereotyped  ;  results  an  iJ 
not  scientific  unless  they  are  identical — that  is  the  criterion.  Artistic  re  • 
suits  are  essentially  various  and  variable,  and  the  more  individuality  then 
is  in  the  artist  the  more  is  he  an  artist.  In  the  sciences  there  are  no  schools 
in  the  arts  there  are  as  many  schools  as  there  are  great  masters. 

In  accordance  with  the  definition  which  I  have  given  of  science,  provide  < 
the  inferences  which  I  have  drawn  from  that  definition  be  correct,  I  shal  1 
be  allowed  to  regard  medicine  as  an  art ;  and  those,  even,  avIio  mos  p 
ardently  desire  to  see  it  raised  to  the  rank  of  a  science  will  doubtless  admi 
with  me  that,  up  to  the  present  time,  it  is  very  little  deserving  of  the  hono 
which  they  wish  to  confer  on  it.  It  would,  no  doubt,  be  very  desirable  t 
see  all  physicians,  in  a  given  malady,  calculating  the  causes,  the  issue,  and 
the  treatment,  with  mathematical  precision  ;  it  would  be  beautiful  to  see 
all  persons  intrusted  with  the  sanitary  regulations  of  communities  making 
up  annually  an  exact  balance-sheet  of  their  practice,  and  proudly  submit- 
ting their  inflexible  results  to  the  inflexible  examination  of  a  court  oft 
medical  accountants.  Unfortunately,  such  a  consummation  can  never  be  ; 
we  shall  always  be  called  upon  to  lament  the  deplorable  uncertainty  of 
medicine,  precisely  for  this  reason,  that  if  science  necessarily  has  princi- 
ples, art  (which  even  ignores  itself,  which  often  goes  forward  to  its  object 
through  darkness)  can  at  best  only  have  processes  very  difficult  of  trans- 
mission. In  medicine,  do  not  confound  art  and  science.  All  cannot  be- 
come artists ;  but  persons  of  the  most  ordinary  intelligence  can  make  ac- 
quisitions in  science;  it  does  not,  however,  gentlemen,  follow  that  science 
is  useless,  or,  in  the  present  day,  an  unnecessary  part  of  the  education  of 
the  greatest  men  of  art. 

"We  are,  therefore,  entitled  to  exact  from  you  evidence  of  the  possession 
of  scientific  knowledge,  because  it  is  something  which  can  be  acquired,  and 
which  by  industry  is  acquired  by  all,  in  greater  or  less  proportion  ;  but  we 
will  never  exact  more  than  scientific  knowledge,  for  the  rest  is  a  natural 
gift.  Take  care  not  to  fancy  that  you  are  physicians  as  soon  as  you  have 
mastered  scientific  facts  ;  they  only  afford  to  your  understandings  an  oppor- 
tunity of  bringing  forth  fruit,  and  of  elevating  you  to  the  high  position  of 
a  man  of  art. 

I  still  recollect  the  concluding  years  of  my  medical  studentship.  Like 
many  others,  I  went  to  a  celebrated  amphitheatre  to  study  operative  medi- 
cine; like  many  others,  I  was  led  away  by  the  exactitude  of  the  methods 
which  directed  the  knife  and  the  Lithotome  in  so  invariable  a  manner;  like 
many  others,  1  made  a  hobby  of  the  most  laborious  surgical  operations; 
and  when  we  were  drawn  by  curiosity  and  the  desire  for  instruction  to  the 
Hotel  Dieu  or  the  Charite"  hospitals,  where  ihe  masters  of  the  surgical  arl 
were  about  to  put  in  practice1  the  precepts  which  we  knew  so  well,  we  often, 
with  sly  satisfaction,  detected  thai  the  knife  was  going  astray  between  the 

rough    surfaces  of  a  refractory  articulation,  or  was  not  held   at  a   siitlieienl 

angle  to  avoid  a  vessel  with  certainty  ;  and  then  we  were  not  far  from  think- 
ing that  our  right  places  wore  not  on  the  benches  among  the  -indents. 
What    did    it  matter,  though  the   operator  was  the    best   surgeon  who    over 

amputated  at  the  shoulder-joint _  ,,,-  whether  operative  medicine  waa  an 
iiccupation  more  difficult  than  that  of  the  carver!     Assuredly,  if  wee. old 

collect    and   reanimate  the  a>hes  of  Ambrose  I'are,  if  we  could  here   evoke 


WHAT    IS    CLINICAL    MEDICINE?  59 

the  most  illustrious  surgeon  of  modern  times,  J.  L.  Petit,  I  much  fear  that 
these  two  great  men  would  be  found  less  brilliant  operators  than  many 
young  students  proud  of  possessing  so  easy  a  talent ! 

<  rentlemen,  most  of  you  know  more  chemistry  than  Paracelsus,  many  of 
you  more  than  Scheele  and  Priestley,  some  of  you  even  more  than  our  La- 
voisier. You  know  chemistry,  but  still  you  are  not  chemists;  and  among 
those  who  now  hear  ire,  do  you  believe  that  there  are  many  whom  posterity 
will  deem  worthy  of  "oeing  placed  beside  the  men  whose  glorious  names  I 
have  just  mentioned?  Thus  it  is,  gentlemen,  that  there  is  a  great  difference 
between  the  man  of  science  who  reaps,  and  the  man  of  art  who  produces. 
Do  not,  therefore,  fancy  yourselves  physicians  because  you  have  acquired 
the  habit  of  applying  to  the  diagnosis  of  diseases  the  ingenious  proceedings 
by  which  science  has  become  enriched  since  the  beginning  of  this  century. 
The  admirable  diagnostic  methods — auscultation  and  percussion — given  by 
Laenuec  to  the  public  for  the  general  good,  and  of  which  no  one  is  allowed 
to  be  ignorant,  are  in  our  hands  what  the  telescope  and  the  magnifying- 
glass  are  in  the  hands  of  the  astronomer  and  the  naturalist — instruments 
intermediary  between  external  objects  and  the  mind ;  but  a  magnifying- 
glass  will  no  more  make  a  Tournefort  or  a  Galileo,  than  a  stethoscope  will 
make  a  Sydenham  or  a  Torti. 

And  moreover,  gentlemen,  it  is  undeniable  that  the  increased  means  of 
investigation  possessed  in  the  present  day,  by  multiplying  elementary  facts, 
or  at  all  events  by  rendering  them  more  exact,  does  not  fit  the  mind  for 
producing  more  prolific,  more  practical,  or  more  reliable  manifestations  of 
art.  How,  then,  does  it  happen  that  the  mind  becomes  indolent  in  propor- 
tion to  the  increase  of  scientific  notions,  satisfied  to  receive  and  profit  by, 
but  caring  little  to  elaborate  or  originate  them  ?  Scientific  processes  assist 
art  less  than  is  supposed.  Chemistry  teaches  you  how  to  form  colors  ;  it 
has  told  you  wherefore,  and  when,  they  do  not  blend ;  it  has  taught  you  to 
fix  them  upon  a  canvas  less  liable  to  change  and  better  prepared.  An 
illustrious  man  of  science  has  given  you  a  knowledge  of  the  modifications 
which  shades  of  color  produce  upon  each  other ;  in  a  word,  he  has  made  a 
science  of  the  harmony  of  colors.  And  yet,  the  blood  still  circulates  under 
the  palette  of  Rubens,  textile  fabrics  still  shine  resplendent  upon  the  can- 
vas of  Van  Dyck,  and  the  Madonnas  of  Raphael  retain  all  the  divinity 
and  sweetness  of  their  beauty.  Why,  then,  with  so  many  ways  of  study, 
with  so  much  valuable  scientific  knowledge  at  command,  have  our  painters 
remained  so  far  behind  the  less  scientific  masters  who  constitute  the  glory 
of  the  art  ?  Why,  then,  do  not  we,  so  rich  in  preparatory  knowledge,  so 
rich  in  means  of  diagnosis,  produce  such  men  as  Baillie,  Sydenham,  Torti, 
and  Stoll  ?  '  It  certainly  is  not  because  nature  has  been  more  chary  of  her 
gifts  to  us ;  each  century  brings  forth  the  same  class  of  minds,  and  ages 
the  most  abjectly  barbaric  have  probably  given  birth  to  men  of  as  vigorous 
intellects  as  those  which  produced  Pericles,  Augustus,  Leo  X,  and  Louis 
XIV.  How  often  in  our  intercourse  with  the  young  men  who  crowd  our 
benches  do  we  meet  with  intellects  of  the  highest  class,  who  only  require  a 
fitting  opportunity  and  a  favorable  direction  to  produce  fruit !  But  some 
of  you  who  have  shown  exceptionally  great  talents,  when  you  have  acquired, 
by  long  study,  perhaps,  but  without  difficulty,  a  knowledge  of  the  prepara- 
tory sciences  (to  which  unfortunately  so  large  a  place  is  accorded  in  the 
medical  curriculum),  when  in  a  few  months  you  have  equalled,  or,  it  may 
be,  surpassed  your  masters  in  the  easy  art  of  applying  the  senses  and  the 
various  obtainable  instruments  to  local  diagnosis,  becoming  elated  by  a  con- 
quest which  has  cost  you  so  little,  and  strengthened  in  the  good  opinion  of 
yourselves  by  persons  who  look  on  medicine  as  consisting  only  of  the  com- 


60  INTRODUCTION. 

mon  stock  of  knowledge,  accustom  your  minds  to  no  efforts  of  productioi  ~i, 
and  sink  down  into  a  sort  of  moral  inertia  ;  while,  on  the  other  hand,  w  re 
see  that  our  predecessors,  less  rich  than  we  are  in  available  knowledge, 
ceaselessly  labored  to  originate  :  poor  they  were,  but  they  turned  to  accoui  tit 
the  tiny  stock  of  information  which  chance  or  experience  had  given  then  ti ; 
they  exercised  their  intellectual  powers  as  constantly  as  wrestlers  exerci 
their  muscles,  and  the  result  was  power,  which  sometimes  showed  itself  \ 
singular  aberrations,  but  likewise  also  in  views  full  of  greatness  and  fe 
tility.     The  very  poverty  of  means  increased  the  intellectual  efforts,  and 
the  results  were  immense ;  and  you,  surrounded  by  a  profusion  of  ineam', 
spoiled,  enervated,  cloyed  with  the  abundance  presented  to  you,  know  only 
how  to  receive  and  gorge,  while  your  lazy  intellects  are  smothered  with 
obesity,  and  are  sterile. 

For  mercy's  sake,  gentlemen,  let  us  have  a  little  less  science,  and  a  little 
more  art ! 

But  I  said  that  a  man  is  born  the  artist,  and  that  he  becomes  the  savant  ; 
I  said  that  scientific,  knowledge  is  easy:  well !  already  I  hear  persons  who 
either  understand  me  amiss,  or  think  they  ought  to  do  so,  accuse  me  of 
encouraging  young  men  in  apathy  and  fatalism.  If,  say  they,  we  are  born 
artists,  we  are  likewise  born  physicians ;  let  us  quietly  wait  for  the  natural 
inspirations  of  art. 

I  do  not  allow  any  one  so  to  misinterpret  my  words.  A  man  is  born  an 
artist  in  this  sense — that  if  nature  has  refused  you  artistic  aptitude,  do 
what  you  like,  you  will  never  be  savants;  but,  with  the  most  happy  aptitudes, 
you  will  be  nothing  without  hard  work.  Hard  work  is  a  powerful  source 
of  inspiration  ;  contemplation  of  the  masterpieces  of  art  constitutes  the  educa- 
tion of  the  artist,  and  a  painter,  endowed  with  the  loftiest  intelligence,  who 
would  not  go  to  pass  some  years  of  his  life  in  that  atmosphere  of  genius  which 
is  breathed  on  the  other  side  of  the  Alps,  will  never  be  more  than  an 
incomplete  man,  shut  up  in  his  own  straitened  individuality,  whereas  with 
study,  with  example,  he  will  at  once  profit  by  the  laborious  inventions  of 
artists  of  past  ages  now  belonging  to  and  easily  obtained  from  science,  he 
will  correct  the  flights  of  his  impetuous  imagination,  which  will  be  con- 
stantly brought  back  to  the  beautiful  by  the  contemplation  of  the  beauti- 
ful ;  he  will  instinctively,  involuntarily  purify  his  taste,  and  all  his  origin- 
ality, henceforth  properly  directed,  will  throw  itself  in  full  force  with  the 
greatest  ease  into  the  lofty  regions  of  art,  and  bring  forth  those  wonderful 
productions  which  the  artist  bequeaths  to  the  admiration  of  future  genera- 
tions. 

God  made  Lavoisier,  but  our  immortal  chemist  would  not  have  been 
more  than  a  happy  farmer  of  taxes  if  he  had  not,  amid  the  fumes  of  1 1 1 «. - 
furnace,  and  by  frequenting  the  society  of  the  scientific  men  of  his  day, 
educated  that  intellect  which  was  destined  to  give  birth  to  the  most  pro- 
lific of  chemical  discoveries. 

Do  you  suppose  that  Pare,  J.  L.  Petit,  Sabatier,  and  Dupuytren — do 
you  suppose  that  Baillou,  Fernel,  Laennec,  and  Corvisarl — do  you  suppose 
that  Lavoisier,  Fourcroy,  Berthollet,  and  Dumas — do  you  suppose  that 
they,  and  many  others  whose  names  are  in  the  mouth  of  every  one  of  you. 
could  by  the  powerful  gifts  which   nature   bestowed   on   them    have  become 

princes  of  their  art  unless  they  had  cultivated  their  oaturaJ  powers  at  an 
early  stage  of  their  career,  unless  they  had  in  early  lite  greedily  devoured 
the  treasures  of  science  which  were  spread  out  around  them  as  they  are 
spread  out  around  you — unless,  though  wearied  by,  they  had  never  been 
satiated  with  labor,  and  had  believed  that  they  had  no  right  to  reserve  for 

their  own  use  the  riches  which  they  had  acquired,  the  discoveries  by  which 


WHAT    IS    CLINICAL    MEDICINE?  61 

they  made  themselves  illustrious,  and  bad  been  jealous  to  see  their  country, 
already  foremost  in  literary  lvnown,  become  foremost  also   in  scientific 

glory  ? 

May  this,  gentlemen,  be  your  noble  heritage.  But  to  secure  it  toilsome 
exertions  are  required.  Whilst  you  are  young,  and  while  you  make  your 
first  essay  in  arms,  let  your  fields  be  the  hospitals  and  the  clinics;  when 
your  knowledge  has  increased,  let  the  hospitals  and  clinics  still  be  your 
fields;  and  let  the  hospitals  and  clinics  continue  to  be  your  fields  of  industry 
after  you  have  acquired  all  the  scientific  knowledge  which  we  exact  from 
you  at  the  probationary  examinations.  By  pursuing  this  plan,  you  will 
attain  expertness  in  the  practice  of  your  art,  knowing  what  science  teaches, 
and  having  the  power  within  yourselves  of  originating  ;  then,  also,  will 
you  begin  that  priesthood  which  will  honor  you,  and  to  which  you  will  do 
honor ;  then,  too,  will  commence  the  life  of  sacrifice,  in  which  your  days 
and  nights  will  be  the  patrimony  of  your  patients.  You  must  resign  your- 
selves to  sow  in  devotion  that  which  you  must  often  reap  in  ingratitude ; 
you  must  renounce  the  sweet  pleasures  of  the  family,  and  that  repose  so 
grateful  after  the  fatigue  of  laborious  occupations ;  you  must  know  how  to 
confront  loathsomeness,  mortifications  of  spirit,  and  dangers;  you  must  not 
retreat  before  the  menaces  of  death,  for  death  achieved  amid  the  perils  of 
your  profession  will  cause  your  names  to  be  pronounced  with  respect. 


LECTURES 


CLINICAL  MEDICINE. 


LECTUEE   I. 

SMALL-POX.       . 

Gentlemen  :  Since  the  great  discovery  of  Jenner,  small-pox  seems  to 
have  occupied  a  much  less  important  place  in  medicine.  It  was  even  hoped 
in  the  early  days  of  vaccination  that  a  means  had  been  found  to  destroy  the 
worst  scourge  which  ever  decimated  the  human  race ;  but  ere  twenty-five  or 
thirty  years  had  passed  away,  in  spite  of  the  practice  of  vaccination,  epi- 
demics of  small-pox  reappeared,  and  did  not  always  spare  the  vaccinated. 
In  giving  the  history  of  cowr-pox,  I  propose  to  tell  how  it  has  lost  some  of 
its  original  properties,  to  study  the  plan  by  which  it  may,  perhaps,  be  pos- 
sible to  restore  to  the  vaccine  virus  that  which  it  has  lost,  and  likewise  to 
state  the  methods  by  which  vaccination  may  henceforth  be  made  as  effica- 
cious as  possible. 

Cases  of  small-pox  are  at  present  so  common  that  a  week  does  not  pass 
without  our  seeing  patients  afflicted  with  this  disease  in  our  wards ;  whereas, 
thirty  years  ago,  in  the  same  wards,  they  were  exceedingly  rare,  and  only 
met  with  in  persons  who  had  not  been  vaccinated.  Is  not  one  entitled  to 
ask,  whether  this  change  does  not  depend  upon  the  medical  constitution 
through  which  we  have  been  passing  for  a  certain  number  of  years,  and 
which  might  have  been  otherwise  more  troublesome  had  it  not  been  ren- 
dered milder  by  cow-pox  ?  Although  epidemics  of  small-pox  do  not  spare 
even  those  who  have  been  vaccinated,  it  must  be  owned  that  they  spare 
most  of  them ;  again,  in  most  of  the  vaccinated,  the  disease  has  generally 
been  modified  in  its  form  and  symptoms,  so  that  vaccination,  though  it  has 
not  in  our  day  its  original  efficacy,  still  retains  a  degree  of  efficacy  which 
cannot  be  disputed. 

Xevertheless,  although  antecedent  vaccination  generally  modifies  the 
disease,  small-pox  is  a  terrible  calamity  when  it  scourges  even  vaccinated 
communities,  but  it  is  the  most  severe  of  all  epidemic  diseases  when  it  at- 
tacks the  unvaccinated.  Perhaps  some  of  you  have  read  the  account  of  the 
epidemic  of  small-pox  which  ravaged  the  aboriginal  Indian  tribes  of  Canada 
some  years  ago  ;  nearly  twenty -two  thousand  persons  were  attacked,  and  in 
from  five  to  six  months  almost  the  entire  population  was  carried  off  by  this 
frightful  fever.     At  the  close  of  last  century,  in  proportion  as  the  naviga- 


64  •  SMALL -POX. 

tors  penetrated  into  the  isles  of  the  Pacific  Ocean,  small-pox,  which  the  men 
of  the  old  continent  brought  with  them,  burst  forth  with  fury  among  the 
inhabitants  of  the  newly-discovered  world,  and  the  mortality  assumed  a 
frightful  magnitude. 

It  appears,  then,  that  the  study  of  small-pox  is  a  matter  of  great  impor- 
tance, and  this  importance  will  probably  increase  more  and  more  in  conse- 
quence of  the  neglect  of  the  practice  of  revaccination,  which,  though  as 
commendable  as  it  ever  was,  is  rejected  by  many  physicians,  and  is  not 
universally  accepted  by  the  public. 

For  fifty  years  the  study  of  small-pox  had  come  to  be  looked  on  as  of 
secondary  importance  in  medical  education.  It  has  now  become  necessary 
to  return  to  it  and  insist  upon  it ;  I  also  propose,  therefore,  to  sketch  the 
principal  features  of  the  disease.  Though  I  have  acquired  a  sad  experience 
in  small-pox,  I  have  learned  almost  nothing  regarding  it  which  has  not 
been  much  better  observed  and  described  before  me.  I  shall,  therefore, 
take  Sydenham  as  my  guide.  Some  of  you  have  in  your  hands  extracts 
from  his  writings,  which  I  have  arranged  in  the  form  of  aphorisms  in  a 
pamphlet  of  a  few  pages,  containing  the  most  important  statements  made 
on  this  subject  by  the  English  Hippocrates.  I  now  propose  to  paraphrase 
this  little  book,  and  to  add  to  it  some  critical  remarks ;  I  will  sometimes 
appeal  from  the  writings  of  Sydenham  to  the  clinical  studies  which  we 
pursue  together  in  the  hospital,  and,  without  changing  much  of  what  that 
illustrious  man  has  said,  I  hope  to  teach  you  everything  which  it  is  essential 
to  know  regarding  this  exanthematous  pyrexia. 

Small-pox  differs  from  scarlatina  in  this  respect,  that  it  always  shows 
itself  to  the  eye.  During  the  first  few  days,  during  the  period  of  invasion, 
one  may  not  have  suspected  it,  but  as  soon  as  the  eruption  appears  there  is 
no  longer  any  scope  for  hesitation.  Its  manifestations  are  unmistakably 
characteristic,  and  it  ought  not  to  be  possible  to  confound  variola  even  with 
varicella,  an  essentially  different  disease,  though  the  two  are  sometimes 
confounded  with  each  other. 

Small-pox  is  subject  to  modification  in  respect  of  the  eruption,  and  the 
course  which  the  disease  runs.  This  modification,  or  new  phase,  is  the 
consequence  of  antecedent  small-pox  or  cow-pox.  It  is  an  error,  as  I  shall 
afterwards  explain,  to  apply  the  term  varioloid  to  modified  small-pox. 
Under  all  circumstances,  whether  modified  or  unmodified,  small-pox  ap- 
pears under  two  principal  forms,  viz.,  the  distinct  and  confluent;  and 
whichever  form  it  assumes,  the  symptoms  are  either  normal  or  abnormal. 

It  is  not  a  matter  of  indifference  to  establish  the  varieties  of  the  disease, 
and  it  is  quite  essential  to  recognize  its  two  principal  forms:  for  distinct 
small-pox  is  generally  free  from  danger,  while  confluent  small-pox  i>  one 
of  the  most  terrible  of  diseases,  almost  always  proving  fatal  to  those  whom 
it  attacks.  The  course  and  termination  of  the  two  arc  so  different,  and  the 
phenomena  which  characterize  them  so  decisively  distinctive,  that  it  is  of 
the  utmost  importance,  following  Sydenham's  example,  to  describe  and 
study  each  separately. 

Distinct  Small-pox.  —  f  bnstipation. —  <  bnvulsions. —  RacMalgia. —  Para- 
plegia of  dmoU-pox. — Duration  of  il"  Period  of  Invasion. —  Eruption 
considered  with  reference  to  He  position  on  tJu  Face,  Trim/:,  <ni<l  Limbs. 
—  Orehitii  of  Smallpox. — D<  siecation. 

In  every  case  of  Bmall-pox,  th<-  clinical  observer  can  recognise  a  period 
of  incubation,  and  four  other  periods,  viz.,  those *of  invasion,  eruption, 
maturation    or  suppuration  ,  and  desiccation. 


DISTINCT    SMALL-POX.  65 

The  period  of  incubation  has  a  duration  the  extent  of  which  has  been  es- 
tablished by  observation  in  cases  of  ordinary  contagion,  and  demonstrated 
by  experiment  for  more  than  half  a  century  in  Europe,  by  the  inoculation 
of  natural  small-pox.  Attentive  observers,  then,  have  satisfied  themselves 
in  a  precise  manner  as  to  the  number  of  days  which  elapse  bet  ween  inocu- 
lation and  the  manifestation  of  the  disease;  they  have  ascertained  that, 
except  in  extraordinary  and  exceptional  cases,  the  period  of  incubation  ex- 
tends to  between  eight  and  eleven  days. 

The  period  of  invasion,  in  distinct  small-pox,  is  characterized  by  a  violent 
rigor,  or  sometimes  by  many  rigors,  interrupted  by  accessions  of  burning 
heat ;  and  these  phenomena  are  always  more  decided  in  this  disease  than 
in  any  of  the  other  exanthematous  pyrexia?.  The  skin  continues  relaxed 
up  to  the  eighth  day,  and,  in  the  adult,  sweating  is  an  essential  symptom ; 
in  children  it  is  otherwise.  The  perspiration,  which  appears  w7ith  the  first 
access  of  fever,  is  checked  by  nothing,  and  continues,  even  when  the 
patients  are  lightly  covered,  up  to  the  period  of  'maturation  ;  it  then  goes 
on,  even  when  the  fever  has  subsided,  and  after  the  completion  of  the 
eruptive  process ;  it  seems  to  constitute  a  favorable  crisis  on  the  part  of  the 
skin,  coming  in  aid,  as  a  sort  of  emunctory  discharge,  to  the  great  cutane- 
ous eruptive  manifestation.  I  must  here  remark,  that  in  confluent  small- 
pox this  tendency  to  diaphoresis  is  generally  absent. 

In  distinct  small-pox,  the  period  of  invasion  is  also  characterized  by 
vomiting,  or  a  desire  to  vomit ;  this  symptom  is  very  seldom  absent.  A 
more  important  symptom,  still  more  rarely  wanting  in  adults,  is  constipa- 
tion ;  it  persists  during  the  entire  course  of  the  disease,  or  at  least  the 
bowels  are  relieved  with  difficulty.  It  must  be  mentioned,  however,  that 
in  some  epidemics  diarrhoea  has  been  observed  in  adults.* 

Diarrhoea  in  children,  on  the  other  hand,  is  the  rule  and  not  the  excep- 
tion. Besides  this  complication,  there  are  others  met  with  in  children,  to 
which  it  is  still  more  important  to  call  attention.  In  the  first  place,  there 
is  a  tendency  to  sleep ;  and  still  more  frequently,  even  in  those  who  have 
cut  their  teeth,  convulsions  occur.  They  more  frequently  occur  in  children 
in  the  earliest  stage  of  small-pox  than  at  the  corresponding  epoch  in  cases 
of  measles  or  scarlatina.  So  well  aware  was  Sydenham  of  the  frequency 
of  this  symptom,  that  when  he  met  with  convulsions  in  a  child  whose  den- 
tition was  completed,  he  at  once  suspected  that  he  had  to  do  with  a  case  of 
incipient  small-pox ;  he  did  not  consider  convulsions  ushering  in  an  attack 
of  small-pox  as  at  all  a  serious  complication.  This  proposition,  however, 
if  applied  generally,  requires  to  be  stated  in  a  less  absolute  form ;  if  a 
child,  for  example,  has  one  or  two  convulsive  seizures  shortly  before  the 
appearance  of  the  eruption,  it  is  not  in  great  danger,  but  there  is  more  risk 
when  the  convulsions  occur  early  and  recur  frequently.  For  my  own  part, 
however — but  my  experience  of  small-pox  in  children  has  been  small — I 
should  say  that  the  occurrence  of  convulsions  is  a  troublesome  complication 
rather  than  a  favorable  symptom.  It  must  be  borne  in  mind,  too,  that  (as 
Borsieri  has  remarked)  convulsions  may  constitute  a  misleading  as  well  as 
a  serious  symptom,  inasmuch  as  they  sometimes  carry  off  the  patients  be- 
fore the  appearance  of  the  eruption. 

*  Diarrhoea  in  the  adult. — "Inquadam  constitutions  epidemica  variolas  obser- 
vavit  Carolus  Richa,  qua?  cum  alvi  fluxu  incipiebant,  et  eundem  ad  finem  usque 
comitem  habebant,  bono  cum  eventu,  sive  id  a  saburra  primarum  complicate 
eveniret,  sive  a  materia?  variolosa?  portione,  qua?  hac  via  excerneretur.  (Crmsil.  epid. 
Taurin.,  anno  1720,  \  xv). — "Vogelius,  etiam,  diarrhoeam  salutareni  ab  initio  ad  un- 
decimum  usque  diem  vidit,  lethalem  vero  earn  qua?  postea  supervenerit." — Note  of 
Borsieri,  p.  150. 
vol.  i. — 5 


66  DISTINCT    SMALL-POX. 

Simultaneously  with  the  shivering  and  sweating,  the  burning  fever  and 
the  vomiting,  another  important  symptom  supervenes — this  is  pain  in  the 
lumbar  region — (rachialgia) — it  is  hardly  ever  absent,  and  in  no  other 
pyrexia,  excepting  yellow  fever,  is  it  so  severe.  It  is  not,  as  has  been  sup- 
posed, a  muscular  pain,  but  is  dependent  upon  an  affection  of  the  spinal 
marrow.  Here  is  the  proof.  In  a  great  many  cases  fand  last  year  within 
a  few  days  I  could  have  shown  you  two  examples)  the  lumbar  pain  is  ac- 
companied by  paraplegia.  "Without  your  putting  any  leading  questions, 
the  patients  themselves  mention  this  paralysis ;  they  complain  of  painful 
numbness  in,  and  inability  to  move,  the  lower  extremities.  When  you  in- 
quire whether  the  upper  extremities  are  similarly  affected,  you  discover 
that  their  motor  power  is  in  no  degree  impaired.  The  paralysis  sometimes 
affects  the  bladder,  as  is  evidenced  by  retention  of  urine,  or  at  least  by 
great  dysuria. 

The  paralytic  symptoms  are  generally  of  shor^  duration,  but  in  some 
cases  they  continue  till  the  ninth  or  tenth  day;  generally,  they  cease 
spontaneously  when  the  eruption  appears.  There  are,  however,  some 
cases  in  which  the  paralysis  persists  not  only  during  the  whole  course 
of  the  disease,  but  likewise  constitutes  one  of  the  complications  of  conva- 
lescence. 

When  the  lumbar  pains  are  not  very  acute,  the  patient  only  experiences 
lassitude  and  dull  pains  (like  those  of  rheumatism)  in  all  the  limbs,  with 
occasionally  pain,  increased  by  pressure  at  the  pit  of  the  stomach.  "Doloris 
sensus  in  partibus  quae,  serobiculo  cordis  subjacent,  si  manu  premantur"  says 
Sydenham. 

To  sum  up :  the  period  of  invasion  is  characterized  by  rigors,  ardent 
fever,  and  constant  sweating,  by  nausea  and  constipation,  by  disturbance 
of  the  nervous  system,  such  as  convulsions  in  children  ;  by  general,  but 
particularly  by  lumbar  pains,  with  which  are  frequently  associated  paral- 
ysis of  the  inferior  extremities,  and  occasionally  paralysis  of  the  bladder. 

I  must,  nevertheless,  remark  that  in  some  exceedingly  rare  eases  men- 
tioned by  old  authors,  small-pox  proved  so  mild  that  the  eruption  made 
its  appearance  without  having  been  preceded  by  any  febrile  disturbance  : 
the  outbreak  of  the  pustules  was  either  the  sole  manifestation  of  the  dis- 
ease, or  if  there  was  any  fever,  it  was  so  slight  as  to  have  passed  unnoticed. 
In  such  cases,  as  Borsieri  has  remarked,  there  is  no  appreciable  period  of 
invasion. 

In  distinct  small-pox  the  period  of  invasion  is  usually  three  complete 
days;  rarely  three  days  and  a  half;  still  more  rarely  four  days;  and 
almost  never  only  two  days.  This  duration  is  so  generally  the  rule,  that 
when  one  sees,  after  the  inoculation  of  natural  small-pox,  the  fever  of  in- 
vasion set  in  with  a  certain  amount  of  vehemence,  and  three  times  twenty- 
four  hours  elapse  before  the  eruption  is  developed,  it  may  he  prognosticated 
with  certainty  that  the  attack  will  not  be  severe.  The  fact  is,  that  ///-• 
longer  the  eruption  is  in  appearing,  the  less  serious  will  tli>  disease  prove;  and 
the  less  delay  there  is  in  it*  appearance,  the  more  dangerous  will  ili>  disease 
prove  When  the  eruption  appears  at  the  end  of  the  second  day.  it  i-  cer- 
tain to  he  confluenl  :  it'  on  the  third,  it  i>  almost  always  confluent.  If,  on 
the  other  hand, the  eruption  does  doI  appear  till  the  fourth  day,  still  more, 

if  it  he  delayed   till    the  fifth  or  sixth  (as  in  :i  Case  observed   by  Yiolantei. 

or  till  the  fourteenth  (as  in  a  young  girl  whose  case  is  re< led  by  I  fen  . 

it  is  necessarily  distinct. 

Sydenham,  nevertheless,  informs  ns  that  in  Borne  exceptional  cases  in 
consequence  of  greal  organic  Lesions,  ob  atrocius  aliquoa  symptoma,  the 
eruption  may  he  retarded  till  the  sixth  or  seventh  day  both  in  distinct  and 


DISTINCT    SMALL-POX.  67 

confluent  cases.  But  under  such  circumstances,  there  exist,  in  addition  to 
the  ordinary  symptoms  of  the  period  of  invasion,  others  depending  upon 
the  profound  disturbance  of  the  economy  and  the  danger  which  lies  con- 
cealed in  the  affection  of  an  internal  organ.  In  support  of  the  observation 
of  Sydenham,  let  us  recall  the  circumstances  of  a  case  which  we  had  in 
1862  in  the  St.  Bernard  Ward,  bed  27.  The  patient  was  a  woman  of  30, 
in  whom  the  eruption  did  not  appear  till  the  fifth  day;  at  the  commence- 
ment of  her  attack  of  small-pox,  she  had  had  all  the  symptoms  of  sporadic 
cholera,  such  as  vomiting,  purging,  cramps,  general  coldness,  blanching  of 
the  mucous  membranes,  dry  cold  tongue,  injection  of  the  conjunctiva,  and 
a  dull  appearance  of  the  cornea.  The  choleraic  symptoms  ceased  on  the 
fourth  day,  and  on  the  fifth  the  eruption  of  small-pox  appeared. 

At  the  commencement  of  the  second  period,  that  is,  as  soon  as  the  erup- 
tion appears,  the  fever  subsides,  and  the  other  symptoms  cease,  except,  as 
has  already  been  stated,  the  tendency  to  perspire,  which  continues  till  the 
maturation  of  the  pustules.  Recollect  that  I  am  now  speaking  exclusivelv 
of  distinct  small-pox ;  in  the  confluent  form  the  symptoms  in  question  do 
not  cease  with  the  appearance  of  the  eruption. 

I  ought  here  to  remark  that  modern  scientific  precision  has  confirmed  the 
observation  of  the  old  clinical  observers.  The  thermometrical  researches 
of  Wunderlich  and  his  scientific  emulators  show  that  when  the  eruption 
appears,  and  when  the  pulse  is  found  to  diminish  in  frequency,  the  other 
phenomena  characteristic  of  fever  disappear ;  there  is  simultaneously  a 
notable  fall  in  the  general  temperature,  which  gradually  returns  to  its 
normal  standard,  which,  as  you  know,  is  37  degrees  in  the  axilla. 

Here  are  the  leading  facts  in  relation  to  the  progressive  change  of  tem- 
perature in  the  distinct  form :  At  the  commencement  of  the  disease  the 
temperature  rises  very  quickly,  and  remains  as  high  for  a  considerable  time 
as  from  40°  5"  to  41°  5",  that  is  to  say,  that  the  temperature  of  the  body 
rises  from  three  to  four  and  a  half  degrees  above  the  temperature  in  health, 
which  is  an  enormous  increase.  From  the  time  of  the  appearance  of  the 
eruption  the  fall  of  temperature  is  so  rapid  that  in  about  thirty-six  hours  it 
has  gone  down  to  below  thirty-eight,  or,  in  other  words,  has  become  normal. 
This  diminution,  though  gradual,  is  not  continuous,  for  while  there  is  a  fall 
of  one  degree  in  the  morning,  there  is  a  rise  of  half  a  degree  in  the  evening. 
It  appears,  however,  that  from  the  time  of  the  disease  becoming  external, 
so  to  speak,  the  central  temperature  falls,  and  there  is  a  complete  remission 
in  the  general  symptoms.  The  Germans  apply  the  term  defervescence  to 
the  return  of  the  body  to  its  natural  temperature. 

We  shall  afterwards  attend  to  the  thermometrical  phenomena  which  are 
seen  when  every  pustule  has  become  a  centre  of  suppuration.  I  now  return 
to  the  description  of  the  eruption. 

The  Eruption. — The  eruption  first  shows  itself  on  the  face  and  neck;  but, 
according  to  Swieten  and  Borsieri,  it  appears  also  at  the  same  time  upon 
the  scalp,  a  fact  which  can  be  most  easily  verified  in  persons  who  are  bald ; 
it  then  comes  out  a  little  upon  the  upper  part  of  the  chest ;  soon  afterwards 
it  takes  possession  of  the  arms  and  hands,  and  later  of  the  trunk,  that  is, 
of  the  lower  part  of  the  chest  and  of  the  abdomen,  in  which  latter  situ- 
ation the  pustules  are  very  few  in  number,  and  sometimes  altogether  want- 
ing ;  last  of  all,  the  eruption  invades  the  legs. 

The  successive  order  in  the  appearance  of  the  pustules  is  not  so  regular 
as  authors  describe  it  to  be.  If  the  eruption  appears  to  commence  on  the 
face,  it  is  because  it  is  best  seen  there.  When  I  have  uncovered  patients, 
I  have  seldom  found  pustules  on  the  face  without  finding  them  in  quite  as 
advanced  a  state  on  the  trunk  and  limbs.     From  the  commencement,  also. 


68  DISTINCT    SMALL-POX. 

of  the  eruptive  period,  the  patients  complain  of  pain  in  the  throat,  which 
depends  upon  the  existence  of  pustules  on  the  mucous  membrane  of  the 
pharynx  and  mouth. 

In  very  rare  cases,  some  of  which  have  been  described  by  authors,  and 
some  of  which  I  have  seen,  the  only  symptoms  characteristic  of  the  disease 
were  a  few  pustules  on  the  pharynx  and  pendulous  veil  of  the  palate. 

The  skin,  to  which  one  naturally  ought  first  to  look,  is,  at  the  commence- 
ment, studded  with  spots  resembling  exceedingly  fine  pricks  made  with  a 
needle,  and  still  more  with  papulae,  such  as  are  met  with  in  persons  affected 
by  lichen  or  prurigo;  these  small  specks,  which  are  red,  slightly  pointed, 
and  hardly  above  the  surface  of  the  skin,  are  disseminated  over  the  face, 
neck,  and  upper  part  of  the  chest.  Next  day  they  are  more  prominent, 
and  from  the  sixth  day  of  the  disease,  which  is  the  third  of  the  eruption, 
the  vesicular  papules  begin  to  contain  a  milk-like  fluid  ;  next  day  they 
increase  very  perceptibly,  their  elevation  is  great,  and  the  fluid  which  they 
contain  becomes  a  little  more  opaque.  On  the  eighth  day  they  have 
become  much  larger  still,  and  their  opacity  is  also  more  decided. 

After  the  eighth  day,  it  is  very  important  to  consider  small-pox  in  rela- 
tion to  the  eruption  as  seen  on  the  different  parts  of  the  body,  because  it 
takes  very  different  forms,  according  to  the  parts  affected.  On  examining 
the  face,  neck,  trunk,  and  upper  part  of  the  limbs,  we  perceive  a  sort  of 
gradation,  which  enables  us,  however,  to  recognize  the  eruption  as  essen- 
tially the  same  in  these  various  situations :  nevertheless,  on  comparing  the 
papules  on  the  hands  with  those  on  the  face,  the  differences  between  the 
appearances  of  the  two  strike  one  as  being  considerable. 

On  the  face,  as  I  have  already  said,  the  eruption,  on  the  first  day  it  is 
visible,  presents  the  appearance  of  small,  red,  slightly  acuminated  papules, 
which  next  day  become  more  elevated,  and  on  the  third  day  (which  is  the 
sixth  of  the  disease)  are  filled  with  an  opaque,  but  as  yet  non-purulent 
fluid.  They  go  on  increasing  in  size :  they  generally  vary  in  size,  and  do 
not  all  resemble  one  another :  some  are  small  and  some  are  large,  but  none 
attain  a  magnitude  equal  to  that  seen  on  other  parts  of  the  body;  and 
whatever  be  their  size,  they  all  pass  through  the  same  stages.  On  the 
seventh  day  of  the  disease,  they  still  further  augment  in  volume  ;  and  upon 
the  circumference  of  the  base  of  each  papule  a  redness  begins  to  be  per- 
ceptible. On  the  eighth  day,  this  coloration  becomes  bright,  and  the  more 
bright  and  rosy  it  is,  so  much  the  more  may  the  disease  be  regarded  as 
normal.  The  eruption  now  consists  of  small  abscesses — of  pustules;  the 
pustules  become  painful,  and  swelling  begins.  This  is  the  starting-point  of 
the  third  period — the  period  of  maturation  and  suppuration. 

The  swelling  attains  its  maximum  on  the  following  day,  that  is,  on  the 
ninth  day  of  the  disease;  it  decreases  on  the  tenth,  and  by  the  eleventh 
day  has  disappeared.  The  tumefaction,  which  is  always  great  in  propor- 
tion to  the  abundance  of  the  eruption,  is  apparently,  but  not  really  greater, 
in  the  distinct  than  in  the  confluent  form;  it  is  specially  conspicuous  in 
certain  situations,  particularly  upon  the  eyelids,  which  swell  oul  in  a  re- 
markable manner,  from  the  laxity  of  their  cellular  tissue.     When  even 

there   are   only  three   or   four   pustules    upon    the  eyelids,   they   become   80 

swollen,  that  Sydenham  compared  them  to  puffed-oul  bladders — vesicam 
inflatam  mm  male  refert;  and  on  the  ninth  and  tenth  days  they  prevent  the 
patienl  from  opening  his  eyes.  It  Bometimes  happens,  as  in  a  ease  which 
we  saw  in  the  clinical  wards,  thai  pustules  occur  on  the  ocular  conjunctiva. 
The  swelling  is  sometimes  quite  as  conspicuous  in  other  regions  as  on  the 
eyelids.  Nan  Bwieten,  for  example,  .-aw  a  .-ingle  pustule  on  the  prepuce 
of  a  child  produce  a  phimosis,  which  occasioned  difficulty  in  passing  the 


DISTINCT    SMALL-POX.  69 

urine.  And  here,  gentlemen,  let  me  recall  the  fact  to  your  recollection, 
that  tlif  cellular  tissue  of  the  prepuce  is  of  exactly  the  same  nature  as  that 
of  the  eyelids.  In  confluent  small-pox,  to  which  we  shall  afterwards  return, 
the  -welling  of  the  face  being  more  general,  the  tumefaction  of  the  eyelids 
has  the  appearance  of  being  less  than  it  really  is,  and  less  than  in  that  form 
of  the  disease  which  we  are  now  studying. 

At  the  beginning  of  the  period  of  maturation,  the  progress  of  the  pus- 
tules on  the  face  is  special.  Up  to  the  eighth  day,  they  are  velvety  and 
soft  to  the  touch — leves  ad  taetum,  to  use  Sydenham's  expression  ;  but  after 
that  day,  upon  passing  the  hand  over  the  nose  and  cheeks,  they  are  felt  to 
be  rough — asperiorus,  ad  taetum  rudiores;  and  this  roughness  depends  upon 
a  slight  oozing  from  the  surface  of  the  pustule  of  a  yellowish  matter  like 
thick  honey.  This  exudation  only  takes  place  from  the  pustules  on  the 
face,  where  they  dry  up  immediately,  the  desiccation  being  complete  on  the 
eleventh  day. 

The  pustules  on  the  trunk  and  extremities  have  a  more  regular  form, 
and  present  more  similarity  to  each  other ;  while  those  on  the  face  are  not 
navel-shaped,  those  on  the  body  begin  to  flatten  on  the  eighth  day,  and 
sometimes  to  exhibit  in  their  centres  a  small  grayish  depression  called  the 
umbilication.  It  must  not,  however,  be  supposed  that  the  formation  of  this 
umbilication  is  a  necessary  occurrence.  Upon  the  arm  of  patients  affected 
with  true  small-pox,  I  lately  circumscribed  a  certain  number  of  pustules, 
and  it  was  found  that  in  only  two  or  three  of  them  did  umbilication  occur. 
Do  not  suppose,  then,  that  the  undergoing  this  change  of  form  is  a  special 
character  of  the  small-pox  pustule ;  you  will  find  this  very  same  umbilica- 
.tion  occurring  in  the  simple  pustules  of  ecthyma,  particularly  in  the 
ecthyma  produced  by  friction  with  tartar  emetic.  And  let  me  here  remark, 
as  a  circumstance  noteworthy  in  connection  with  .this  point,  though  not 
otherwise  of  any  importance,  that  some  physicians  of  the  last  century  re- 
garded it  as  an  inauspicious  sign  when  pustules  were  observed,  which, 
though  somewhat  prominent,  were  not  acuminated,  but,  on  the  contrary, 
bore  a  small  central  depression — in  apice  faveolam  impressam  gerunt. 

About  the  eleventh  day,  the  pustules  are  filled  with  a  purulent  fluid : 
from  that  time  may  be  noticed  upon  the  upper  part  of  the  limbs,  and 
particularly  on  the  knees  and  elbows,  a  drying  up  of  some  of  the  smallest, 
but  without  any  exudation  similar  to  that  seen  to  proceed  from  face  pus- 
tules :  between  the  fourteenth  and  seventeenth  days,  as  a  general  rule, 
desiccation  is  completed. 

On  the  hands,  the  appearances  presented  are  different  from  those  hitherto 
described.  From  the  eighth  to  the  eleventh  day,  the  pustules  resemble 
those  on  the  body,  if  it  be  not  that  the  inflammation  of  the  base  commences 
later ;  but  towards  the  close  of  the  ninth  day,  the  hands  continue  to  be  a 
little  painful ;  on  the  tenth  they  swell,  and  concurrently  with  the  tumefac- 
tion of  the  hands,  cedematous  swelling  of  the  forearm  is  observed,  which 
extends  to  the  elbow,  and  is  very  painful.  This  condition  is  seldom  of 
equal  intensity  on  both  sides,  a  fact  which  I  am  unable  to  explain.  Per- 
haps it  may  depend  upon  the  crop  of  pustules  being  a  little  more  decided 
on  one  side  than  on  the  other,  or  upon  the  patient  resting  more  on  one  side, 
and  the  swelling  being  greatest  where  the  impediment  to  the  venous  circu- 
lation is  greatest.  If  the  eruption  has  been,  I  do  not  say  confluent,  but 
somewhat  abundant,  the  patient  is  unable  to  close  his  hands  from  the 
tumefaction  of  the  skin.  The  existence  of  this  cedemato-phlegmonous  swell- 
ing is  shown  in  a  very  simple  manner.  It  is  sufficient  to  press  more  or  less 
gently  upon  the  skin  between  the  pustules  to  leave  the  mark  of  the  finger ; 
this  swelling  and  pain,  which  never  set  in  before  the  eleventh,  continue  till 


70  DISTINCT    SMALL-POX. 

the  fourteenth  day.     Similar  phenomena  occur  in  the  feet,  as  in  the  hands, 
when  the  eruption  is  copious  upon  them. 

"While  the  pustules  have  generally  acquired  their  greatest  size  upon  the 
trunk  about  the  eleventh  day  of  the  disease,  they  continue  to  increase  in 
volume  till  about  the  fourteenth  day  upon  the  hands,  feet,  forearms,  and 
lower  part  of  the  legs  ;  the  cedemato-phlegmonous  swelling  by  which  they 
are  surrounded  then  goes  down,  leaving  them  without  umbilication,  and 
presenting  the  exact  appearance  of  beautiful,  perfectly  round  drops  of  vir- 
gin wax.     They  are,  in  fact,  thickish  phlyctsense  filled  with  pus. 

Generally  speaking  the  pustules  of  the  trunk  and  limbs  burst  instead  of 
desiccating — disruptione  abitum  sibi  parant;  the  pus  which  they  contain 
escapes,  and  soils  the  sheets  and  body-linen  of  the  patient.  The  rupture 
takes  place  in  three  or  four  days ;  but  on  the  hands,  feet,  forearms,  and 
lower  part  of  the  legs,  they  remain  unbroken  until  the  eighteenth,  nine- 
teenth, twentieth,  or  even  twenty-second  day,  an  example  of  which  latter 
occurrence  I  had  an  opportunity  of  showing  you.  Sydenham,  then,  was 
mistaken  when  he  wrote  that  their  duration  is  not  more  than  one  or  two 
days  longer  than  that  of  the  pustules  on  the  body — diei  unius  aid  alterius 
mora  Was  rincunt.  I  have,  however,  gentlemen,  pointed  out  to  you  at  the 
bed  of  the  patient,  that  if  the  pustules  on  the  back  of  the  hand  and  on  the 
forearm  present  the  characteristics  with  which  I  have  just  made  you  ac- 
quainted as  occurring  on  the  dorsal  aspect  of  the  fingers  and  toes,  they 
cornify  and  desiccate  without  suppuration,  exactly  like  the  pustules  of 
modified  small-pox,  or  like  those  of  the  knees  and  elbows  of  the  unmodified 
disease. 

Before  leaving  this  subject  I  must  remark  that  it  is  in  the  most  vascular 
parts  of  the  skin  that  the  eruption  is  most  copious  ;  and,  as  was  pointed  out 
long  ago  by  observers,  fhe  situations  in  which  the  pustules  are  most  numer- 
ous are  the  face,  the  extremities,  the  circumference  of  small  wounds  (such, 
for  example,  as  those  made  by  the  cautery),  or  the  vicinity  of  blisters.  Let 
me  recall  to  your  recollection,  as  a  case  in  point,  the  patient  who  occupied 
bed  ISo.  9  of  St.  Agnes's  "Ward,  a  lad  in  whom  the  eruption  was  very  abun- 
dant on  the  posterior  aspect  of  the  forearms;  he  was  a  cook,  and  in  that 
capacity  constantly  had  these  parts  exposed  to  the  heat  of  kitchen-stoves. 

At  the  commencement  of  the  period  of  maturation  or  suppuration,  there 
is  a  new  manifestation,  viz.,  the  fever  of  maturation.  The  serious  symptoms 
present  at  the  beginning  of  the  disease  had  so  entirely  disappear*  d  with  the 
coming  out  of  the  eruption,  that  the  patient  had  regained  his  cheerfulness 
and  appetite  ;  but  they  return  on  the  eighth  day.  and  constitute  the  fever 
of  maturation. 

Here,  again,  investigation  with  the  aid  of  the  thermometer  gives  valuable 
information.  We  have  seen  that  on  the  fourth  day  of  the  disease,  at  the 
date  of  the  appearance  of  the  eruption,  and  also  whilsl  it  continues,  there 
is  a  fall  in  the  temperature  of  the  body  and  a  truce  to  the  fever,  the  entire 
morbid  effort  being  concentrated,  so  to  speak,  in  the  skiii,  but  the  tempera- 
ture does  not  remain  for  more  than  a  day  or  two,  or  for  three  .lavs  at  the 
most,  at  the  normal  standard  of  37°  J  it  rises  a  little  during  the  period  of 
BUppuration,  bul  does  not  become  so  high  as  it  was  during  the  initial  lever. 
In  Bevere  cases,  however,  the  fever  which  attends  suppuration  is  more  in- 
tense, and  the  temperature  may  even  rise  as  high  as  it  was  before  the  erup- 
tion appeared.  To  he  more  precise  -in  slighl  cases,  within  three  day.-,  the 
temperature  rises  to  aboul  38.5  ,  while  in  the  more  severe  cases  it  may 
rapidly  ascend  to  40.6  ,  and  even  to  A\:l\  This  greal  elevation  of  tem- 
perature, however,  is  most  frequently  observed  in  the  confluenl  form  of  the 

disease,  Oi   which   I  shall  immediately  have  to  speak  to  you.      hi  the  mean- 


DISTINCT    SMALL-POX.  71 

time,  to  sum  up  what  has  now  been  stated,  I  may  say  that  the  central  tem- 
perature rises  anew  about  the  seventh  or  eighth  day  of  the  disease. 

The  fever  of  maturation  lusts  for  three  days;  on  and  after  the  eleventh 
day  of  the  disease  the  patient  is  free  from  it,  provided  the  case  is  of  the 
distinct  form.  The  temperature  becomes  again  the  exact  index  of  the 
progress  of  the  fever  ;  thus,  after  having  riseu  to  at  least  38.7°  in  the  fever 
of  maturation,  it  falls  progressively  in  three  days  to  the  normal  standard. 
If  the  fever  continue  longer,  it  depends  on  complications,  which,  as  I  have 
already  said,  are  rare  in  the  distinct  form  of  the  disease. 

Orchitis,  and  ovaritis,  its  analogue  in  the  female,  next  claim  our  attention 
as  phenomena  which  sometimes  occur  concurrently  with  the  appearance  of 
the  eruption.  M.  Beraud,  an  hospital  surgeon,  has  in  recent  years  treated 
the  subject  in  a  very  complete  manner.*  We  must  not  restrict  the  terms 
orchitis  and  ovaritis  to  inflammation  of  the  parenchyma  of  the  testicle  or 
ovary,  but  extend  it  to  inflammation  of  the  tunica  vaginalis,  and  the  folds 
of  peritoneum  which  surround  the  ovaries.  The  inflammation  of  the  serous 
membrane  is  the  result  of  the  small-pox  eruption  affecting  them  as  it  does 
the  skin,  although  of  course  the  appearances  presented  in  the  two  situations 
have  very  different  characters,  just  as  herpes  on  a  mucous  surface  is  very 
different  from  herpes  on  the  skin.  Small-pox  manifests  itself  upon  other 
serous  membranes  than  those  now  named.  Long  ago,  Van  Swieten  and 
Hoffmann  had  called  attention  to  variolous  meningitis;  Fernel,  Werlhoff, 
and  Violante  have  mentioned  variolous  affections  of  the  lungs  and  intestines 
twenty-seven  years  ago ;  Pedzholdt  published  the  observations  he  made  on 
variolous  meningitis  and  peritonitis,  in  the  epidemic  which  prevailed  at 
Leipsic  during  the  winter  of  1832  and  1833.  Variolous  orchitis  is  detected 
by  the  patient  complaining  of  pain  when  the  slightest  pressure  is  made  on 
the  scrotum,  or  when  he  moves  ;  forthwith,  swelling  of  the  parts  is  perceived, 
and  subsequently  fluctuation  ;  the  pain  is  less  acute  when  the  inflammation 
occupies  the  parenchyma  of  the  organ.  The  symptoms  of  ovaritis  are  not 
so  well  marked,  and  are  less  known. 

The  facts  recorded  by  Beraud  have  been  regarded  as  exceptional.  Till 
he  wrote,  neither  my  attention  nor  the  attention  of  any  one  had  been 
specially  fixed  upon  this  subject;  but  his  work  had  scarcely  been  published 
when,  within  a  week,  I  showed  you  two  cases  of  variolous  orchitis  in  my 
wards.  Since  that  time,  we  have  had  very  many  similar  cases,  not  because 
they  are  more  common  now  than  in  Sydenham's  time,  but  because  we  now 
look  out  for  the  affection,  and  have  learned  how  to  detect  its  presence.  In 
the  same  category  we  must  include  diphtheritic  paralysis  and  rheumatismal 
disease  of  the  heart,  affections  which,  though  not  more  common,  have  recently 
been  better  observed. 

From  all  I  have  now  said,  gentlemen,  respecting  the  rise  and  fall  of  the 
temperature  of  the  body  in  small-pox,  it  follows  that  the  thermal  line  drawn 
for  this  disease  is  a  material  and  striking  representation  of  the  singular 
course  of  the  fever.  Indeed,  there  is  nothing  more  characteristic  than  the 
curve  in  the  line  which  indicates  the  rise  and  fall  of  temperature  in  small- 
pox. There  is,  first  of  all,  the  rapid  rise  at  the  beginning  of  the  attack,  then 
the  continuance  of  the  high  temperature  for  two  or  three  days,  that  is  during 
the  initial  fever;  secondly,  there  is  a  gradual  diminution  in  heat  during  the 
two  days  which  correspond  to  the  period  of  eruption  ;  thirdly,  a  fresh  rise 
of  temperature  (more  moderate  than  is  seen  at  the  beginning),  correspond- 
ing to  the  fever  of  suppuration  ;  while  fourthly  and  lastly,  the  diagram  in- 

*  Beraud:  Archives  Generales  de  Medecine,  Mars  et  Mai,  1859. 


72  DISTINCT    SMALL -POX. 

dicates  a  return  to  the  normal  temperature,  marking  the  period  of  desicca- 
tion to  have  been  reached. 

Period  of  Desiccation. — Let  us  now  study  this  fourth  period,  and  consider 
how  cicatrization  is  accomplished. 

Upon  the  face  and  body,  crusts  are  formed,  which  fall  off;  upon  the 
hands,  the  abraded  epidermis  leaves  in  its  place  a  small  red  surface,  ex- 
actly like  that  left  by  the  pustule  of  ecthyma.  Upon  the  fall  of  the  crusts 
— which  takes  place  from  the  face  pustules  about  the  fifteenth,  eighteenth, 
or  twentieth  day,  and  a  little  later  from  the  body-pustules — there  remains 
in  their  stead,  not  a  depression,  but  a  projection  of  a  violet-red  hue,  deep 
in  shade  as  in  the  skin  of  individuals  who  have  been  exposed  to  cold.  On 
this  projection  a  small  scale  of  epidermis  forms,  which  separates  in  a  few 
days,  and  is  succeeded  by  a  thinner  scale,  which  in  turn  gives  place  to 
another  thinner  still,  and  thus,  in  succession,  epidermic  scales  form  and  fall 
during  a  period  of  from  ten  to  thirty  days.  By  degrees  the  projection 
diminishes  ;  after  from  four  to  six  weeks  there  is  seen  in  its  place  a  slight 
depression ;  in  four,  five,  or  six  months,  the  redness  of  the  skin  has  disap- 
peared, leaving  only  the  small  whitish  puckered  cicatrix  familiar  to  all  of 
you.  It  must,  however,  be  recollected  that  when  the  disease  has  been  of 
the  distinct  form,  and  when  the  pustules  on  the  face  have  not  been  very 
large,  the  red  marks  generally  disappear  without  leaving  more  than  a 
slight  and  transitory  unevenness  of  surface;  but  there  are  other  cases  in 
which,  notwithstanding  the  absolutely  "distinct"  character  of  the  pus- 
tules, deep  cicatrices  are  left. 

Such  is  the  normal  course  of  the  distinct  form  of  small-pox ;  it  is  not  a 
fatal  disease. 

Distinct  small-pox,  however,  though  apparently  strictly  normal,  may 
sometimes,  though  very  rarely,  terminate  in  a  manner  totally  unlooked  for, 
as  so  often  happens  in  scarlatina.  Recall  to  your  recollection  a  young 
woman  of  twenty-one  who  lay  in  bed  No.  7  of  St.  Bernard's  Ward.  She 
had  passed  through  a  remarkably  mild  attack  of  distinct  small-pox.  The 
sister  of  the  ward  had  left  her  at  eight  o'clock  in  the  evening  in  a  perfectly 
satisfactory  state.  Soon  afterwards  she  was  seized  with  cerebral  symptoms, 
and  difficulty  in  breathing  ;  in  an  hour  she  was  dead.  It  is  a  curious, 
anomalous  fact,  that  when  distinct  small-pox  does  prove  fatal,  death  occurs 
earlier  than  in  the  confluent.  Sydenham  observed,  and  so  have  I  in  many 
cases,  that  when  death  occurs  in  distinct  small-pox,  it  happens  about 
the  eighth  or  ninth  day,  but  not  till  the  eleventh  or  thirteenth  in  the  con- 
fluent. 

The  illustrious  physician  whom  I  have  just  named,  Sydenham,  and  after 
him  Van  Swieten  and  Borsieri,  observed  anomalous  and  malignant  epi- 
demics of  distinct  small-pox.  They  were  characterized  in  the  prodromoua 
period  by  the  severity  of  the  pain  in  the  head  and  back,  great  prostration 
of  strength,  anxiety,  agitation,  stupor,  and  sometimes  by  delirium.  'I  ho 
want  of  appetite,  amounting  to  disgust  for  every  kind  of  food,  was  very 
marked.      Sometimes  there  was  delirium  and  sleeplessness;   at    other  times, 

profound  coma,  twitchings  of  the  tendons,  a  tendency  to  syncope,  and  very 
often,  irregular,  quick,  and  Laborious  breathing — the  latter,  an  indication 
of  greal  danger.  The  fever  was  at,  times  very  high,  and  at  other  times  the 
pulse  was  small,  feeble,  and  irregular;  there  was  doI  much  heat  of  skin; 

the    perspiration    was   very  copious.      The   eruption    came   out   well    on    the 

third  or  fourth  day,  but  there  was  more  thi oe  crop:  on  the  fifth  or 

sixth  day  fresh  pimples  appeared  ;  all  the  pustules  did  not  attain  the  same 
size,  some  remaining  pale  and  indolent,  while  in  cases  where  the  eruption 
was    mild,  pressure   on    a    level  with   the    pustules   occasioned    acme    pain. 


CONFLUENT    SMALL-POX.  73 

The  fever  and  other  disturbances  of  the  system  continued,  in  place  of  sub- 
siding on  the  appearance  of  the  eruption,  as  in  ordinary  cases.  Inordinate 
perspiration  stopped  suddenly,  and  could  not  be  recalled  in  any  degree  by 
treatment.  Micturition  was  frequent,  but  scanty,  and  sometimes  there  was 
suppression  of  urine,  a  symptom  which  Sydenham  regarded  as  of  most 
unfavorable  augury  at  that  stage  of  the  disease,  as  well  as  in  the  decline  of 
the  distinct  form.  Occasionally,  copious  diarrhoea  set  in.  At  last,  the 
patient  sunk,  as  I  have  already  said,  on  the  eighth  or  ninth  day,  under  the 
nervous  and  comatose  symptoms  of  which  I  have  spoken. 

From  the  facts  now  stated,  it  appears  that  when  the  eruption  does  not 
come  well  out  by  the  fifth,  sixth,  or  seventh  day — when  the  pustules  are 
irregularly  developed  ;  when  the  perspiration  ceases,  and  cannot  be  restored ; 
and,  lastly,  when  delirium,  profound  coma,  and  twitching  of  the  tendons 
continue  or  supervene,  the  worst  possible  prognosis  must  be  formed.  The 
fatal  issue  is  impending  and  very  near.  Delirium,  however,  must  not  be 
confounded  with  acute  mania,  of  which  we  had  a  case  in  a  woman,  who, 
during  the  progress  of  modified  small-pox,  presented  no  disturbance  of  the 
nervous  system,  except  attacks  of  mania  without  fever.  At  the  beginning 
of  the  fever  of  maturation,  on  the  sixth  or  seventh  day  of  the  disease,  it  is 
not  unusual,  even  in  distinct  small-pox,  to  meet  with  delirium,  lasting  for 
one  or  two  days  ;  it  is  most  frequently  observed  at  night ;  sometimes  it  is 
rather  violent.  At  one  time  I  used  to  be  much  alarmed  by  the  occurrence 
of  delirium ;  but  at  present  it  is  a  symptom  which  gives  me  no  anxiety. 
It  subsides  without  the  intervention  of  art,  and  modifies  neither  the  general 
character  nor  the  prognosis  in  distinct  small-pox.  Here  I  must,  however, 
make  certain  reservations.  I  do  not  fear  delirium  if  the  pulse  maintain 
its  volume  and  do  not  become  rapid,  if  sweating  continues  ;  but  if  the  skin 
is  dry  and  cold — if  the  pulse  lose  its  proper  strength  and  become  small, 
sharp,  or  irregular,  the  delirium  has  a  very  different  meaning,  and  is  a 
certain  sign  of  approaching  death. 

Confluent  Small-pox. — Diarrhoea  {chiefly  in  children)  at  the  commence- 
ment of  the  illness. — Salivation. — Swelling  of  the  Face. — Swelling  of  the 
Hands  and  Nervous  Complications. — Boils. — Abscesses. — Purulent  Infec- 
tion.— A  Ibuminuria. — A  nasarca. —  Treatm  ent. 

When  the  fever  of  invasion  is  exceedingly  intense — when  the  initial 
shivering  has  been  greatly  prolonged,  the  pain  in  the  loins  acute,  the 
paralysis  of  the  lower  extremities  and  bladder  very  decided,  the  vomiting 
continuous — when  sometimes,  even  in  adults,  the  cerebral  disturbance  has 
been  great — and,  finally,  when  the  perspiration  has  not  been  abundant — 
when  such  circumstances  arise — it  may  be  concluded  that  the  case  is  to  be 
confluent.  But  there  is  another  sign,  independent  of  the  symptoms  now 
enumerated,  by  which  we  may  confidently  predict  the  same  result,  when 
the  disease  is  normal ;  and  that  is,  the  appearance  of  the  eruption  at  the 
end  of  the  second  day,  or  not  later  than  during  the  third  day.  In  normal 
distinct  small-pox,  as  I  have  already  said,  the  eruption  is  generally  delayed 
till  the  fourth,  or  even  till  the  fifth  day.  These  remarks,  however,  are  only 
applicable  to  the  normal  course  of  the  two  forms  of  the  disease,  for  in  some 
bad  cases,  malo  semper  omine,  as  Sydenham  and  Borsieri  observed,  the 
eruption  does  not  come  out  till  the  fifth,  sixth,  or  seventh  day,  or  even 
later. 

Diarrhoea  is  very  often  observed  in  confluent  small-pox  from  the  com- 
mencement of  the  illness,  both  in  adults  and  children,  but  particularly  in 


<4  CONFLUENT    SMALL -POX. 

the  latter ;  whereas,  in  distinct  sniall-pox,  as  I  have  already  mentioned, 
constipation  is  the  rule,  at  least  in  adults.  This  diarrhoea,  which  is  most 
common  in  children,  continues  not  only  to  the  fourth  and  fifth  day  of  the 
disease — the  second  and  third  of  the  eruption — but  even  to  the  ninth  and 
tenth  ;  and  in  young  subjects  it  takes  the  place  of  salivation,  which  in  adults 
is  a  leading  feature  of  the  confluent  form.  While  in  the  distinct  form,  on 
the  appearance  of  the  eruption,  the  fever  ceases,  or  at  least  diminishes  to 
such  an  extent  that  the  patient  is  free  from  discomfort  and  seems  restored 
to  health,  it  does  not  at  all  abate  in  the  confluent  form  when  the  eruption 
comes  out ;  on  the  contrary,  it  goes  on,  and  even  increases,  up  to  the  eighth 
day,  and,  indeed,  sometimes  up  to  even  the  thirteenth  day.  Here  you  no 
longer  find  the  period  of  initial  fever  from  the  first  to  the  fourth  day,  and 
the  period  of  maturation  fever  from  the  eighth  to  the  tenth  day.  The  fever 
is  continuous  from  the  beginning  of  the  illness  to  the  end  of  the  second 
week,  or  often  to  a  later  date.  There  is  a  reduction  of  heat  for  not  more 
than  twenty-four  hours,  to  the  extent  of  one  degree.  During  the  suppura- 
tion of  the  pustules,  the  temperature  may  rise  to,  or  even  exceed,  forty-one 
degrees. 

The  confluent  is  still  further  characterized  by  three  great  phenomena  not 
seen  in  the  distinct  form.  I  have  already  alluded  to  salivation.  I  now 
add  great  tumefaction  of  the  face  and  swelling  of  the  hands  and  feet.  The 
two  last-mentioned  symptoms  do  not  exist  in  distinct  small-pox,  or  at  least 
if  they  are  present  when  the  eruption  is  rather  abundant  on  the  extremities, 
it  is  in  an  insignificant  degree  as  compared  with  what  is  met  with  in  the 
confluent  form.     Salivation  is  almost  never  seen  in  distinct  small-pox. 

Let  us  now  attend  to  the  characteristic  features  of  the  eruption  in  con- 
fluent small-pox. 

On  the  first  day  of  the  eruption — the  end  of  the  second  or  beginning  of 
the  third  day  of  the  disease — a  redness  appears  on  the  face,  which,  unless 
it  be  closely  examined,  has  a  diffuse  aspect.  This  redness  is  so  great  on 
the  following  day,  that  it  is  often  impossible  to  know  whether  the  eruption 
be  that  of  small-pox  or  measles.  This  is  a  point  on  which  Sydenham  lays 
great  stress,  remarking,  in  reference  to  external  appearances,  that  the  erup- 
tion of  confluent  small-pox  coming  out,  nunc  erysipelatis  ritu,  nunc  morbu- 
lorum,  it  is  very  difficult  for  those  who  have  not  had  great  experience  in 
the  two  diseases  to  avoid  confounding  them,  unless  attention  be  paid  to  the 
general  phenomena  of  the  case;  though  with  this  precaution  it  is  impossible 
to  mistake  the  one  for  the  other. 

It  is  not  till  the  third  day  of  the  disease  that  notable  projections  are 
visible  on  the  countenance.  The  diffuse  patches  of  redness,  which  at  an 
earlier  stage  might  have  been  mistaken  for  measles,  have  now  become  pap- 
ules, some  of  which  already  contain  a  little  milky  fluid.  On  the  face  the 
papules  have  hardly  any  space  between  them,  so  that  when  the  hand  is 
drawn  across  the  forehead  or  cheek  of  the  patient,  the  inequalities  on  the 
surface  of  the  skin  can  scarcely  be  detected.  The  papules,  besides  being 
smaller  than  in  distinct  small-pox,  have  a  less  determinate  form,  running 
more  or  less  into  each  other.  However,  inwards  the  tilth  day — the  seventh 
day  of  the  disease — their  projection  from  the  surface  i-  more  appreciable, 

and  the  .-willing  of  the  face,  although  far  from  having  attained  its  maxi- 
mum, is  universal.  The  epidermis  is  elevated  by  a  slight  secretion  of  a 
milky  appearance,  and  on  the  following  day  patches  are  to  be  seen  similar 
to  those  produced  by  the  application  01  a  blister.  This  hind  of  vesication 
is  sometimes  bo  general  thai  the  fare  looks  as  if  it  were  covered  with  a  mask 
of  whitish-gray  paper,  of  an  opaline  Lusl  re,  like  papit  r  Joseph  or  parchmenl : 
"Pjebgamem  Especiem  vieu  Korrendam  (cutis facet)  exhibet"  as  Morton  said 


CONFLUENT    SMALL -POX.  75 

in  his  "Pyretologia."  This  is  the  pathognomonic  symptom  of  confluent 
small-pox;  it  is  never  met  with  in  the  distinct  form  of  the  disease,  except 
in  a  very  limited  degree,  when  the  pustules,  h.-inir  coherent,  form  a  few  iso- 
lated patches. 

The  swelling  of  the  face  increases  up  to  about  the  end  of  the  ninth  day, 
when  it  has  attained  its  maximum  ;  it  remains  stationary  on  the  tenth,  and 
ought  to  begin  to  decrease  on  the  eleventh  day.  The  head  and  face,  par- 
ticularly at  the  angles  of  the  jaws  and  around  the  ears,  are  much  swollen 
— as  much  and  more  than  in  erysipelas;  the  eyelids,  though  less  swollen 
than  in  distinct  small-pox,  participate  in  the  general  tumefaction  of  the 
face,  and  for  four,  five,  or  six  days  the  patients  remain  without  opening  their 
eyes.  The  eruption  does  not  spare  even  the  globe  of  the  eye ;  it  involves 
the  conjunctiva  and  cornea,  and  so  gives  rise  to  more  or  less  severe  oph- 
thalmia, leading  to  perforations  and  purulent  discharges,  which  may  ulti- 
mately involve  complete  loss  of  vision. 

I  shall  now  resume  consideration  of  the  character  of  the  eruption,  and 
particularly  the  subject  of  the  universal  uplifting  of  the  epidermis,  caused 
by  the  confluence  of  the  pustules.  This  sometimes  proceeds  to  such  an 
extent  that  the  surface  of  the  skin  presents  the  appearance  of  one  large 
phlyctaena.  About  the  eleventh  day  (and  not  on  the  eighth,  as  in  distinct 
small-pox)  the  phlyctsena  becomes  yellow,  begins  to  be  wrinkled,  and  ex- 
hales a  horrible  stench,  which  is  never  present  in  the  distinct  form  of  the 
disease. 

From  the  second,  sometimes  from  the  first  day  of  the  eruption,  salivation 
sets  in.  At  first,  the  secretion  consists  of  a  fluid  resembling  clear  saliva, 
slightly  viscous,  but  the  viscidity  of  which  increases  on  the  succeeding  days, 
while  at  the  same  time  the  amount  of  fluid  secreted  goes  on  increasing  till 
the  sixth  or  seventh  day  of  the  eruption  (eighth  or  ninth  of  the  disease),  when 
it  is  so  enormous  in  quantity,  that  a  patient  will  give  off  from  one  to  two 
litres.*  The  inconvenience  arising  from  this  discharge  is  very  great,  and 
prevents  the  patient  from  sleeping.  When  he  does  fall  asleep,  with  his 
head  resting  on  the  pillow,  a  constant  flow  of  saliva  inundates  the  bed,  and, 
awaking,  is  followed  by  great  discomfort ;  finally,  he  is  tormented  by  a 
burning,  inextinguishable  thirst.  The  salivation  is  coincident  with  the  ap- 
pearance of  pustules  on  the  inside  of  the  mouth,  veil  of  the  palate,  and 
pharynx.  I  say  salivation  is  coincident  with,  not  that  it  is  dependent  on, 
the  presence  of  pustules  on  the  mucous  membrane  of  the  mouth.  The 
salivary  excretion  may  be  connected  up  to  a  certain  point  with  extension 
of  the  inflammatory  excitement  to  the  glands;  but  it  is  no  less  true  that 
excessive  salivation  in  confluent  small-pox  is  a  phenomenon  in  some  degree 
independent  of  this  excitement,  and  dependent,  perhaps,  upon  the  essential 
nature  of  the  disease.  In  proof  of  the  accuracy  of  this  statement,  it  is  im- 
portant to  call  attention  to  the  fact  that  salivation  does  not  take  place  in 
distinct  small-pox,  even  when  there  are  numerous  pustules  on  the  buccal 
mucous  membrane.  We  had  an  example  of  this  in  a  young  man,  who,  in 
July,  1857,  lay  in  bed  No.  11  Ms,  St.  Agnes's  Ward.  He  had  distinct 
small-pox,  with  an  abundant  eruption  on  the  inside  of  the  mouth,  and  yet 
there  was  no  salivation. 

On  the  third  day  of  the  eruption,  evidence  is  afforded  of  the  existence  of 
the  pustules,  which  become  confluent,  and  cause  inflammation  of  the  entire 
mucous  membrane  of  the  mouth  and  pharynx.  The  swelling  is  greatest  on 
the  sixth  day  of  the  eruption,  when  also,  as  I  formerly  stated,  the  salivation 

*  A  litre  is  rather  more  than  a  British  Imperial  quart. — Translator. 


76  CONFLUENT     SMALL-POX. 

is  most  abundant ;  it  continues  till  at  least  the  ninth  or  tenth  day,  the  sali- 
vation likewise  going  on,  and  lasting  one  or  two  days  after  the  swelling  has 
somewhat  subsided.  There  is,  therefore,  another  cause  for  the  salivation, 
as  was  well  illustrated  by  the  case  of  a  young  girl,  who  occupied  bed  No.  7 
of  St.  Bernard's  Ward.  Every  day  she  filled  three  or  four  spittoons.  She 
stated  that  the  act  of  spitting  excited  violent  pain  in  the  throat,  which  pre- 
vented her  from  swallowing  the  saliva.  She  was  equally  unable  to  swallow 
beverages,  which  she  rejected  after  rinsing  the  mouth  with  them.  I  would 
not,  however,  maintain,  gentlemen,  that  in  this  case  salivation  resulted  solely 
from  dysphagia,  for  in  scarlatina,  for  example,  in  which  there  generally  is 
very  violent  sore  throat,  salivation  is  not  observed.  Salivation,  therefore, 
is  a  complex  phenomenon,  for  which,  although  a  certain  number  of  causes 
may  be  assigned,  it  is  not  easy  to  give  to  each  its  proper  share. 

The  patient  coughs;  his  voice  assumes  a  certain  degree  of  hoarseness. 
These  symptoms  are  explained  by  the  affection  of  the  larynx,  to  which 
organ  the  inflammation  is  propagated  from  the  mouth  and  back  of  the 
throat,  and  which  is  also  often  invaded  by  the  eruption.  The  laryngeal 
affections  are  not  without  gravity,  for  it  sometimes  happens  that  in  conse- 
quence of  them,  patients  are  suddenly  carried  off  by  fits  of  suffocation.  You 
may  have  seen  three  cases  of  this  kind  in  this  hospital.  Three  small-pox 
patients,  at  the  eighth  day  of  the  disease,  which  had  run  a  perfectly  normal 
course,  were  suddenly  seized  with  a  fit  of  suffocation,  which  carried  them  off 
in  a  few  seconds,  before  there  was  time  for  any  one  to  come  to  their  assist- 
ance. In  one  of  them  there  was  found,  on  examination  after  death,  indica- 
tions of  inflammation  of  the  larynx,  and  variolous  pustules  below  the 
glottis. 

The  salivation  has  generally  reached  its  maximum  about  the  ninth  or 
tenth  day  of  the  disease,  and  on  the  following  day ;  consequently,  on  the 
eleventh  day  of  the  disease,  or  occasionally  a  little  later,  it  begins  to  de- 
crease, and  at  the  same  time  the  swelling  of  the  face  diminishes. 

At  this  stage  appears  a  symptom  not  less  momentous  than  the  salivation 
and  swelling  of  the  face ;  it  is  swelling  of  the  hands  and  feet.  This  is  an 
essential  part  of  an  attack  of  confluent  small-pox  ;  it  succeeds  the  saliva- 
tion, and  still  more  the  swelling  of  the  face.  When  it  fails  to  appear  the 
patient  almost  invariably  dies.  Since  I  began  practice  I  have  only  seen 
three  patients  recover  from  confluent  small-pox,  without  having  swelling 
of  the  hands  and  feet,  after  the  subsidence  of  the  salivation  and  tumefac- 
tion of  the  face.  Of  the  three  individuals  to  whom  I  now  refer,  one  was 
in  our  wards  two  years  ago;  another  was  our  patient  during  the  current 
year,  and  some  of  you  may  have  seen  him,  and  may  recollect  that  he  was 
very  ill  indeed  ;  for  more  than  four  months  he  suffered  from  large  abscesses 
and  numerous  very  painful  boils  on  the  limbs  and  other  parts  of  the  body. 
The  third  was  a  young  man  who  occupied  bed  No.  12  of  St.  Agnes's  Ward, 
in  August,  1861.  He  reached  the  thirteenth  day  of  an  attack  of  confluent 
small-pox  without  having  had  any  tumefaction  of  the  extremities.  The 
general  symptoms  were  so  grave  that  we  were  despairing  of  his  recovery. 
Under  these  circumstances  1  resolved  to  subject  him  several  limes  a  day  to 
ablutions  with  cold  water,  giving  him,  at  the  same  time,  the  sulphuric  lem- 
onade recommended  by  Sydenham.  To  our  greal  joy,  he  was  somewhat 
better  uexl  day,  ami  in  four  days  convalescence  was  established,  although 
there  was  no  swelling  of  the  hands  or  feet. 

Is  not  the  red  oedema  of  the  hands  and  feet  seen  in  continent  small-|><>\ 
simply  a  consequence  of  a    natural   determination    to   these   parts,  in    itself 

salutary,  and  proportionate  to  the  number  of  pustules  which  ate  proceed- 


CONFLUENT    SMALL -POX.  77 

ing  to  norma]  inflammatory  evolution?  If  it  be  so,  we  can  understand 
why  cold  affusions,  by  actiug  energetically  upon  the  whole  system,  may  re- 
establish the  functions  of  the  skin,  and  bring  the  disease  back  to  its  normal 
course. 

The  tumefaction  of  the  extremities  sets  in  at  the  end  of  the  ninth  day 
with  rather  acute  pain,  which  on  the  eleventh  or  twelfth  becomes  very 
violent.  The  swelling  and  pain  then  cease.  It  is  a  symptom  similar  to 
the  swelling  of  the  face,  and,  like  it,  depends  on  the  maturation  of  the  pus- 
tules. As  in  distinct  so  in  confluent  small-pox,  the  face-pustules  attain 
their  full  development  sooner  than  those  on  the  body  ;  and  they  are  smaller 
than  in  the  distinct  form  of  the  disease.  The  pustules  mature  more  quickly 
on  the  trunk  than  on  the  extremities ;  concurrently  with  the  inflammation 
which  arises  around  the  pustules  (commencing  about  the  tenth  day,  and 
attaining  its  maximum  on  the  eleventh  or  twelfth),  it  is  not  surprising  that 
the  extremities  should  swell,  and  that  the  swelling  of  the  face  should  cease. 
But  the  great  question  to  be  determined  with  reference  to  the  swelling  of 
the  hands  and  feet  is,  What  is  the  value  of  this  symptom  ?  Sydenham, 
Morton,  Van  Swieten,  and  Borsieri  attached  immense  importance  to  it,  and 
in  relation  to  prognosis  I  wish  again  to  insist  on  its  great  value,  and  to  re- 
peat that  swelling  of  the  hands  and  feet  is  a  necessary  phenomenon  in  con- 
fluent small-pox,  that  patients  almost  invariably  succumb  when  it  is  absent, 
unless  there  be  a  great  critical  discharge  by  the  kidueys  or  bowels.  When 
there  is  absence  of  the  swelling  of  the  hands  and  feet  diarrhoea  is  as  bene- 
ficial as  it  is  to  be  dreaded  in  opposite  circumstances.  This  opinion  was 
held  even  by  Sydenham  and  Morton,  who,  as  a  general  rule,  considered 
jDurging  a  formidable  complication. 

Swelling  of  the  extremities,  which  is  the  rule  in  confluent  small-pox,  is 
an  exceptional  occurrence  in  the  distinct  form  of  the  disease,  and  is  only 
met  with  in  it  when  the.  pustules  are  numerous  on  the  hands  and  feet.  In 
a  young  woman,  whom  we  had  as  a  patient  in  the  Hotel  Dieu,  in  January, 
1861,  with  normal  distinct  small-pox,  although  she  bore  three  true  vacci- 
nation marks,  there  occurred  tumefaction  of  the  hands  and  feet  at  the  end 
of  the  ninth  day,  when,  however,  the  face  and  neck  were  still  very  swollen. 
The  swelling  of  the  hands  and  feet  continued  to  the  thirteenth  day. 

At  the  beginning  of  confluent  small-pox,  as  I  have  already  said,  nervous 
symptoms  appear  pretty  frequently,  such  as  tremors  and  sometimes  slight 
delirium.  When  this  delirium  is  met  with,  it  generally  occurs  as  a  tran- 
sient phenomenon  just  as  the  eruption  is  coming  out,  and  returns  about  the 
third  day  of  the  eruption  (fifth  of  the  disease),  and  continues  to  the  end  of 
the  attack,  or  at  least  to  the  thirteenth  or  fourteenth  day  of  the  disease. 
When  it  is  violent — when  it  assumes  the  form  of  typhic  delirium — when  it 
is  accompanied  by  coma  vigil,  picking  the  bedclothes,  and  twitching  of  the 
tendons,  its  prognostic  significance  is  exceedingly  grave. 

The  same  may  be  said  of  diarrhoea.  It  generally  shows  itself  in  the  early 
days  of  the  disease,  and  ceases  about  the  fifth  day  from  the  date  of  the  in- 
vasion, that  is  to  say,  about  the  second  or  third  of  the  eruption ;  but  when 
it  continues,  and  is  violent  about  the  eighth,  ninth,  and  tenth  days,  the 
prognosis  is  unfavorable,  except  in  the  exceptional  conditions  formerly  men- 
tioned ;  in  ordinary  cases  patients  who  have  violent  diarrhoea  at  or  after 
the  eighth  day  almost  always  die.  This,  however,  was  not  the  opinion  of 
Hoffmann,  who,  so  far  from  dreading  diarrhoea,  even  when  violent,  in  con- 
fluent small-pox,  looked  upon  it  as  beneficial ;  but  the  opposite  opinion, 
which  I  hold,  is  that  of  Sydenham,  Morton,  and  Borsieri. 

When  the  eruption  has  reached  its  thirteenth  or  fourteenth  day,  just 
when  the  swelling,  which  has  for  two  or  three  days  left  the  face,  appears  in 


78  CONFLUENT    SMALL-POX. 

\ 
the  extremities,  the  patient  exhales,  as  I  have  already  said,  an  insupport- 
able fetor.  If  you  raise  the  bedclothes  you  are  shocked  with  the  disgusting 
smell  which  comes  from  the  putrefaction  of  the  pus  exuded  by  the  pustules. 
This  putrefaction  has,  perhaps,  something  to  do  with  the  serious  complica- 
tions which  occasionally  supervene  at  this  period.  There  may  be  absorption 
of  the  putrescent  fluids  and  miasms,  poisoning  the  blood,  and  producing  in 
that  way  the  grave  symptoms  which  arise.  I  dare  not,  however,  assert 
positively  that  facts  are  in  exact  harmony  with  this  theory,  which  has  Bor- 
sieri  as  a  supporter.  With  a  view  of  preventing  the  dreaded  purulent  in- 
fection, some  practitioners,  as  you  are  aware,  are  in  the  habit  of  opening 
the  pustules  as  soon  as  possible,  and  bathing  the  skin  very  frequently  with 
chlorinated  lotions.  This  practice,  at  least  to  the  extent  of  opening  the 
pustules,  was  followed  by  the  Arabian  physicians  Avicenna  and  Rhazes. 
Ambrose  Pare  also  adopted  it.  It  may  be  very  beneficial ;  but  its  perform- 
ance must,  in  my  opinion,  be  often  exceedingly  difficult.  The  baths  have 
likewise  great  utility,  as  have  all  measures  which  conduce  to  cleanliness — 
a  maxim  strongly  put  by  Van  Swieten,  when  he  recommended  that  the 
patients  should  have  their  linen  changed  frequently.  It  must  be  clearly 
understood,  however,  that  such  proceedings  demand  great  precautions,  and 
that  in  our  hospital  practice  it  is  sometimes  very  difficult  to  carry  out  the 
very  useful  precepts  now  noticed. 

As  the  disease  advances,  as  the  patient  enters  the  third  week,  the  delirium, 
which  had  continued  up  to  the  thirteenth  or  fourteenth  day,  ceases ;  the 
fever,  however,  continues,  and  generally  goes  on  till  the  twentieth,  twenty- 
first,  or  twenty-second  day,  which  is  accounted  for  by  the  persistence  of  the 
violent  inflammation  of  the  skin,  still  almost  entirely  covered  with  pustules 
more  or  less  deeply  ulcerated.  Then,  however,  the  crusts  formed  upon  the 
ulcerated  surfaces  present  the  appearance  of  ecthyma  crusts ;  they  become 
detached,  leaving  the  dermis  more  or  less  scooped  out.  New  crusts,  thinner 
than  their  predecessors,  then  form ;  they  also  fall  off,  and  are  succeeded  by 
others  thinner  still ;  and  so  on  during  two,  three,  or  four  weeks,  crusts  suc- 
ceed each  other  on  the  small  ulcerations  which  ultimately  cicatrize,  leaving 
the  scars  more  or  less  rugged,  which  seam  the  faces  of  persons  who  have 
gone  through  confluent  small-pox. 

After  the  fourth  week  of  the  disease  it  often  happens  that  the  fall  of  the 
crusts  is  followed  by  a  true  furuncular  diathesis.  Patients  may  have,  on 
the  surface  of  the  body,  as  many  as  twenty,  thirty,  or  even  a  hundred  boils, 
causing  excruciating  pain,  and  succeeding  each  other  so  as  to  maintain  the 
crop  for  from  two  to  six  months. 

The  tendency  to  suppuration,  consecutive  to  confluent  small-pox,  not  only 
shows  itself  in  an  outbreak  of  boils,  but  also  by  the  formation  of  abscesses 
more  or  less  deepseated.  Too  often  these  abscesses  prove  very  dangerous 
complications.  We  see  our  convalescent  patients  suddenly  seized  with  rigors 
and  the  most  intense  fever;  they  complain  of  pain  in  the  deepseated  mus- 
cles; and  the  fluctuation  detected  on  examining  the  pails  gives  clear  evi- 
dence of  the  existence  of  a  more  or  less  considerable  collection  of  pus  to 
which  it  will  be  necessary  to  afford  an  exit.  The  abscesses,  like  the  boils, 
go  on  in  succession  lor  from  two  to  six  months,  unless  the  patient  unfortu- 
nately SUCCUmbs  previously,  as  IS  generally  the  ease,  exhausted  hy  the  pro- 
tracted   suppuration.      Almost    always  these  ahseesses   occur  in    the    limbs. 

Sometimes  they  are  situated  around  the  anus,  and  give  rise  t<>  detachment 
of- the  rectum  from  the  surrounding  cellular  tissue,  necessitating,  al  a  later 

date,  the  operation    for  fistula.      In   some  Still    rarer  cases  the   abscess   may 

he  more  deeply  seated,  and  cause  dreadful  complications. 

( )n  the  7i li  February,  L861,  we  performed  the  autopsy  of  a  lad  who  died 


CONFLUENT    SMALL -POX.  79 

after  an  attack  of  confluent  small-pox,  whom  you  saw  when  he  occupied 
bed  No.  21  of  St.  Agnes's  Ward.  During  convalescence  he  had  numerous 
boils  and  subcutaneous  abscesses,  some  of  which  opened  spontaneously,  and 
others  of  which  were  opened  by  us.  He  nevertheless  complained  of  acute 
pain  in  swallowing,  which  I  attributed  to  the  persistence  of  an  inflamma- 
tory condition  of  the  pharynx  and  curtain  of  the  palate,  which  existed 
when  the  small-pox  was  running  its  course.  About  the  end  of  January, 
when  an  epidemic  of  influenza  was  prevailing,  he  was  seized  with  acute 
bronchitis,  and  we  soon  afterwards  detected  slight  pleurisy  at  the  back  of 
the  left  side  of  the  chest.  The  inflammation  of  the  chest  seemed  to  have 
moderated,  when,  on  the  5th  of  February,  I  found  him  unable  to  breathe 
in  the  horizontal  position,  with  difficult,  wheezing  inspiration,  and  very 
laborious  expiration ;  the  symptoms  of  oedema  of  the  glottis  were  unmis- 
takably evident ;  I  was  under  the  impression  that  there  was  necrosis  of  a 
portion  of  the  larynx,  and  erysipelato-phlegmonous  inflammation  of  the 
aryteno-epiglottidean  folds.  I  ordered  a  solution  of  tannin  to  be  applied 
to  the  back  of  the  pharynx  by  means  of  the  apparatus  of  Mathieu,  and  at 
the  same  time  directed  that  everything  should  be  in  readiness  for  trache- 
otomy. At  four  in  the  afternoon  the  symptoms  had  become  so  formidable 
that  the  sister  of  the  ward  summoned  the  chaplain  before  she  sent  for  the 
interne  on  duty;  when  the  latter  arrived,  the  patient  was  dead.  You  will 
recollect  that,  on  examination  after  death,  we  found  cedematous  inflamma- 
tion of  the  aryteno-epiglottidean  folds,  and  an  abscess,  as  large  as  a  pigeon's 
egg,  between  the  oesophagus  and  back  of  the  larynx  ;  this  abscess,  limited 
in  front  by  the  denuded  cricoid  cartilage,  spread  under  the  cellular  tissue 
within  the  larynx,  and  bulged  out  considerably  into  the  larynx  above  the 
vocal  cords. 

It  is  not  usual  for  oedema  of  the  glottis  to  occur  in  this  manner  in  cases 
of  small-pox.  It  appears,  as  I  have  already  said,  between  the  ninth  and 
twelfth  day  of  the  disease,  when  the  eruption  is  very  confluent  on  the  mu- 
cous membrane  of  the  throat  and  larynx ;  the  tumefaction  of  the  aryteno- 
epiglottidean  ligaments  comes  on  as  does  that  of  the  eyelids  and  hands ; 
and  you  have  seen  a  young  man  die  in  our  wards,  in  a  few  hours,  suffocated 
by  this  form  of  variolous  oedema  of  the  glottis.  But,  gentlemen,  you  can 
remember  a  young  woman  in  St.  Bernard's  Ward,  in  1860,  who,  about  the 
twelfth  day  of  an  attack  of  small-pox,  was  seized  with  dyspnoea,  hoarseness, 
and  wheezing  inspiration,  and  who,  nevertheless,  was  completely  and  quickly 
cured  by  injecting  a  saturated  solution  of  tannin  into  the  back  part  of  the 
throat. 

We  have  lately  had  an  opportunity  of  observing  a  case  of  distinct  small- 
pox in  a  child  of  twenty  months,  which  is  full  of  clinical  instruction.  This 
patient,  on  the  third  day  of  the  eruption,  was  seized  with  dyspnoea,  which 
seemed  to  be  chiefly  dependent  on  cedematous  laryngitis.  Tracheotomy 
was  performed:  at  the  moment  of  opening  the  windpipe,  two  false  mem- 
branes were  thrown  out  through  the  wound.  The  child  died  a  few  hours 
after  the  operation.  An  autopsy  showed  that  the  small-pox  had  been  com- 
plicated by  a  pseudo-membranous  inflammation  extending  to  the  larger 
bronchial  tubes ;  on  the  right  side  there  were  isolated  masses  of  purulent 
pneumonia,  and  on  the  same  side  a  small  quantity  of  purulent  effusion. 
This  is  an  exceedingly  rare  complication,  but  still  it  is  well  to  notice  it  to 
you. 

I  take  this  opportunity  of  remarking  that  all  inflammatory  action  has  a 
great  tendency  to  become  purulent  in  cases  of  small-pox,  and  that  we  see 
this  in  the  inflammatory  affections  of  the  cellular  tissue  and  parenchyma 
of  organs.     But,  in  addition  to  this  tendency,  the  result  of  a  special  dia- 


80  CONFLUENT    SMALL-POX. 

thesis  which  belongs  to  small-pox,  another  complication  may  arise,  viz., 
metastatic  abscesses  presenting  analogous  general  symptoms  to  similar  col- 
lections of  pus  occurring  after  amputations  and  in  puerperal  women.  This 
manifestation  of  metastatic  abscesses  begins  particularly  between  the  ninth 
and  fourteenth  day  of  the  disease,  that  is  to  say,  when  the  skin  is  covered 
with  a  sheet  of  pus.  Possibly  there  exists  at  this  time  capillary  phlebitis, 
as  the  starting-point  of  the  purulent  infection,  a  view  maintained  by  Pubes, 
and  which  Legallois  has  endeavored  to  establish  in  his  essay  on  purulent 
infection.  The  existence  of  capillary  phlebitis  in  small-pox  has  not  been 
demonstrated,  but  the  hypothesis  of  its  presence  becomes  very  truthlike 
when  we  recollect  that  we  sometimes  meet  with  erysipelas  of  the  arms  and 
legs  in  confluent  small-pox ;  in  these  cases  the  lymphatic  vessels  or  veins 
may  participate  in  the  purulent  inflammation  of  the  skin,  and  become  the 
cause  of  infection. 

It  is  only  in  exceptional  cases  that  distinct  small-pox  is  fatal ;  but  we 
have  said  enough  to  show  that  it  is  far  otherwise  with  the  confluent  form 
of  the  disease.  The  history  of  epidemics  proves  this :  in  some  epidemics, 
the  half;  in  others,  four-fifths ;  and  in  others,  less  fatal,  we  And  that  one- 
third  die  of  those  attacked.  It  is  therefore  the  most  deadly  of  all  pesti- 
lences ;  the  mortality  is  much  in  excess  of  that  from  yellow  fever  or  cholera. 
The  terrible  feature  of  small-pox  is,  that  it  not  only  kills  in  the  acute  stage, 
but  even  after  it  seems  to  have  left  the  patient,  and  when  all  danger  ap- 
pears to  be  past.  It  proves  fatal  by  the  deepseated  suppurations  of  which 
we  have  spoken — suppurations  which  invade  the  cellular  tissue  of  the  limbs, 
and  likewise  become  developed  in  the  serous  cavities,  more  frequently  in 
the  pleurae  than  in  the  peritoneum ;  it  proves  fatal  by  peri-pneumonia, 
which  rapidly  proceeds  to  suppuration,  and  that  so  late  as  the  second  or 
third  month  from  the  beginning  of  the  eruptive  fever.  We  are  then  right 
in  saying,  and  repeating,  that  small-pox  is  the  most  formidable  of  epidemic 
diseases ;  for  while  other  diseases  strike  down  their  victims,  they  rarely  do 
so  during  convalescence. 

In  small-pox,  when  death  occurs  during  the  course  of  the  disease  itself, 
it  occurs  at  a  period  which  it  is  necessary  to  indicate,  inasmuch  as  it  is  of 
the  highest  importance  to  know  when  to  expect  the  fatal  issue  so  that  we 
may  be  able  to  foresee  and  predict  it.  In  confluent  small-pox  the  patient 
very  seldom  dies  before  the  eleventh  day,  and,  in  general,  the  most  fatal 
epochs  are  the  twelfth,  thirteenth,  and  fourteenth  days.  However  alarm- 
ing the  symptoms  may  be,  even  when  death  seems  imminent  on  the  seventh 
or  eighth,  we  may  hope  that  life  will  be  prolonged  at  least  to  the  eleventh 
or  twelfth  day.  Sometimes,  nevertheless,  the  disease  terminates  fatally 
within  the  first  five  or  six  days,  but  this  is  only  when  it  has  assumed  an 
anomalous  form,  and  is  of  an  exceptionally  malignant  type.  Quite  suddenly, 
and  without  apparent  cause,  the  strength  fails,  unusual  symptoms,  noi  in 
accordance  with  the  ordinary  course  of  the  disease,  show  themselves;  there 
is  a  formidable  increase  in  the  nervous  symptoms — in  the  delirium,  coma, 
prostration,  anxietj — ami  also  in  the  dyspnoea,  although  there  is  no  ap- 
preciable thoracic  Lesion.     A  rapidly  fatal  issue  is  particularly  apt  to  take 

place  iii  those  frightful  cases  of  hemorrhagic  small-pox  of  which  we  had 
some  in  the  hospital,  and  of  which   I  shall  immediately  speak. 

Anasarca,  which  supervenes  in  the  lasl  period  of  scarlatina,  and  occa- 
sionally, though  rarely,  al  the  end  of  an  attack  of  measles,  also  occurs  in 
conllueiil  small-pox  ;  il  IS  rarer  than  in  scarlatina,  and  more  fre.pient  than 
in   measles. 

Albuminuria  is  almost  as  common  in  confluent  Bmall-pox  as  in  scarlet 

fever.    There  is  this  difference,  however,  that  in  scarlatina  the  albuminuria 


CONFLUENT    SMALL-POX.  81 

appears  during  the  decline,  and  in  confluent  small-pox  during  the  acute 
period  of  the  disease  Extensive  observations  made  by  Dr.  Abeille*  have 
shown  that,  in  confluent  small-pox,  as  in  scarlatina,  albuminuria  is  met  with 
in  about  one-third  of  the  cases.  Developed  at  the  beginning  of  the  attack, 
the  renal  affection  may  continue  to  the  end  of  it,  so  as  then  to  present  a 
kind  of  analogy  with  scarlatinous  albuminuria.  Although  albuminuria 
does  not  show  itself  nearly  so  often  during  convalescence  from  small-pox  as 
in  the  decline  of  scarlatina,  the  occurrence  is  sufficiently  frequent  to  be 
remembered  as  a  possible  complication.  The  same  remark  applies  to  hwm- 
aturia,  an  affection  which  often  precedes  and  announces  the  existence  of 
scarlatinous  albuminuria.  It  is  rarer  in  confluent  small-pox  than  in  scar- 
latina ;  and  when  it  does  occur,  it  is  at  the  commencement  of  the  disease,  and 
not  during  the  period  of  its  decline.  Independently  of  the  cases  in  which 
the  hematuria  is  connected  with  Bright's  disease  of  more  or  less  transient 
character  [affection  Brightique  plus  on  moins  passagere  de  reins],  there  are 
others  in  which  passing  blood  by  the  urethra  constitutes  an  epiphenomenon  of 
the  most  serious  import.  Such  is  it  when  coincident  with  nasal,  buccal,  bron- 
chial, and  subcutaneous  hemorrhages,  as  in  the  terrible  forms  of  the  malady 
described  by  the  ancients  as  variolas  nigrce,  or  black  small-pox. 

Many  of  you,  gentlemen,  ought  still  to  recollect  two  cases  of  this  kind 
which  we  saw,  in  1860,  in  the  wards  of  our  colleagues,  Drs.  Legroux  and 
Pelletan.  The  two  patients  to  whom  I  refer  had  bleeding  from  the  nose, 
mouth,  eyes,  anus,  urethra — in  point  of  fact,  from  all  the  emunctories 
— accompanied  by  a  general  subcutaneous  eruption  of  frightful  intensity, 
of  a  violet-red  color,  like  the  lees  of  wine,  so  that  the  individuals  looked  as 
if  they  had  been  soaked  in  vats  full  of  the  residuum  of  pressed  grapes.  You 
recollect  that  some  of  the  pustules  were  stained  reddish-black  by  the  blood 
with  which  they  were  filled,  and  you  were,  no  doubt,  particularly  struck  by 
the  small  number  of  the  pustules,  although  the  date  of  their  appearance, 
within  forty-eight  hours  of  the  pyrexial  invasion,  left  no  room  to  doubt  that 
the  disease  was  confluent  small-pox. 

Some  years  earlier,  in  1854,  we  had  analogous  examples  in  our  wards. 
But  in  them — to  which  I  shall  return  when  I  speak  of  measly  and  scar- 
latinous eruptions  in  modified  small-pox — in  them  the  hemorrhagic  compli- 
cations were  essentially  milder,  and  had  not  the  disastrous  consequences 
seen  in  the  other  two  cases,  the  small-pox  having  been  modified  by  antece- 
dent vaccination.  The  two  unfortunate  patients  of  1860  were  seized  with 
delirium,  restlessness,  and  high  fever,  and  sunk  rapidly  from  the  beginning 
of  the  attack. 

In  young  children  small-pox  presents  important  peculiarities  in  its  onset, 
course,  and  issue. 

In  them  the  period  of  incubation  is  the  same  as  in  the  adult,  viz.,  from 
nine  to  eleven  clays.  The  initiatory  symptoms  often  pass  unobserved, 
because  the  little  patient  cannot  tell  what  he  feels  ;  still,  the  experienced 
clinical  observer  will  always  be  on  the  outlook  for  the  eruption  of  small-pox, 
when  he  meets  with  quick  pulse,  vomiting,  diarrhoea,  restlessness,  convul- 
sions or  coma,  in  an  unvaccinated  child,  whose  previous  morbid  condition 
was  inadequate  to  explain  the  appearance  of  these  symptoms.  Two  or 
three  days  after  these  epiphenomena  a  variolous  eruption,  distinct  or  con- 
fluent, is  observed.  It  appears  on  the  surface  of  the  skin,  in  successive  out- 
breaks ;  in  some  places  it  may  be  distinct,  while  it  is  confluent  in  parts  where 
there  is  a  previously  existing  cause  of  irritation,  as  on  the  hips  and  other 

*  Aiseille  :  Traite  des  maladies  a  urines  albumineuses  et  sucrees. 
ArOL.   i. — 6 


82  CONFLUENT    SMALL -POX. 

parts  irritated  by  the  contact  of  the  uriue  and  the  swaddling  bands.  The 
development  of  the  pustules  in  children  differs  in  no  respect  from  their  de- 
velopment in  adults  ;  but  the  younger  the  patient  is,  the  more  reason  is 
there  to  fear  that  the  course  of  the  disease  will  be  anomalous.  Thus,  it  is 
not  uncommon  in  infants  of  one,  two,  or  three  months  to  see  the  eruption 
fade  on  the  first  day  of  the  appearance  of  the  papules ;  under  such  circum- 
stances, the  surface  of  the  body  is  very  pale,  and  the  papules  have  an 
opalescent  aspect.  At  other  times,  and  particularly  about  the  second,  third, 
or  fourth  day  of  the  eruption,  it  has  a  hemorrhagic  appearance,  the  herald  of 
a  speedy  and  fatal  issue ;  the  patients  remain  drowsy,  with  small,  thready, 
irregular  pulse,  and  they  die  without  a  struggle.  It  sometimes  happens 
that  immediately  after  the  first  outbreak  of  the  eruption,  they  take  the 
breast  eagerly  ;  their  skin  continues  hot,  their  pulse  somewhat  frequent,  but 
regular,  and  they  support  well  the  fever  of  maturation.  Infants  above  a 
year  old  may  recover,  but  under  that  age  almost  invariably  die.  On  the 
fourteenth  or  fifteenth  day,  just  when  we  are  believing  that  the  case  is  pro- 
gressing favorably,  death  takes  place,  either  without  a  struggle,  or  after 
one  or  two  fits  of  convulsions. 

These  remarks  show  how  very  reserved  we  ought  to  be  in  our  prognosis 
of  small-pox  in  childhood,  even  when  to  all  appearance  the  case  seems  to 
be  going  on  well.  Small-pox,  confluent  or  distinct,  is  almost  always  fatal 
in  children  under  two  years  of  age  ;  they  may  be  carried  off  without  having 
had  any  of  the  complications  looked  upon  as  so  inauspicious  in  adults. 
When  death  occurs  during  the  first  few  days,  it  seems  to  be  caused  by 
variolous  toxaemia ;  when  it  occurs  later,  say  about  the  third  week,  it  is 
apparently  the  result  of  the  long  struggle  having  exhausted  the  vital  power 
of  the  patient.  Xeed  I  recall  to  your  recollection  that,  in  distinct  small- 
pox in  children,  diarrhoea  is  not  a  serious  complication,  that  on  the  con- 
trarv,  it  seems,  like  perspiration  in  the  adult,  to  be  a  favorable  symptom  ; 
that  in  them,  in  the  confluent  form  of  the  disease,  it  takes  the  place  of  sali- 
vation, and  ceases  spontaneously  on  the  appearance  of  tumefaction  in  the 
hands  and  feet?  Young  children,  when  they  do  not  succumb,  often  have, 
like  adults,  numerous  abscesses  on  the  surface  of  the  body. 

As  it  is,  for  obvious  reasons,  in  the  wards  of  an  hospital,  that  there  is  the 
most  danger  of  contracting  small-pox  the  physician  in  charge  ought  at  once, 
on  the  admission  of  children,  to  inquire  whether  they  have  been  vaccinated  ; 
and  if  they  have  not,  his  first  care  ought  to  be  to  have  the  operation  per- 
formed, unless  there  are  circumstances  which  constitute  a  positive  contra- 
indication. 

The  treatment  of  true  small-pox,  distinct  and  confluent,  has  now  to  be 
considered.  Necessarily,  I  -hall  be  brief  on  this  subject,  tor  there  is  rarely 
room  for  energetic  medical  interference  in  the  eruptive  fevers.  These  dis- 
easi  -  run  ;i  natural  course,  which  is  inevitable  ami  definite;  this  remark  is 
strictly  true  in  respect  of  measles  ami  scarlatina,  but  it>  correctness  is  even 
more  strikingly  manifest  in  small-pox,  the  different  periods  of  which  arc 
distinctly  determined,  mathematically  limited,  so  to  speak,  according  i<>  the 
form  of  the  disease  being  distinct  or  continent. 

Distinct  Bmall-pox  is  generally  a  mild  malady,  and  may  generally  be 

left  to  itself.     We  may  resl   satisfied  with  prescribing^^ Lingbevei 

ami  slightly  acidulated  diet-drink-,  such  as  lemonade,  orangeade,  and  cur- 
rant-water. 

Confluent  small-pox,  unfortunately,  does  not  call  for  any  very  different 
treatment  in  recent  times,  the  advantages  resulting  from  the  employment 
of  certain  medicines  have  been  vaunted,  but   the   (acts  uj which  such 


MODIFIED    SMALL -POX.  83 

opinions  rest  arc  for  from  being  conclusive.  My  practice  is,  excepting  when 
there  are  complications  involving  special  indications,  to  confine  myself  to 
prescribing  diet-drinks  acidulated  with  sulphuric  acid,  as  recommended  by 
Sydenham  and  Van  Swieten  under  the  name  of  antiseptics. 

When  there  is  much  cerebral  disturbance,  baths  and  the  cold  affusion  do 
real  service,  though  less  than  in  scarlatina.  Baths  and  lotions,  not  exactly 
cold,  but  of  a  moderate  temperature,  demand  a  very  important  place  in  the 
hygienical  treatment  of  small-pox.  We  have  already  ^een  that  some  prac- 
titioners bathe  their  patients  frequently  with  a  view  of  preventing  the 
purulent  infection  likely  to  result  from  the  formation  and  stagnation  of 
variolous  pus  on  the  surface  of  the  body.  It  is  an  equally  useful  measure 
to  change  the  linen  frequently ;  and  without  going  the  length  of  Van 
Swieten,  who  inculcates  exposing  it  to  the  vapor  of  aromatic  substances,  to 
get  rid  of  the  lye  and  the  soapy  smell,  one  cannot  be  too  careful  as  to  the 
way  of  carrying  out  in  practice  the  frequent  change  of  linen.  The  risk  of 
exposing  small-pox  patients  to  cold  air  has  been  exaggerated.  Sydenham 
combated  the  erroneous  opinion  that  persons  suffering  from  eruptive  fevers 
ought  to  be  kept  iu  rooms  at  a  high  temperature  ;  there  is  nothing  so  danger- 
ous as  this  vulgar  prejudice,  which  caused  patients  to  be  smothered  under 
a  load  of  bedding,  and  to  be  placed  in  chambers  having  every  chink  stopped 
up,  and  the  airing  of  Avhich  was  hardly  ventured  upon.  Cold  is  less  dan- 
gerous than  excessive  heat.  For  this  reason,  Sydenham  prohibited  the  too 
much  covering  of  small-pox  patients,  aud  in  distinct  small-pox,  in  warm 
summer  weather,  he  did  not  confine  them  to  bed.  Cullen  and  Stoll  went 
still  further,  and  directed  that  they  should  be  exposed  to  moderately  cool  air. 

Diarrhoea  in  confluent  small-pox  is  a  terrible  complication  when  it  con- 
tinues till  the  eighth,  ninth,  or  tenth  day ;  it  requires  to  be  kept  in  check 
by  small  doses  of  opiurn,  but  constipation  must  be  equally  guarded  against. 
This  was  the  opinion  of  Sydenham,  Freind,  Lobb,  Huxham,  and  many 
others.  Morton  himself,  who  so  much  dreaded  intestinal  flux,  recommended, 
nevertheless,  the  employment  of  lavements,  and  even  of  purgatives,  when 
the  patients  were  without  stools,  and  the  reaction  excessive ;  he  advised 
similar  means  to  be  resorted  to  when  it  was  desirable  to  excite  a  salutary 
crisis,  in  consequence  of  salivation  ceasing,  without  the  swelling  of  the 
extremities  taking  place. 

In  small-pox,  as  in  typhoid  fever,  it  is  not  judicious  to  place  our  patients 
on  too  low  diet ;  they  ought  to  have  meat  broth,  and  light  soups,  made  with 
or  without  meat,  should  be  given  frequently  and  in  small  quantities  through- 
out the  twentv-four  hours. 


Modified  Small-pox. — Does  not  differ  from  true  Small-pox  in  its  essence. 
— It  differs  from  Varicella  or  Chicken-pox. — It  ivas  xvell  known  before 
our  times. — In  the  period  of  Invasion  it  is  Identical  with  Small-pox. — 
Scarlatiniform  and  Petechial  Eruptions  at  the  commencement. — Black 
Small-pox. — Particular  Modes  of  Desiccation. — Is  seldom  a  dangerous 
disease. 

Gextlemex:  Let  us  now  attend  to  the  subject  of  modified  small-pox. 

In  recent  times  a  proper  custom  has  arisen  of  designating  by  the  terms 
rheumatoid  pains  and.  diphtheroid  exudations,  the  pains  and  exudations 
which  resemble  rheumatic  pains  and  diphtheritic  exudations,  the  object  of 
using  these  new  names  being  to  point  out  that  there  is  only  an  analogy  in 
the  manifestations,  and  not  an  identity  in  the  nature  of  the  maladies  ;  thus, 
the  pains  which  belong  to  syphilis  may  be  called  rheumatoid,  and  we  may 


84  MODIFIED    SMALL-POX. 

designate  a.-?  diphtheroid  the  pultaceous  exudations  •which  proceed  from 
certain  inflammatory  affections  of  the  mucous  membranes  of  the  mouth  and 
genital  organs,  not  in  any  way  dependent  upon  the  general  disease  named 
diphtheria.  If  it  was  right  to  introduce  this  phraseology,  it  would  be  wrong 
to  continue  to  apply  the  term  "  variolo'ide "  to  modified  small-pox,  as  it 
would  leave  room  for  supposing  that  the  natural  and  modified  diseases  are 
essentially  different  from  each  other.  Henceforth,  therefore,  we  shall  sub- 
stitute for  the  word  " variolo'ide"  the  expression  " variole  modifii." 

Modified  small-pox  has  been  observed  long  ago.  Such  of  you  as  would 
wish  to  read  the  histories  of  anomalous  epidemics  of  small-pox  by  Syden- 
ham, the  "Commentaries"  of  Van  Swieten,  and  the  Institutes  of  Borsieri, 
will  be  soon  convinced  that  long  before  the  discovery  of  vaccination  persons 
had  been  observed  to  be  affected  with  a  form  of  small-pox  presenting  all  the 
characteristics  of  the  modified  small-pox  of  the  present  day.  The  modified 
disease  showed  itself  in  those  who  had  had  small-pox  previously,  whether 
communicated  by  accidental  contagion,  by  intentional  inoculation,  or  by 
intra-uterine  communication  ;  this  has  been  demonstrated  beyond  the  possi- 
bility of  doubt  in  our  day,  and  was  perfectly  well  known  to  the  ancients. 
One  cannot  too  often  peruse  and  reperuse  the  interesting  passage  in  the 
"Commentaries"  of  Van  Swieten  on  Boerhaave's  "Aphorisms,"  in  which, 
when  discussing  the  subject  of  second  attacks  of  small-pox,  the  illustrious 
phvsician  of  Vienna  describes  several  kinds  of  modified  or  bastard  small- 
pox, although  he  has  confounded  under  the  name  of  varioke  spuria:  chicken- 
pox  and  small-pox,  which  are  essentially  different  from  one  another. 

Modified  small-pox  is  simply  small-pox  modified  either  by  antecedent 
small-pox,  or  by  antecedent  vaccination.  Varicella  or  chicken-pox  is,  on 
the  contrary,  a  special  and  specific  malady,  having  no  relationship  whatever 
with  small-pox.  It  is  easy  to  demonstrate  the  truth  of  both  statements. 
When  we  come  to  study  varicella  we  shall  see  that  it  never  engenders  small- 
pox, just  as  small-pox  never  engenders  varicella.  Again,  vaccination  has 
no  preventive  influence  against  varicella.  With  respect  to  modified  small- 
pox, we  see  that  it  is  very  different.  If  a  patient  suffering  from  natural 
small-pox,  distinct  or  confluent,  enter  a  ward  where  there  are  individuals 
who  have  been  vaccinated,  but  who  no  longer  enjoy  the  vaccinal  immunity 
in  a  sufficient  manner,  these  individuals  may  take  the  disease;  but  it  will 
present  features  different  from  those  of  natural  small-pox;  they  will,  in  fact, 
have  modified  small-pox.  Again,  if  a  patient  affected  with  modified  small- 
pox, in  its  simplest  and  mildest  form,  be  placed  in  contact  with  one  who 
has  neither  had  small-pox  nor  been  vaccinated,  the  latter  may  contract  the 
disease;  and  if  so,  it  will  not  be  the  modified  form,  but  natural  small-pox, 
distinct  or  confluent;  he,  in  his  turn,  may  communicate  the  variolous  con- 
tagion to  a  third  person,  in  whom  the  case  will  assume  the  natural  or  modi- 
fied form,  just  as  lie  has  or  has  not  been  vaccinated — that  is,  just  as  he  may 
he  in  the  condition  of  the  first  or  second  patient.  Such  cases  a-  1  now  refer 
to  you  have  seen;  they  are  quite  sufficient  to  demonstrate,  rigorously  and 
incontestably,  the  absolute  identity  of  the  modified  and  the  natural  .-mall- 
pox.  This  identity  may  also  be  demonstrated  in  another  ami  more  direel 
manner. 

An  imperious  necessity  has  several  times  obliged  me  to  practice  inocula- 
tion, both  in  this  hospital  and  in  my  wards  for  children  at  the  Necker  II"-- 
pital.  Having  do  vaccine  lymph,  and  small-pox  being  prevalent  in  the 
ward-,  I  hoped  by  Inoculation  to  impart  a  milder  form  of  the  disease  than 
that  which  the  persons  I  inoculated  might  contract  from  the  patients  who 
had  small-pox.  You  can  understand  that,  under  such  circumstances,  1  only 
inoculated  with  viru-  lak.ii  from  a  case  of  modified  small-pox.  in  which  the 


MODIFIED    SMALL-POX.  85 

characters  of  the  distinct  form  of  the  disease  were  as  well  marked  as  I  could 
possibly  find  them.  Now,  in  spite  of  that  precaution,  I  always  communi- 
cated natural  small-pox,  of  the  distinct  form,  it  is  true,  but  still  umistakable, 
natural  small-pox.  So  legitimate  was  the  disease  I  imparted,  that  if  Borne 
days  after  recovery  I  introduced  the  vaccine  matter  into  one  arm,  and  the 
variolous  matter  into  the  other,  neither  declared  themselves.  The  individual 
had  lost  his  aptitude  for  contracting  the  disease,  which,  like  the  other  erup- 
tive fevers,  does  not  attack  the  same  person  a  second  time,  save  in  excep- 
tional cases.  .Small-pox,  natural  and  modified,  are,  therefore,  identical, 
because  they  repi'oduee  natural  small-pox. 

During  the  first  quarter  of  this  century  the  existence  of  modified  small- 
pox was  almost  disputed.  However,  at  the  London  Small-pox  Hospital 
persons  were  from  time  to  time  received  who  said  they  had  been  vacci- 
nated ;  and  Jenner  himself  avows  having  seen  some  such  cases ;  but  as  there 
was  a  desire  at  that  time  to  make  out  that  vaccination  could  never  fail,  it 
was  alleged  that  vaccinated  persons  who  took  small-pox  had  been  badly 
vaccinated,  and  their  attacks  were  looked  upon  as  natural  small-pox.  At 
last  evidence  became  irresistible,  when,  about  the  year  1822,  epidemics  of 
small-pox  were  seen  to  strike  vaccinated  populations,  when  three  years  later 
they  reached  Paris,  where  in  recent  years  they  have  continued  to  prevail. 

The  influence  which  the  variolous  matter  exerts  on  the  economy,  and  the 
modifications  which  it  imprints  on  the  organism,  being  necessarily  subordi- 
nate to  the  predisposition  acquired  by  the  organism  under  the  variolous 
influence,  or  (which  is  the  same  thing)  under  the  influence  of  antecedent 
vaccination,  it  necessarily  follows  that  a  second  variolous  inoculation  will 
produce  on  the  economy  various  effects  proportionate  to  the  degree  of  im- 
munity previously  conferred  upon  it,  and  which  it  still  possesses  more  of 
less  completely.  Also,  although  modified  small-pox  is  in  its  essence  iden- 
tical with  natural  small-pox,  it  is  far  from  being  identical  in  its  forms.  In 
place  of  having,  like  natural  small-pox,  fixed  and  precise  features,  it  even 
presents  essential  differences  from  itself,  and  has  no  settled  character.  So 
correct  is  this  statement,  that  the  only  way  to  describe  modified  small-pox 
is  to  speak  of  each  of  its  numerous  varieties  as  I  now  propose  to  do. 

There  is  one  period  in  which  modified  is  always  identical  in  symptoms 
with  natural  small-pox;  that  is,  the  period  of  invasion.  However  much 
attention  you  may  bestow  upon  initiatory  phenomena  of  the  disease,  it  will 
be  as  impossible  for  you  as  it  was  for  me  to  establish  a  difference  between 
symptoms  of  each  during  that  period.  Pugors  followed  by  heat,  anxiety, 
headache,  pain  in  the  epigastric  region,  nausea,  retching,  vomiting,  pain  in 
the  back,  feebleness,  paralysis  of  the  inferior  extremities  and  bladder — -such 
is  the  train  of  prodromic  symptoms  which  alike  supervene  in  modified  and 
natural  small-pox.  In  both  the  symptoms  are  mild,  if  the  case — be  it 
natural  or  modified  small-pox — is  going  to  take  the  distinct  form;  and  in 
both  they  are  more  or  less  violent,  if  it  is  going  to  take  the  confluent  form. 
The  eruption  comes  out  on  the  same  clays  and  in  the  same  manner;  that  is 
to  say,  on  the  fourth  day  in  the  distinct,  and  on  the  second  or  third  in  the 
confluent. 

Here,  thermometric  investigation  furnishes  valuable  information  ;  thus, 
for  example,  the  temperature,  which  had  risen  as  high  as  40  or  41  degrees, 
suddenly  falls  to  about  37  degrees  on  the  appearance  of  the  eruption. 
This  rapid  decrease  of  heat  takes  place  continuously,  and  not  slowly,  as  in 
distinct  small-pox.  The  rapid  subsidence  of  heat  may  enable  us  to  diag- 
nose modified  small-pox,  when  from  the  apparent  gravity  of  the  symptoms, 
we  might  have  supposed  that  the  case  was  one  of  natural  srnall-pox.  Let 
me  add  that,  in  modified  small-pox,  we  begin,  as  pustules  appear,  to  dis- 


86  MODIFIED    SMALL-POX. 

cover  some  of  the  characters  of  anomalous  small-pox  described  by  Syden- 
ham, such  as  a  premature  appearance  of  the  eruption  in  the  distinct,  and  a 
retardation  of  it  in  the  confluent  form. 

Delirium,  as  we  have  seen,  may  supervene  in  confluent  small-pox  during 
the  period  of  invasion,  and  continue  to  the  end,  the  patients  dying  about 
the  twelfth  day.  In  modified  small-pox,  cerebral  complications  are  ob- 
served more  frequently  than  in  natural  small-pox  ;  but  there  is  this  capital 
difference,  that  they  have  not  an  unfavorable  prognostic  signification  in  the 
former.  Last  year,  amoug  others  with  modified  small-pox,  we  had  some  in 
our  wards  who  were  a  prey  to  violent  delirium,  which,  after  continuing, 
not  only  on  the  morrow  of  the  eruption,  but  also  for  the  two  or  three  fol- 
lowing days,  ceased  abruptly  on  the  seventh  or  eighth  day  of  the  disease, 
when  the  patients  became  convalescent. 

It  is  more  common  to  meet  with  anomalous  cutaneous  eruptions,  accord- 
ing to  the  prevailing  epidemic  constitution,  in  modified  than  in  unmodified 
small-pox ;  they  appear  the  day  before  or  simultaneously  with  the  pustular 
eruption.  Sometimes  they  so  much  simulate,  as  to  be  mistaken  for,  the 
eruption  of  measles,  even  when  they  are  looked  at  closely  ;  still  more  do 
they  sometimes  resemble  the  exanthem  of  scarlatina.  The  spots  are  small, 
of  a  more  or  less  deep  red  color,  sometimes  blackish,  nearly  always  running 
into  each  other,  so  as  to  form  large  patches,  hemorrhagic-looking,  to  which, 
the  English  have  given  the  name  of  ras/i.*  This  is  in  a  slight  degree  that 
of  which  I  spoke  of  to  you  as  black  hemorrhagic  small-pox,  recalling  to 
your  recollection  the  terrible  examples  we  had  in  the  wards  of  our  col- 
leagues, MM.  Legroux  and  Pelletan.  These  hemorrhagic  scarlatiniform 
eruptions,  which  in  natural  small-pox  constitute  an  alarming  symptom,  do 
not  lead  to  an  unfavorable  prognosis  in  modified  small-pox.  They  gener- 
ally show  themselves  in  the  groin,  on  the  thighs,  and  on  the  lower  part  of 
the  abdomen.  They  do  not  disappear  on  pressure  with  the  finger,  or  at 
least  there  remains  a  greenish-yellow  mark,  which  quickly  acquires  the 
reddish  hue,  of  a  more  or  less  violet  shade,  momentarily  effaced  by  the 
pressure  of  the  finger.  This  rash  is  sometimes  more  uniformly  diffused ; 
the  condition  of  the  patient  is  then  apparently  more  serious ;  and  I  recol- 
lect that,  in  1854,  we  had  in  our  wards  three  remarkable  cases  of  modified 
small-pox,  accompanied  by  hemorrhagic  scarlatiniform  and  measly  erup- 
tions, which  presented  very  alarming  symptoms  at  the  beginning  of  the 
attack. 

In  two  of  these  cases,  to  which  allusion  has  already  been  made,  the  pa- 
tients were  young  women  between  twenty  and  twenty-three  years  of  age, 
who  came  into  the  hospital  complaining  of  violent  pains  in  the  loins, 
nausea,  vomiting,  and  rigors;  the  pains  in  the  loins  were  accompanied  by 
extreme  debility  in  the  inferior  extremities  and  partial  paraplegia.  On 
the  third  day  in  one  case,  and  on  the  fourth,  in  the  other,  we  >a\\  an  erup- 
tion of  small  red  livid  spots,  varying  in  size  from  a  pin's  head  to  a  lentil  ; 
they  did  not  disappear  on  pressure.  In  one  of  these  young  women,  I  he 
eruption  was  limited  to  (ho  groins  and  axilla' ;  in  the  other,  although  it  was 

more  confluent   in  these  situations,  it  likewise  covered  the  upper  pari  and 

base  of  the  neck;  il  showed  itself  on  the  legs,  where  it  was  of  a  deep  -hade. 
and  was  even  disseminated  over  the  entire  surface  of  the  body,  which  pre- 
sented an   appearance  of  small  dots,  of  a   bright  rosy  hue,  which  became 

*  Tin'  author  is  evidently  no!  aware  thai  English  physicians,  as  well  as  the 
general  public,  use  the  term  rash  when  Bpeaking  of  any  exanthem atous  eruption, 
:oh1  thni  the  word,  except  with  the  assistance  of  one  or  more  other  words,  does 
iini  indicate  a  Bpecial  exanthem,  nor  :i  particular  form  of  exanthem- — Tba  nsl  ltor. 


MODIFIED    SMALL-POX.  87 

effaced  on  being  pressed  by  the  finger.  This  eruption  was  more  copious  on 
the  following  day  ;  but  on  that  day,  which  was  the  sixth  from  the  beginning 
of  the  disease,  the  characteristic  eruption  of  small-pox  came  out.  The 
hemorrhagic  discolorations  enlarged  still  more  on  the  second  day  from  the 
appearance  of  the  pustules,  and  during  the  night  the  patient  had  slight 
bleeding  from  the  nose.  She  had  at  that  time  persistent  fever,  much 
delirium,  and  great  restlessness,  both  of  which  continued  till  the  eleventh 
day  of  the  disease.  At  that  date,  the  greater  part  of  the  variolous  pustules 
aborted,  and  the  rest  desiccated  ;  while  simultaneously  the  general  symptoms 
ceased  without  any  treatment.  Thus,  in  this  case,  there  was  not  only  scar- 
latiniform  eruption,  but  likewise  a  true  nasal  hemorrhage  ;  and  between 
the  twelfth  and  thirteenth  day  of  the  disease  the  subcutaneous  sanguineous 
stains  left  characteristic  traces,  some  reddish  and  others  yellowish.  An 
additional  cause  of  great  anxiety  was  the  continuance  of  the  fever,  delirium, 
and  extreme  restlessness  up  to  the  eleventh  day.  The  nervous  phenomena, 
however,  ceased  in  an  abrupt  manner,  and  the  patient  recovered.  In  another 
young  woman,  and  in  a  young  man  whom  we  had  under  observation  about 
the  same  time,  the  general  symptoms  and  hemorrhagic  eruptions  were  nearly 
as  strongly  marked  as  in  the  first  mentioned  of  the  two  young  women  ;  and 
the  issue  was  equally  favorable.  We  had  to  do  with  persons  who  had  been 
vaccinated,  for  we  found  true  characteristic  vaccinal  cicatrices  ;  and  we  had 
to  do  with  modified  small-pox.  Under  such  circumstances,  even  when  the 
symptoms  have  an  alarming  aspect,  the  case  generally  terminates  favorably. 
I  have  hitherto  spoken  of  cases  of  modified  small-pox,  in  which  scarlatini- 
form  eruption  remained  after  the  appearance  of  variolous  pustules;  there  are 
others  in  which  it  disappears  rapidly,  and  may  escape  observation. 

It  is  a  remarkable  fact,  and  one  to  which  attention  was  long  ago  directed, 
that  variolous  pustules  are  either  not  developed,  or  are  only  developed  very 
sparingly  in  parts  where  the  scarlatiniform  eruption  exists. 

I  have,  gentlemen,  been  speaking  to  you  of  the  scarlatiniform,  and  not 
of  the  scarlatinous  eruption  ;  and  I  have  much  insisted  on  the  name  scar- 
latiniform, which  I  have  given  to  it.  I  wish  still  more  to  insist  on  this  name, 
for  I  confess  that  I  am  at  a  loss  to  understand  how  grave  men,  hospital 
physicians,  occupying  an  eminent  position  in  our  art,  can  constantly  say 
and  print  that  small-pox  was  complicated  with  scarlatina  in  cases  similar 
to  those  which  I  have  just  brought  under  your  notice.  This  deplorable 
mistake  is  made  by  the  anatomical  school  of  pathology,  which,  determining 
the  nature  of  a  disease  by  one  of  its  manifestations  on  the  exterior  of  the 
body,  does  not  take  into  account  the  constituent  elements  of  the  disease, 
the  aggregate  of  which  represents  the  morbid  unity  of  which  we  ought  to 
form  a  conception.  The  cases  now  under  consideration  have  no  more  to  do 
with  scarlatina  than  with  dothienteritis — no  more  than  pneumonia,  small- 
pox, or  scarlatina  have  to  do  with  typhoid  fever,  when  typhoid  symptoms 
appear  in  the  course  of  an  attack  of  any  one  of  them. 

Sometimes,  though  rarely,  the  eruption  is  measly.  In  July,  1862,  we 
received  into  the  clinical  wards  a  young  woman  in  the  third  day  of  an 
attack  of  small-pox.  She  had  been  vaccinated.  The  symptoms  of  the 
initiatory  period  had  been  rather  severe ;  but  there  was  nothing  abnormal 
in  the  aspect  of  the  case.  At  the  visit  hour  the  patient  had  already  some 
characteristic  pustules  ;  at  the  same  time  we  found  an  eruption  resembling 
measles  on  the  hands,  posterior  aspect  of  the  forearms,  on  the  elbows, 
knees,  and  anterior  surface  of  the  thighs.  It  was  displayed  in  irregular 
patches,  separated  by  oddly-shaped  intervals  of  white.  The  exanthem  was 
morbilliform,  and  not  scarlatiniform.  But  some  of  the  red  patches  on  the 
forearms  and  thighs  presented  a  very  particular  character.     In  the  centre 


88  MODIFIED    SMALL-POX. 

was  a  small  red  papule,  around  which  there  was  au  areola  of  about  a 
centimetre  in  diameter.  The  singularity  of  the  appearance  consisted  in 
the  injection  of  the  dermis  not  proceeding  outwards  from  the  central  papule, 
and  diminishing  in  intensity  as  it  got  nearer  the  healthy  skin  ;  so  far  from 
this  being  the  case,  the  discoloration  was  sharply  defined  by  a  narrow, 
bright-red  band,  between  which  and  the  centre,  the  hue  was  notably  less 
deep  in  color. 

The  characteristic  eruption  of  modified  small-pox  comes  out  like  that  of  the 
natural  disease.  It  begins  on  the  face,  forthwith  gains  the  trunk  and 
limbs,  and  finishes  with  the  hands  in  from  thirty-six  to  forty-eight  hours 
from  the  commencement  of  its  appearance.  It  is  at  first  identical  with  the 
natural  variolous  eruption.  Like  it,  it  is  formed  of  small  red  spots,  which 
become  acuminated,  and  then  flatten  towards  the  third  day.  But  generally 
from  the  third  or  fourth  day  of  the  eruption — the  seventh  or  eighth  of  the 
malady — they  undergo  a  remarkable  modification,  which  is  never  seen  in 
natural  small-pox,  whether  distinct  or  confluent.  In  place  of  showing  a 
tendency  to  increase  up  to  the  eighth  day — in  place  of  becoming  surrounded 
by  an  inflammatory  areola,  and  beginning  on  the  nose  and  chin  to  be 
covered  with  small,  yellowish  rough  crusts,  they  dry  up  without  exhibiting 
the  inflammatory  areola  ;  and  they  leave  in  their  place  small  hard,  corneous 
projections,  which  fall  by  a  sort  of  desquamation  between  the  tenth  and 
fifteen  days.  Such  is  modified  small-pox  in  its  elementary  form,  and  as  it 
is  known  to  the  English  by  the  name  of  "  horn-pox." 

In  some  cases,  however,  the  pustules  continue  for  from  three  to  six  days, 
or  longer.  If  you  examine  three  patients  with  modified  small-pox  at  pres- 
ent in  St.  Agnes's  Ward — one  in  bed  No.  8,  another  in  bed  No.  11  bi$, 
and  the  third  in  bed  No.  17 — you  will  see  in  the  first  that  the  pustules 
became  horny  on  the  eighth  day  of  the  eruption  ;  in  the  second,  they 
assumed  that  appearance  on  the  ninth  ;  and  in  the  third,  they  did  not  dry 
up  till  the  twelfth,  thirteenth,  and  even  fourteenth  clay.  These  three  cases 
are  examples  of  the  varieties  of  the  disease,  which  they  show  you  is  in 
reality  abortive  small-pox,  and  that  is  only  developed  on  account  of  the 
morbific  germ  having  been  thrown  upon  a  congenial  soil.  It  appears,  in 
fact,  that  there  are  certain  diseases,  among  which  small-pox  is  conspicuous, 
which,  like  the  seeds  of  plants  when  sown  in  different  soils,  germinate  and 
grow  up  in  different  manners ;  in  soil  suited  to  their  nature,  they  spring  up 
invested  with  all  their  natural  characteristics,  they  blossom,  shed  their 
seed,  and,  in  a  word,  attain  to  perfection  ;  in  a  poorer  soil  they  grow  with 
more  difficulty,  scarcely  blossom,  and  ripen  badly  ;  in  a  still  poorersoil  they 
germinate,  but  almost  immediately  die.  The  seeds  of  diseases,  like  the 
seeds  of  plants,  are  liable  to  degenerate.  The  quality  of  the  germ,  the 
receptive  power  of  the  soil,  whether  it  be  the  earth  or  the  human  body  to 
which  the  germ  is  committed,  are  not  always  the  same.  Under  certain 
circumstances,  the  organism  undergoes  a  constitutional  change  in  virtue  of 
which  it  is  more  or  less  fitted  for  the  reception  and  germination  of  the 
morbific  seed;  hooping-cough,  for  example,  impresses  the  economy  in  so 
special  a  manner  that  the  same  person  will  not  take  that  disease  twice, and 
the  same  is  true  in  respecl  of  scarlatina  and  small-pox.  This  is  mosl  con- 
spicuously true  in  respecl  iii'  the  latter,  though  the  explanation  <>f  the  fad 
is  as  inexplicable  in  the  one  as  in  the  others.  A-  already  said,  small-pox 
and  vaccination  place  the  organism  in  thai  special  condition  in  which  it 
is  incapable  of  again  contracting  small-pox.  This  resistance,  however,  to 
the  morbific  conception  is  nol  absolute.  Second  attacks  of  small-po*  and 
attacks  of  small-pox  in  vaccinated  persona  do  occur,  bul  in  such  cases  the 
morbid  germ  does  not  grow  up  with  its  natural  characteristics.     The  effects, 


MODIFIED    SMALL-POX.  89 

as  I  before  said,  are  proportionate  to  the  degree  of  immunity  which  has 
been  conferred,  and  this  degree  of  immunity  appears  most  frequently  to 
depend  on  the  longer  or  shorter  interval  which  has  elapsed  between  the 
second  attack  of  small-]>ox  and  the  antecedenl  small-pox  or  vaccination. 
If  the  vaccination  is  of  recent  date,  the  nature  of  the  small-pox  will  be 
more  radically  modified,  milder,  for  example,  than  if  twenty-nine  or  thirty 
years  had  elapsed.  Side  by  side  with  cases  of  benignant  modified  small- 
pox, yon  will  see  others  which  for  ten  or  twelve  days  follow  the  exact 
course  of  natural  small-pox;  the  swelling  of  the  face  and  eyelids  takes 
place,  the  pustules  on  the  limbs  are  surrounded  by  an  inflammatory  areola, 
and  pain  is  complained  of  in  the  regions  which  they  occupy  ;  then  this 
swelling  subsides  more  rapidly  than  in  natural  small-pox;  the  pustules  on 
the  hands,  in  place  of  attaining  their  maximum  of  development  on  the 
fourteenth,  are  filled  with  pus  on  the  eleventh  or  twelfth,  when  they  wither, 
instead  of  waiting  till  the  eighteenth  or  up  to  the  twenty-second  day,  as 
happens  in  distinct  natural  small-pox.  The  disease,  in  a  word,  in  some 
individuals,  after  seeking  to  exhibit  itself  in  its  usual  character,  suddenly 
changes  its  manifestations,  and  terminates  in  a  rather  abrupt  manner,  while 
in  others  it  altogether  fails  to  develop  itself. 

In  some  persons  the  organism  seems  so  refractory  to  the  action  of  vario- 
lous matter,  or,  to  continue  the  comparison  which  we  formerly  employed, 
the  soil  is  so  ill  prepared  to  receive  the  morbific  germ,  that  although  there 
has  been  neither  antecedent  small-pox  nor  vaccination,  the  small-pox, 
when  it  is  contracted,  is  modified.  Dr.  Firmin  lately  mentioned  to  me 
the  following  case  which  he  had  just  met  with  in  his  practice  :  A  patient 
had  been  vaccinated  by  him,  and  the  vaccination  did  not  take  effect. 
Some  time  afterwards,  when  he  was  thinking  of  repeating  the  operation, 
he  was  called  to  see  the  patient,  whom  he  found  suffering  from  distinct 
small-pox,  which  ran  a  course  exactly  like  that  of  modified  small-pox. 
Does  not  this  case  offer  a  certain  analogy  to  that  of  the  young  woman 
who  now  lies  in  bed  No.  18  of  St.  Bernard's  Ward?  She  took  small-pox  a 
few  days  after  her  child,  who  had  just  died  of  that  disease  in  its  confluent 
form.  This  young  woman  was  never  vaccinated,  and  she  never  had  small- 
pox, so  she  said  ;  and  she  bore  no  traces  either  of  vaccination  or  small-pox. 
On  and  after  the  tenth  day,  however,  the  case  followed  the  usual  course  of 
the  modified  disease.  The  period  of  invasion  was  characterized  by  general 
discomfort,  great  lassitude  and  muscular  pains,  nausea,  and  epigastric  pain  ; 
of  the  usual  symptoms,  rachialgia  alone  was  absent. 

There  are  still  two  circumstances  which  remain  to  be  noticed.  In  dis- 
tinct, natural  small-pox,  there  is  a  cessation  of  the  fever  upon  the  appear- 
ance of  the  eruption,  but  we  see  it  return  on  the  eighth  day,  when  the  pus- 
tules on  the  face  are  beginning  to  maturate,  to  continue  during  the  ninth 
and  tenth  clay,  finally  to  cease  on  the  eleventh.  In  modified  small-pox, 
even  when  maturation  begins  on  the  eighth  day,  which  is  very  unusual, 
there  is  hardly  any  febrile  excitement,  and  it  does  not  last  for  more  than 
twenty-four  hours ;  the  temperature  in  the  axilla  is  likewise  at  that  time 
hardly  raised.  In  confluent  natural  small-pox,  at  the  coming  out  of  the 
eruption,  salivation  appears,  and  is  the  great  phenomenon  of  that  form  of 
the  disease ;  then  on  the  fifth  day  there  is  swelling  of  the  face,  which 
goes  on  increasing  till  the  ninth,  when  it  has  attained  its  maximum,  at 
wdiich  it  remains  on  the  tenth,  and  on  the  eleventh  it  diminishes  simulta- 
neously with  the  appearance  of  tumefaction  of  the  extremities.  In  modified 
small-pox,  even  when  veiy  confluent,  salivation  almost  never  occurs,  swell- 
ing of  the  face  is  rare,  and  when  it  does  appear  there  is  no  swelling  of  the 
hands  and  feet. 


90  VARIOLOUS    INOCULATION. 

Modified  small-pox  generally  has  a  favorable  issue,  but  it  is  not  invari- 
ably a  mild  disease.  Five  years  ago,  I  lost  a  relation  by  confluent  modi- 
fied small-pox.  Delirium  supervened  at  the  beginning  of  the  attack,  and 
continued  to  the  last ;  death  took  place  on  the  thirteenth  day.  swelling  of 
the  face  having  previously  shown  itself.  This  person  had  been  vaccinated, 
and  bore  evident  marks  of  vaccinia;  yet  he  died  with  the  symptoms  of 
confluent  small-pox  in  a  very  slightly  modified  form.  The  immunity 
afforded  by  vaccination  is  nearly  or  wholly  lost  by  some  individuals  after 
the  lapse  of  a  certain  number  of  years ;  but  even  in  such  persons  confluent 
small-pox,  which  is  the  only  form  of  the  disease  fatal  to  those  who  have 
been  vaccinated,  does  not  present  its  normal  characters. 

Cases  of  a  second  attack  of  small-pox — a  rare  occurrence,  I  repeat — 
have  been  recorded  by  highly  trustworthy  authors.  Diemerbroeck  even 
mentions  having  seen  individuals  take  the  disease  three  times  in  three 
months  ;  and  Borsieri,  referring  to  these  cases,  quotes  others,  and  among 
them  one  celebrated  in  history,  that  of  Louis  XV,  who  died  of  confluent 
small-pox  at  the  age  of  74,  although  he  had  had  the  disease  when  four- 
teen years  old.  I  have  had  in  my  wards  a  medical  student  who,  though 
he  bore  the  marks  of  two  attacks  of  small-pox,  took  it  a  third  time,  and 
that  too  in  a  rather  severe  form. 


LECTURE  II. 

VARIOLOUS   INOCULATION. 

Advantages  of  Inoculation. — Experiments  on  Clavelization* — Dangers  of  In- 
oculation and  Means  of  Diminishing  them. — Methods  of  Inoculating. — 
The  Mother-Pock  and  its  Satellites. —  General  Symptoms. 

Gentlemen:  Nations  dismayed, and  physicians  intensely  occupied  with 
the  terrible  ravages  of  small-pox,  were  in  search  of  some  possible  means  of 
protection  from,  or  at  least  of  some  means  of  moderating,  the  scourge. 
Remedies  alleged  to  be  rational,  and  empirical  nostrums  seemed  equally  in 
vogue;  but  all  prophylactic  measures  had  alike  proved  failures,  when,  in 
1721,  a  woman,  Lady  Mary  Wortley  Montague,  announced  to  England 
that  she  had  witnessed  a  practice  at  Constantinople  which  afforded  perpetual 
protection  from  the  disease  to  all  who  availed  themselves  of  it.  This  prac- 
tice of  variolous  inoculation,  derived  from  China  and  Persia,  countries  in 
which  from  time  immemorial  it  had  been  in  common  use,  as  well  as  in 
Georgia,  Circassia,  and  Greece,  consisted  in  giving  small-pox  to  persons  in 
health.  It  was  already  known  by  experiment  that  the  prophylaxis  of  the 
pestilence  was  in  the  pestilence  itself;  it  was  known  that  those  who  had 
been  once  attacked,  however  mild  the  symptoms  might  have  been,  were 
henceforth  in  a  condition  to  traverse  small-pox  epidemics  with  impunity, 
and  to  expose  themselves  without  risk  to  the  contagion  of  the  disease ;  it 
was  known  thai  second  attacks  were  exceedingly  rare,  and  altogether  ex- 


*  Clavelization  is  a  term  derived  from  clavelie,  the  French  name  for  ovine  variola, 
popularly  known  in  England  u>  " tag-Bore,"  or  "rot,"  or  Bmall-pos  of  sheep. 
Tbanslatob. 


VARIOLOUS    INOCULATION.  91 

ceptional ;  but  it  was  also  known,  on  the  one  hand,  that  small-pox  could 
not  be  communicated  at  pleasure  by  simple  contact ;  and,  on  the  other  hand, 
that  even  it' it  could  he  communicated  in  that  way,  there  existed  no  method 
of  moderating  the  attacks  by  subjecting  the  individual  to  the  contagion  of 
a  mild  case.  Inoculation  seemed  to  offer  every  desired  advantage ;  while 
it  conferred  an  almost  absolute  immunity  for  the  future,  it  was  attended  by 
no  danger.  Never,  it  was  said,  has  small-pox  proved  serious  when  commu- 
nicated by  inoculation ;  the  disease  has  always  assumed  the  distinct  form, 
has  probably  left  no  trace  of  its  passage,  or,  at  all  events,  there  have  been 
none  of  those  horrible  cicatrices  to  deplore,  which  so  often  remain  after 
attacks  produced  by  contagion. 

The  wonderful  statements  of  Lady  M.  W.  Montague,  who,  when  residing 
at  Constantinople  in  1717,  had  not  shrunk  from  having  inoculation  prac- 
ticed upon  her  own  son,  a  boy  of  six  years  of  age,  the  new  example  which 
she  gave,  when, on  her  return  to  London,  she  proceeded  to  have  her  daughter 
also  submitted  to  the  same  treatment,  the  successful  results  proclaimed  by 
her,  and  of  which  she  offered  proofs,  enlisted  the  sympathy  of  a  great  num- 
ber of  right-minded  persons,  both  among  physicians  and  in  general  society. 

Experiments  were  speedily  set  on  foot  in  England,  where  inoculation  was 
soon  adopted,  and  was  ere  long  generally  employed.  The  new  practice 
(which  had  many  opponents  as  well  as  adherents)  was  carried  to  America 
in  the  same  year  that  it  was  introduced  into  England,  and  three  years  later 
it  became  known  in  Germany,  where  some  of  the  children  of  the  first  fami- 
lies of  Prussia  were  inoculated.  The  practice  of  inoculation  did  not  obtain 
a  footing  in  England,  America,  and  Germany,  without  opposition ;  but 
opposition  showed  itself  in  France  in  an  inveterate  manner.  It  was  abso- 
lutely prohibited  when  first  proposed  in  1723 ;  and  it  was  not  till  1756, 
thirty-three  years  later,  that  any  one  ventured  to  try  it.  Although,  in 
France,  the  movement  in  its  favor  originated  in  high  places — for  those 
first  inoculated  were  the  children  of  the  Luke  of  Orleans — it  was  far  from 
being  general.  Such  of  you  as  have  a  curiosity  to  know  the  different  phases 
through  which  the  question  of  variolous  vaccination  has  passed  in  our  own 
and  foreign  countries,  ought  to  read  its  history  as  written  by  Sprengel.* 
The  controversy  ended  in  variolation  being  accepted  and  generally  prac- 
ticed till  it  was  dethroned  by  vaccination ;  and  perhaps  you  still  know  of 
individuals  who  were  inoculated  at  the  beginning  of  this  century,  when,  in 
its  turn,  the  discovery  of  Jenner  was  meeting  with  numerous  adversaries. 

At  that  epoch,  although  very  advantageously  replaced  by  vaccination, 
variolous  inoculation,  which  at  first  had  excited  so  much  opposition,  had 
rallied  resolute  partisans,  particularly  in  England,  where,  as  I  have  just 
told  you,  it  was  first  introduced  on  its  arrival  from  the  East.  It  was  em- 
ployed in  England  down  to  1841,  and  to  eradicate  the  practice  it  was  found 
necessary  to  pass  a  stringent  act  of  Parliament.  It  has  now  been  every- 
where entirely  superseded  by  vaccination.  Circumstances  occur,  however, 
in  which,  for  reasons  which  I  will  explain  to  you,  one  is  still  obliged  to  have 
recourse  to  inoculation,  notwithstanding  the  palpable  inconveniences  which 
it  presents.  I  have  found  myself  placed  in  such  circumstances  ;  and,  as  it 
is  my  duty  always  to  give  you  an  account  of  my  proceedings  at  the  bed  of 
the  patient,  I  have  something  to  say  to  you  on  the  subject  of  variolous  in- 
oculation. As  I  stated  when  speaking  of  modified  small-pox,  I  have  repeat- 
edly practiced  variolation.     I  did  so  for  the  first  time  long  ago  at  the  Xecker 

'  *  Sprexgel  :  Histoire  de  la  MSdecine  ;  traduite  de  l'allcmand,  par  A.  J.  Jour- 
dan,  tome  vi. 


92  VARIOLOUS    INOCULATION. 

Hospital,  arid  more  recently  here,  under  your  observation.  But  neither  at 
the  Necker  Hospital  nor  at  the  Hotel  Dieu  have  I  ever  resorted  to  it,  except 
when  vaccine  matter  was  not  obtainable,  and  when  a  prevailing  epidemic 
of  small-pox  placed  in  imminent  danger  the  lives  of  the  young  children  in 
our  wards. 

In  practicing  variolation  I  have  always  been  anxious — and  this  is  of  the 
highest  importance — to  place  myself  as  much  as  I  could  in  the  position  of 
the  inoculators  of  former  times.  Without  hampering  myself  with  the  pre- 
cautious which  they  considered  necessary — without  preparing,  as  they  sup- 
posed, the  subjects  for  the  operation  by  their  plan  (precautionary  measures 
which  they  themselves  soon  abandoned,  having  found  them  to  be  useless), 
I  proceeded  with  a  view  to  communicate  the  disease  in  as  mild  a  form  as 
possible.  I  was  struck  with  a  fact  which  belongs  to  veterinary  medicine. 
The  tag-sore  of  sheep  is  a  malady  identical  in  its  general  features  with 
small-pox  in  the  human  subject,  and  the  analogy  between  the  two  diseases 
is  sufficiently  great  to  enable  us  to  derive  from  the  study  of  the  one  practical 
lessons  for  the  study  of  the  other. 

Since  last  century  clavelizatiou  has  been  practiced  by  the  most  enlight- 
ened veterinary  surgeons  and  farmers,  whenever  the  disease  has  begun  to 
prevail,  with  a  view  to  prevent  the  ravages  of  an  epizootia.  In  Bessarabia, 
where  inoculation  is  still  universally  practiced,  an  agriculturist  conceived 
the  following  plan  for  obtaining  the  mildest  possible  form  of  ovine  variola: 
he  selected  a  hundred  sheep,  placed  them  in  a  separate  park,  and  then  in- 
oculated them.  In  nine  or  ten  days  the  disease  declared  itself  among  the 
animals.  The  inoculator  then  took  virus  from  one  in  which  the  symptoms 
were  mildest,  and  with  it  inoculated  a  hundred  other  sheep.  He  repeated 
the  same  proceeding  with  a  third  series  of  a  hundred  sheep,  selecting,  as 
before,  the  animal  in  which  the  symptoms  were  mildest.  The  following 
results  were  obtained. 

A  considerable  number  of  the  first  series  died,  the  virus  not  having  lost 
any  of  its  energy.  The  disease,  however,  was  less  fatal  than  if  it  had  been 
produced  by  ordinary  contagion.  The  sheep  of  the  second*  series  had  the 
eruption  in  the  distinct  form,  and  none  of  them  died.  For  the  third  series 
the  distinct  character  was  still  more  decided  than  in  the  second,  and  in 
some  cases  the  only  eruptive  manifestation  was  the  development  of  a  pustule 
at  the  point  of  inoculation.  It  was  then  supposed  that  this  last  result  could 
be  always  obtained.  The  experimenter  had  obtained,  in  point  of  fact,  a 
preservative  virus,  which  conferred  complete  immunity,  and  produced  an 
eruption  limited  to  the  mother  pustule.  Inoculation  of  aggravated  tag-sore, 
performed  on  sheep  so  preserved,  afforded  absolute  proof  of  the  immunity 
which  they  had  acquired,  because  it  produced  no  manifestation. 

These  facts  made  a  great  impression  upon  me,  and  I  asked  myself  whether 
the  same  results  would  he  obtained  in  human  as  in  ovine  variola — whether, 
by  successive  series  of  inoculations  in  the  human  subject,  ;iu  equally  great 
modification  of  the  disease  could  be  produced  as  had  been  produced  in  the 
sheep,  by  which  the.  eruption  had  been  limited  to  a  single  pustule  in  the 

spol   where  the  inoculation  had   been  made.      I  tried  the   experiment  ;il  the 

Necker  Hospital  in  conjunction  with  Dr.  Delpech, then  my  vnterne,TLOVi  my 
colleague  as  physician  to  the  hospitals  and  agrigi  of  our  Faculty.  We 
obtained  the  desired  result  in  some  children,  to  the  extent  thai  the  mother 
pustule,  the  master  pimple  (/e  mattre  bouton  I,  the  pustule  of  inoculation  was 

alone  developed,  and  thai   around  it   there  were  little  pustules,  its  satellites. 

1 1'  we  cuu  Id  be  sure  of  always  attaining  equally  fortunate  results,  inoculation 

ought  to  he  the  rule,  for  then  it  would  be  attended  by  do  risk,  and  it-  con- 
sequences would  be  purely  beneficial.     The  inoculation  would  be  equally 


VARIOLOUS    INOCULATION.  93 

without  danger  to  the  person  inoculated,  and  to  those  with  whom  he  came 
in  contact.  This  localized  variola,  without  general  eruption  or  serious 
symptoms,  would  perhaps  he  no  more  contagious  than  a  cow-pock.  Unfor- 
tunately, matters  did  not  turn  out  so  propitiously. 

In  some  cases,  I  attained  the  complete  success  of  having  only  the  pustule 
of  inoculation  ;  hut  in  others,  in  which  the  very  same  virus  had  been  em- 
ployed, there  were  general  eruptions,  and,  worse  still,  communication  of 
small-pox  to  non-inoculated  persons.  In  one  case,  regarding  which  I  shall 
have  to  speak  in  connection  with  the  subject  of  regeneration  of  vaccine 
virus,  the  small-pox  resumed  all  its  original  violence,  after  having  passed 
through  a  succession  of  individuals  in  a  series  of  inoculations.  This  result 
is  opposed  to  those  recorded  by  the  inoculators,  who  made  out  that  the 
variolous  virus  becomes  progressively  milder  as  the  succession  of  trans- 
plantations proceeds.  The  inconveniences  of  inoculation  are  on  the  one 
hand,  the  risk  of  giving  dangerous  small-pox  to  an  individual,  and  on  the 
other  the  dangerous  possibility  of  thus  establishing  a  focus  of  contagion. 
It  must  be  admitted  that  these  inconveniences  are  serious,  and  they  are 
precisely  the  inconveniences  which,  after  affording  arguments  to  the  adver- 
saries of  inoculation,  caused  it  to  be  abandoned  after  the  discovery  of  vac- 
cination ;  they  are  also  inconveniences  of  such  a  character  as  to  compel  me 
to  discontinue  my  experiments,  and  to  reserve  inoculation  for  the  excep- 
tional circumstances  to  which  I  have  already  alluded,  and  of  which  I  shall 
again  speak.  It  became  my  duty  to  renounce  inoculation,  from  the  fear 
that  even  by  inoculating  with  virus  derived  from  the  mildest  case,  I  might 
cause  the  death  of  persons  who  had  neither  been  vaccinated  nor  inocu- 
lated, through  their  taking  the  disease  in  an  aggravated  form  from  the 
individual  to  whom  I  had  given  it.  I  should  have  acted  otherwise,  if  it 
had  been  possible  to  isolate  the  persons  inoculated.  During  an  epidemic 
of  small-pox,  if  I  could  not  obtain  vaccine  virus,  I  should  not  hesitate 
again  to  try  and  to  recommend  a  trial  of  inoculation,  for  I  should  not  then 
feel  the  responsibility  of  propagating  a  disease  which  was  already  every- 
where. 

There  is  a  small  number  of  persons  so  constituted  as  not  to  take  small- 
pox, though  exposed  a  thousand  times  to  its  contagion,  and  there  are  also 
those  to  whom  it  cannot  be  given  by  inoculation  ;  but  it  is  more  usual  to 
find  others  wdio,  though  more  or  less  insusceptible  to  the  virus,  manifest 
the  disease  very  slowly  after  inoculation. 

To  take  again  the  example  from  comparative  medicine  which  I  have 
already  mentioned,  it  happens  that  when  the  tag-sore,  breaks  out  in  a  flock 
of  five  hundred  sheep,  it  does  not  attack  all  the  individuals  at  once,  but  in 
succession,  so  that  it  rarely  occurs  that  the  epizootia  has  terminated  in  less 
than  from  three  to  five  months.  The  explanation  of  this  is  that  some  of 
the  sheep,  in  virtue  of  a  special  susceptibility,  have  at  once  taken  the  con- 
tagion, while  others  have  required  several  repetitions  of  contact  with  it  for 
the  production  of  the  same  result.     The  same  is  observed  in  small-pox. 

When,  in  former  times,  small-pox  prevailed  as  an  epidemic,  attacking 
the  entire  population  of  a  locality,  hospital,  barrack,  or  prison,  it  was 
observed  that  it  showed  itself  at  successive  intervals  on  different  sections, 
although  every  one  had  been  equally  exposed  at  first  to  the  contagion.  In 
fact,  for  the  production  of  the  disease,  there  must  not  only  be  its  cause  or 
morbific  germ,  but  there  must  also  be  an  economy,  a  soil,  prepared  to 
receive  it ;  a  special  aptitude  of  the  organism  is  wanted,  without  w7hich 
there  can  be  no  conception  of  the  contagion.  Inoculation,  by  forcibly 
introducing  the  virus- into  the  economy,  without  waiting  for  this  aptitude 
to  be  developed,  finds  the  subject  in  that  state  of  unreadiness — the  soil  is 


94  VARIOLOUS    INOCULATION. 

not  sufficiently  prepared,  and  consequently  the  germ  does  not  grow  with 
the  vigor  which  under  other  circumstances  it  would  have  manfested. 
Moreover,  the  inoculation  can  select  the  germ,  that  is  to  say,  take  the 
virus  in  the  conditions  which  are  most  favorable.  By  employing  matter 
from  a  distinct  case  which  has  beeu  modified  by  antecedent  vaccination, 
we  attain  the  greatest  probability  of  communicating  a  very  mild  variola, 
just  as  the  Bessarabian  agriculturist  acquired  by  experiment  the  power  of 
imparting  to  his  sheep  a  very  slight  attack  of  tag-sore. 

Lastly,  inoculation  practiced  daring  an  epidemic  is  a  preservative  against 
aggravated  attacks,  protects  individuals  from  contagion,  the  consequences 
of  which  it  is  impossible  to  estimate,  while,  within  certain  limits,  we  can 
estimate  the  severity  of  attacks  induced  by  inoculation.  It  is  an  excep- 
tional occurrence  for  inoculation  with  virus  taken  from  distinct  small-pox 
to  develop  the  disease  in  its  confluent  form.  When  inoculation  was  first 
introduced  into  Europe,  it  was  more  common  for  it  to  cause  confluent 
small-pox  than  afterwards,  when  vaccinators  took  the  precaution  to  select 
their  virus  under  the  conditions  which  I  have  indicated ;  and  by  reading 
what  our  predecessors  have  written  on  this  subject,  I  have  become  convinced 
that  inoculation  was  day  by  day  diminishing  in  danger,  and  might  have 
become  almost  as  harmless  as  vaccination. 

Inoculation  was  formerly  accomplished  by  inserting  a  thread  impregnated 
with  variolous  matter  in  a  small  incision  in  the  skin,  the  arm  being  the 
part  generally  selected  for  the  operation.  Kirkpatrick,  in  his  "  Treatise  on 
Inoculation,"  said  that  it  was  sufficient  to  rub  the  wound  with  a  bit  of  linen 
soaked  in  variolous  matter.  He  also  stated  that  threads  impregnated  with 
the  virus,  if  shut  up  in  well-closed  boxes,  preserved  their  power  for  several 
months.  To  prove  the  great  length  of  time  variolous  virus  preserves  its 
power,  Dr.  Sunderland,  of  Barmen,  alleges  that  blankets  saturated  with  the 
pus  of  small-pox  preserved  their  contagious  properties  for  more  than  two 
years,  producing  after  that  interval  characteristic  pustules  on  the  udders  of 
cows.  The  blankets  referred  to  were  used  in  his  experiments  upon  the 
regeneration  of  cow-pox  by  communicating  small-pox  to  cow's.  It  was 
necessary,  however,  to  cover  up  carefully  these  blankets  with  paper,  and  to 
keep  them  in  a  little  cask  in  a  shady,  cool  place,  where  the  temperature 
never  rose  to  more  than  10°  of  Reaumur  above  zero.  It  is  recorded  that 
the  Chinese  kept  the  crusts  of  variolous  pustules  in  porcelain  vessels  well 
stopped  with  wax.  They  inoculated  by  introducing  into  the  nostrils  tents 
of  eharpie  covered  with  the  dried  matter. 

At  the  end  of  last  century,  inoculators  performed  the  operation  in  a 
manner  that  was  simpler,  quicker,  and  surer  than  those  I  have  just  de- 
scribed ;  it  consisted  in  raising  the  epidermis  by  means  of  a  lancet,  so  as  to 
introduce  the  matter  with  which  the  lancet  was  charged.  A  prick  is  suffi- 
cient.     The   symptoms  which    ensue   are   the  following  I    First    of  all,  t  here 

are  local  phenomena;  thus,  on  the  second  day  after  inoculation,  there  is 
visible,  in  the  place  where  the  puncture  has  been  made,  a  small  red  pimple 
similar  to  that  which  results  from  vaccination.  About  the  fifth  day  this 
pimple  has  become  an  acuminated  vesicle;  it  sometimes  exhibits  in  its 

centre  the  mark  of  the  puncture,  which    has   a   sunken  appearance,  like  an 

umbilication.  On  the  seventh  day  the  vesicle  has  become  a  pustule,  ami 
is  surrounded  by  a  slightly  r^<\  areola,  which  becomes  flattened,  and 
assume-  a  bluish  tint.  Next  day  the  inflammatory  areola  increases,  and 
on  the  ninth  and  tenth  days  it  increases  Btill  more.     The  pustule,  however, 

continues  to  grow  larger,  becomes  more  depressed  in  the  cent  re,  and  assumes 
more  and  more  the  bluish  tint  ;  it-  edges  have  an  uneven,  puckered  appear- 
ance: there  now  arise  upon  the  inflammatory  areola  a  variable  cumber  of 


VARIOLOUS    INOCULATION.  95 

small  pustules,  teu,  fifteen,  or  twenty  true  satellites  of  the  mother-pustule, 
which  at  first  contain  a  limpid  serosity,  and  afterwards  some  watery  pus. 
At  the  same  time  the  lymphatic  glands  in  the  axilla  begin  to  he  turgid; 
this  turgidity  has  attained  its  maximum  on  the  ninth  day,  after  which  it 
decreases,  and  about  the  fourteenth  or  fifteenth  day  it  disappears.  Gener- 
ally speaking,  in  thirteen  or  fourteen  times  twenty-four  hours,  the  pustule 
of  inoculation  has  dried  up,  but  there  is  sometimes  formed  below  it  a  deep 
slough,  which  separates  in  from  twenty  to  thirty  days,  leaving  a  more  or 
less  misshapen  cicatrix.  In  general,  however,  there  is  no  slough,  and  the 
crust  falls,  being  succeeded^  by  another,  which  in  its  turn  also  separates; 
and  after  a  succession  of  crusts,  there  is  at  last  a  cicatrix  larger  than  that 
which  is  left  after  vaccination. 

The  mother-pustule,  which  is  sometimes  found  when  the  disease  has  been 
communicated  by  contagion  in  the  ordinary  way,  the  "  master  pimple,"  to 
use  the  German  expression,  presents  exactly  the  same  characters  as  the 
pustule  of  inoculation.  You  have  seen  an  example  of  this  in  a  man  who 
occupied  bed  Xo.  11  ter  in  St.  Agnes's  Ward.  He  was  seized  when  in  our 
wards  in  June,  1857,  with  a  varioloid  affection.  Besides  tolerably  distinct 
pustules  developed  on  the  skin,  there  was  observed,  on  a  level  with  the 
nasolabial  line,  a  pustule  larger  than  the  others,  with  a  diameter  almost 
equal  to  that  of  a  twenty-centime  silver  piece  ;  it  was  deeply  hollowed  out 
— cutim .  satis,  prof  uncle  exederat,  as  Van  Swieten  said  of  this  kind  of  pock, 
which  he  called  the  master  polcken.  A  very  red  areola,  as  large  as  a  franc 
piece,  surrounded  it,  and  was  covered  with  small  vesico-pustular  satellites. 
The  patient  affirmed  that  the  great  pimple  had  appeared  at  least  twelve 
days  before  those  on  the  other  parts  of  the  body. 

On  the  ninth  or  tenth  day  after  the  operation,  the  constitutional  symp- 
toms make  their  appearance.  The  patient  has  headache,  pains  in  the  loins, 
vomiting,  and,  in  a  word,  all  the  primary  symptoms  of  small-pox.  About 
the  eleventh,  twelfth,  or  thirteenth  day,  the  specific  erujDtion  is  seen,  which 
in  general  is  but  slightly  confluent,  and  follows  the  course  of  normal  or 
sometimes  that  of  modified  small-pox. 

You  have  had  an  opportunity  of  observing  the  local  and  general 
symptoms  of  inoculated  small-pox  in  an  infant,  upon  whom  I  deemed  it 
right  to  practice  inoculation  at  a  time  when  the  nurses  of  .our  wards  were 
being  carried  off  by  an  epidemic,  and  when  we  had  no  vaccine  virus.  This 
infant,  aged  twenty-four  days,  suckled  by  its  mother,  was  inoculated  by 
means  of  a  puncture  on  the  right  arm,  with  variolous  matter  taken  from  a 
pustule  at  the  eleventh  day  of  the  disease,  in  a  case  of  modified  distinct 
small-pox.  An  unsuccessful  attempt  to  inoculate  this  infant  had  been  pre- 
viously made  with  matter  from  an  exceedingly  distinct  varioloid  case. 
The  result  of  the  second  operation  was  to  produce  on  the  fourth  day  a 
small  umbilicated  pustule,  which,  following  a  regular  course,  left,  on  the 
twenty-first  day  after  its  first  appearance,  a  very  deep  slough.  On  the 
eleventh  day  after  inoculation,  the  seventh  from  the  appearance  of  the 
mother-pustule,  the  infant  had  the  disease  in  its  distinct  form,  and  without 
any  serious  constitutional  symptoms.  The  pustules  dried  up  on  the  seventh 
day  from  the  setting  in  of  the  primary  symptoms,  such  as  vomiting  and 
diarrhoea,  which  began  on  the  ninth  day  from  inoculation.  The  little 
patient  recovered  rapidly,  and  thenceforth  he  was  safe  from  small-pox,  and 
even  unsusceptible  to  vaccination.  Indeed,  on  the  eighteenth  day,  we 
tried  in  vain  to  affect  him  with  the  vaccine  virus,  and  twenty-five  days  later 
we  inoculated  him  with  matter  from  a  case  of  confluent  small-pox,  which 
did  not  even  produce  the  pustule  of  inoculation.  Notwithstanding  the 
complete  success  of  this  experiment — a  success  such  as  I  had  formerly 


96  cow-pox. 

obtained  elsewhere — I  felt  that  it  was  my  duty  to  discontinue  inoculation, 
as  we  had  obtained  a  supply  of  vaccine  virus,  and  the  epidemic  of  small- 
pox seemed  as  if  it  were  on  the  wane. 


LECTURE  III. 


COW-POX. 


Grease  of  Horses. — Coiv-pox  in  the  Cow. —  Cow-pox  in  the  Human  Subject. — 
Cow-pox  and  Horse-pox  are  Analogous  to,  but  not  Identical  with,  Small- 
pox: Practical  Importance  of  this  Distinction. — Regeneration  of  Cow- 
pox. 

Gentlemen  :  Soon  after  the  middle  of  last  century,  when  the  practice 
of  inoculation  had  become  general  in  England,  a  belief  prevailed  in  certain 
counties  that  persons  who  contracted  cow-pox  from  cows  were  permanently 
protected  from  small-pox,  whether  exposed  to  its  contagion,  or  inoculated 
with  its  virus.  Jenner,  the  inoculator  of  the  district  in  which  he  resided, 
was  not  unacquainted  with  this  popular  tradition.  At  first  he  did  not 
believe  in  it ;  but  he  soon  became  convinced  of  its  truth,  having  ascei'tained, 
upon  reliable  evidence,  that  several  persons  who  had  twenty-five,  thirty, 
and  fifty  years  previously  contracted  cow-pox  in  the  dairies  of  the  country 
had,  from  the  date  of  that  occurrence,  escaped  small-pox.  He  was  thus 
led  to  inquire  into  the  conditions  under  which  cow-pox  became  developed 
in  the  human  subject,  and  to  entertain  the  idea  of  inoculating  with  it.  His 
experiments  led  to  results  identical  with  those  produced  by  direct  contagion, 
for  the  persons  to  whom  he  communicated  cow-pox  remained  as  insusceptible 
to  variolous  influence  as  those  who  had  had  natural  small-pox. 

Far  be  it  from  me  to  argue  that  Jenner  was  not  the  discoverer  of  vacci- 
nation ;  for  even  though  he  should  not  be  accepted  as  the  first  who  commu- 
nicated cow-pox  to  man  by  inoculation,  there  would  be  nothing  to  subtract 
Prom  his  glory,  since  it  appears  probable  that  he  did  not  know  of  the 
experiments  which  Benjamin  Jesty  made  in  his  family.  Although  there 
may'be  involved  in  this  history  a  question  of  priority,  Jenner  had  the 
incontestable  merit  of  having  contended  against  all  the  obstacles  put  in  the 
way  of  the  practice  of  vaccination,  and  of  having  communicated  to  con- 
temporary physicians  the  belief  which  he  had  deduced  from  the  observation 
and  rigorous  interpretation  of  facts. 

Respect,  however,  for  historical  verity  makes  it  incumbent  upon  me  to 
lay  before  you  various  documents  lately  translated  in  the  Gazette  M6dicale 
de  Lyon,  from  the  Lancet,  of  London,  and  which  seem  to  prove  that  Ben- 
jamin Jesty,  a  Gloucestershire  Parmer,  was  the  firsi  t<>  inoculate  with  cow- 
pox,  he  having, >io  177  I,  performed  the  operation  upon  his  wife  and  two 
Bona,  Por  the  purpose  of  protecting  them  Prom  small-pox. 

The  same  periodical  publishes  a  note  Prom  Mr.  John  Webb,  showing  thai 
small-pox  maybe  communicated  from  man  to  the  cow,  and  that  persons 
contracting  the  disease  modified  by  this  transmission  are  proof  againsl  vari- 
olous contagion,     Allow  me  to  translate  to  you  John  Webb's  narrative,  a 

letter  from  .Mr.  Alfred  Ilaviland,  surgeon,  regarding  Benjamin  Jesty's  dis- 


cow-pox.  '-'7 

coverv  of  cow-pox,  and  also  an  extract,  on  the  same  subject,  from  the  records 
of  the  Vaccine  Institution. 

First,  then,  I  will  now  read  to  you  the  narrative  of  John  Webb,  which 
was  found  among  his  manuscripts  alter  his  death,  and  is  dated  in  the  year 
17'.)!».  This  document  was  communicated  to  the  Lancet  by  his  grandson, 
Thomas  Watts,  and  is  to  the  following  effect  : 

"Some  time  in  the  month  of  May,  1792,  having  twenty-four  children  col- 
lected together  at  a  house  in  Doynton  for  the  purpose  of  being  inoculated, 
and  a  Betty  Bowman,  then  aged  80,  accidentally  coining  in,  she  was  asked 
by  another  woman  present  whether  she  had  ever  had  the  small-pox;  to 
which  Betty  replied  in  the  negative,  asserting,  with  a  considerable  degree 
of  confidence,  that  she  was  certain  she  never  should,  having  in  her  younger 
davs  caught  the  cow-pox  from  a  cow  that  was  infected  by  a  man  in  the 
small-pox.  Such  an  opinion  naturally  induced  me  to  desire  of  her  a  more 
particular  account  of  the  circumstance,  when  I  was  informed  that,  when 
she  was  twenty-three  or  twenty-four  years  old,  she  lived  in  the  service  of  a 
farmer,  on  whose  estate,  at  a  distance  from  the  farmhouse,  or  any  other  habi- 
tation, there  was  a  small  cottage,  together  with  some  cowsheds;  that  the  cot- 
tage was  let  to  a  man  (probably  one  of  his  laborers)  who  dying  in  the  small- 
pox some  time  betwixt  Michaelmas  and  Christmas,  the  bed  and  bed-mat  on 
which  he  had  lain  were  thrown  out  into  the  sheds ;  that  a  cow  belonging  to 
their  dairy  being,  as  she  termed,  very  chilly,  frequently  went  into  the  cow- 
shed, and  had  been  observed  to  lie  down  on  or  near  the  bed  and  mat ;  that 
shortly  after  the  same  cow  was  seized  with  the  cow-pox,  and  the  whole  dairy, 
consisting  of  nine  cows,  sickened  one  after  the  other,  till  at  length  the  milk 
was  so  bad  that  it  could  not  be  used,  and  of  course  the  cows  were  suffered 
to  go  dry,  till  which  time  she  constantly  assisted  in  milking  them  ;  that  soon 
after  she  wras  seized  with  rigors  and  pains  in  her  limbs,  had  a  tumor  form 
in  the  right  leg  and  axilla,  and  that  three  pustules  appeared  on  the  hand 
near  the  thumb,  from  which  there  was  a  discharge  for  some  time  (she  be- 
lieved about  nine  days)  ;  that,  as  before  mentioned,  she  neither  prior  nor 
subsequent  to  that  period  had  the  small-pox,  though  she  had  frequently 
visited  persons  ill  in  it,  and  once,  in  particular,  lay  on  a  bed  on  which  a 
person  had  died  in  that  disease,  the  bed-clothes  only  being  changed.  She 
likewise  observed  that  two  or  three  persons  who  had  had  the  small-pox 
were  frequently  among  the  cows,  but  received  no  infection.  She  likewise 
informed  me  that  she  knew  a  Mary  Hathaway,  who  milked  infected  cows 
at  one  time,  and  was  not  infected  by  them,  but  that  at  another  time  she  was ; 
that  she  likewise  never  had  the  small-pox  prior  or  subsequent  to  that  period, 
though  she  resided  several  years  in  Bristol."* 

As  a  sequel  to  the  narrative  now  quoted,  the  Lancet  gives  the  following 
statement,  by  Mr.  Alfred  Haviland,  Surgeon  to  the  Infirmary  of  Bridge- 
water.    It  refers  to  Mr.  Benjamin  Jesty,  "the  proto-martyr  of  vaccination: " 

"At  the  Rose  and  Crown  Inn,  IS"ether-Stowey,  county  of  Somerset,  my 
attention  was  drawn,  on  the  31st  of  May  last,  to  a  photograph  taken  from 
a  large  portrait  of  a  good  specimen  of  the  fine  old  English  yeoman,  dressed 
in  knee  breeches,  extensive  double-breasted  waistcoat,  and  no  small  amount 
of  broadcloth.  He  was  represented  sitting  in  an  easy  chair,  under  the 
shelter  of  some  wide-spreading  tree,  with  his  stick  and  broad-brimmed  hat 
in  his  left  hand,  his  ample  frame  was  surmounted  by  a  remarkably  good 
head,  with  a  countenance  which  at  once  betokened  firmness  and  superior 
intelligence." 

*  Lancet:  13th  September,  1862,  p.  291.     London. 
vol.  I. — 7 


98  cow-pox. 

"  I  have  been  thus  particular  in  describing  the  portrait,  for  I  am  not 
quite  certain  whether  the  photograph  was  taken  from  a  drawing, an  engrav- 
ing, or  an  oil-painting ;  if,  however,  the  source  was  an  engraving,  in  all 
probability  there  are  some  copies  still  extant,  which  the  curious  in  such 
matters  may  think  worth  collecting.  On  the  back  of  this  photograph  is  a 
copy  of  the  epitaph  on  our  subject,  as  follows :  '  Sacred  to  the  memory  of 
Benjamin  Jesty,  who  departed  this  life  on  the  16th  April,  1816,  aged  79 
years.  He  was  born  at  Yetminster,  in  this  county,  and  was  an  upright, 
honest  man,  particularly  noticed  for  having  been  the  first  person  {known  I  who 
introduced  cow-pox  by  inoculation;  and  ivho,from  his  great  strength  of  mind, 
made  an  experiment  from  the  cow  on  his  wife  and  two  sons,  in  the  year  1774.' 
(From  the  tomb  in  the  churchyard  at  Yetminster,  Dorset.) 

"  I  am  informed  by  his  relative,  Mrs.  "William  May  (nee  Jesty),  that 
when  the  fact  became  known  that  he  had  vaccinated  his  wife  and  sons,  his 
friends  and  neighbors,  who  had  hitherto  looked  up  to  him  with  respect  on 
account  of  his  superior  intelligence  and  honorable  character,  began  to 
regard  him  as  an  inhuman  brute,  who  could  dare  to  practice  experiments 
on  his  family,  the  sequel  of  which  would  be,  as  they  thought,  their  meta- 
morphosis into  horned  beasts.  Consequently,  the  worthy  farmer  was  hooted 
at,  reviled,  and  pelted  whenever  he  attended  the  markets  in  his  neighbor- 
hood. He  remained,  however,  undaunted,  and  never  failed  from  this  cause 
to  attend  to  his  duties  ;  and  the  secret  of  this  bold  conduct  may  be  traced 
in  his  determined  chin  and  nose  and  firm  lips.  After  living  to  see  another 
enriched  and  immortalized  for  carrying  out  the  same  principles  for  which 
he  had  been  stoned  thirty  years  before,  he  died  of  apoplexy,  like  Jenner, 
in  1816.  Jesty's  experiment  on  his  family  was  performed  in  1774;  and 
.Tenners  on  the  1-ith  of  May,  1796,  just  twenty-two  years  later.7'* 

Dr.  H.  P.  Davis,  of  London,  having  received  from  one  of  Benjamin 
Jesty's  grandsons  a  copy  of  the  following  document,  indited  and  signed 
by  the  medical  officers  of  the  Original  Vaccine-Pock  Institution,  sent  it  to 
the  Lancet. 

''Mr.  Benjamin  Jesty,  farmer,  of  Downshay.  in  the  Isle  of  Purbeck, 
having,  agreeably  to  an  invitation  from  the  medical  establishment  of  the 
Original  Vaccine-Pock  Institution,  Broad  Street,  Golden  Square,  visited 
London  in  August,  1805,  to  communicate  certain  facts  relating  to  tin-  cow- 
pox  inoculation,  we  think  it  a  matter  of  justice  to  himself,  and  beneficial 
to  the  public,  to  attest  that,  among  other  facts,  he  has  afforded  decisive 
evidence  of  his  having  vaccinated  his  wife  and  two  sons — Robert  and  Ben- 
jamin— in  the  year  1774,  who  were  thereby  rendered  unsusceptible  of  the 
small-pox,  as  appears  from  the  exposure  of  all  the  parties  to  that  disease 
frequently  during  the  course  of  thirty-one  years;  and  from  the  inoculation 
of  the  two  -mi-  for  the  small-pox  fifteen  years  ago.  That  lie  was  led  to 
undertake  this  novel  practice  in  1774,  to  counteract  the  small-pox  at  that 
time  prevalent  when'  he  then  resided,  from  knowing  the  common  opinion 
of  the  county  ever  since  lie  was  a  boy,  now  about  sixty  years  ago,  that 
persons  who  had  gone  through  the  cow-pox  naturally,  that  is,  by  taking 

it  from  cows,  were  unsusceptible  of  -mall-pox;   by  himself  being  incapable 

of  taking  the  small-pox  :  by  having  gone  through  the  cow-pox  many  years 
before;  from  having  personally  known  many  individuals  who,  after  the  cow- 
pox,  could  not  have  the  small-po\  excited  :  from  believing  that  the  cow-pox 

\\:i-  .-in  affection  free  from  danger;  ami  from  his  opinion  that  by  the  cow- 
pox  inoculation  he  should  avoid  ingrafting  various  diseases  of  the  human 


*  Lancet:  L8th  September,  1862.     London. 


cow-pox.  99 

constitution,  such  as  the  evil,  madness,  lues,  and  many  other  bad  humors, 
as  he  called  them." 

"The  remarkably  vigorous  health  of  Mr.  Jesty,  his  wife  and  two  sons, 
now  thirty-one  years  subsequent  to  the  cow-pock,  and  his  own  healthy 
appearance  at  the  time  (seventy  years  of  age),  afford  a  singular  proof  of 
the  harmlessness  of  that  affection.  But  the  public  must  with  particular 
interest  hear  that  during  their  late  visit  to  town  Mr.  Robert  Jesty  very 
willingly  submitted  publicly  to  inoculation  for  the  small-pox  in  the  most 
vigorous  manner,  and  that  Mr.  Jesty  also  was  subjected  to  the  trial  of  in- 
oculation for  the  cow-pock  after  the  most  efficacious  mode,  without  either 
of  them  being  infected." 

"The  circumstances  on  which  Mr.  Jesty  purposely  instituted  the  vaccine- 
pock  inoculation  in  his  own  family,  viz.,  without  any  precedent,  but  merely 
from  reasoning  upon  the  nature  of  the  affliction  among  cows,  and  from 
knowing  its  effects  in  the  casual  way  among  men,  his  exemption  from  the 
prevailing  popular  prejudices,  and  his  disregard  of  the  clamorous  reproaches 
of  his  neighbors,  in  our  opinion  well  entitle  him  to  the  respect  of  the  public 
for  his  superior  strength  of  mind.  But  further,  his  conduct  in  again  fur- 
nishing such  decisive  proofs  of  the  permanent  anti-variolous  efficacy  of  the 
cow-pock,  on  the  present  discontented  state  of  many  families,  by  submitting 
to  inoculation,  justly  claims  at  least  the  gratitude  of  the  country." 

"  As  a  testimony  of  our  personal  regard,  and  to  commemorate  so  extra- 
ordinary a  fact  as  that  of  preventing  small-pox  by  inoculation  for  the  cow- 
pock  thirty-one  years  ago,  at  our  request,  a  three-quarter-length  picture  of 
Mr.  Jesty  is  painted  by  that  excellent  artist  Mr.  Sharp,  to  be  preserved  at 
the  original  Vaccine-Pock  Institution." 

"  G.  Pearson,  L.  Nikol,  Thos.  Nelson,  Physicians. 
—  Wheate,  F.  Forster,  Consulting  Surgeons. 
J.  C.  Carpue,  J.  Doralt,  Surgeons. 

F.  Rivers,  E.  A.  Brande,  P.  De  Bruge,  Visiting  Apothecaries. 
J.  Heaviside,  T.  Payne,  Treasurers."* 

Gentlemen,  however  long  you  may  think  these  details,  you  will,  in  con- 
sideration of  the  interest  which  they  present,  pardon  me  for  having  laid 
them  before  you.  I  repeat,  however,  that  if  Jenner  was  not  the  first  to 
inoculate  with  cow-pox,  his  was  no  less  the  honor  of  having  established  the 
practice  of  vaccination. 

Jenner,  in  his  first  publication,  which  appeared  in  1798,  while  he  avoided 
affirming  in  too  absolute  a  manner  that  cow-pox  was  a  complete  preserva- 
tion against  small-pox,  showed  anxiety  to  make  known  the  nature  of  his 
discovery.  Experiments,  repeated  first  by  Pearson,  were  afterwards  under- 
taken on  a  great  scale  by  Woodville,  Physician  to  the  London  Inoculation 
Hospital,  and  ere  long  the  testimony  of  these  physicians,  along  with  that 
of  very  many  others,  was  given  in  favor  of  Jenner's  discovery.  Vaccina- 
tion, in  .spite  of  the  opposition  it  encountered,  in  spite  of  the  violent  and 
unjust  attacks  to  which  it  was  subjected,  in  spite  of  the  most  obstinate 
resistance  and  the  most  absurd  prejudices  with  which  it  had  to  contend 
even  in  England,  soon  came  to  be  generally  employed.  The  favorable 
reception  which  it  immediately  received  in  Hanover  extended  to  the  rest 
of  Germany,  and  almost  simultaneously,  to  France,  Avhere  the  Duke  of 

*  Lancet,  '25th  October,  1862,  p.  461.  London.  The  documents  in  the  text  are 
reprinted  from  the  Lancet;  and  are  not  translations  from  the  French. — Trans- 
lator. 


100  cow-pox. 

Rochefoucault-Liancourt,  who  during  his  residence  in  Great  Britain  had 
seen  its  success,  forcibly  called  the  attention  of  government  and  the  public 
to  this  important  subject. 

Cow-pox,  that  singular  malady  derived  by  man  from  the  cow,  and  then 
transmitted  with  wonderful  facility  from  person  to  person,  had  ceased  to  be 
thought  of  in  relation  to  its  source,  and  had,  so  to  speak,  become  forgotten. 
In  the  years  immediately  subsequent  to  the  discovery  of  vaccination, 
picote*  is  so  seldom  mentioned  by  authors,  that  one  may  be  led  to  believe 
that  cases  of  it  were  then  rare,  that  it  occurred  seldom,  at  long  intervals 
only,  and  in  privileged  places.  In  England  it  had  nearly  ceased  to  be  a 
topic  of  discussion,  when,  in  1812,  attention  was  called  to  several  cases  in 
the  neighborhood  of  Berlin.  In  1816,  it  was  met  with  several  times  in  the 
Duchy  of  Brunswick.  At  a  later  period,  however,  the  occurrence  of  small- 
pox in  persons  who  had  been  vaccinated  having  suggested  the  idea  that  the 
vaccine  virus  had  degenerated,  it  was  deemed  necessary  to  go  back  to  the 
fountain-head,  or,  in  other  words,  to  search  for  cow-pox  in  the  cow.  The 
investigation  began  in  Germany,  where,  at  the  commencement  of  the  in- 
quirv,  it  was  established  that  the  picote  of  cows  was  by  no  means  so  rare 
as  might  be  inferred  from  the  long  silence  which  had  existed  regarding  it. 
In  Holstein,  irrespective  of  isolated  cases,  it  had  prevailed  as  an  epizootia 
five  times  in  eleven  years.  The  attention  of  Government  having  been 
awakened,  orders  were  issued  in  1826,  1829,  1830,  and  1831,  to  search  for 
vaccine  matter  in  the  cow.  Prizes  were  offered  to  the  proprietors  of  cows 
affected  with  the  disease,  and  from  that  time  cases  multiplied  in  Wurtem- 
berg  and  the  Duchy  of  Baden. 

In  1836  a  commission  was  appointed  by  the  Academy  of  Medicine  of 
Paris,  to  examine  into  a  case  at  Passy,  near  Paris.  A  lady  of  the  name 
of  Fleury,  residing  at  Passy,  having  stated  to  Dr.  Perdreau,  of  Chaillot, 
that  her  cow,  affected  with  picote,  had  communicated  the  affection  to  her 
hand,  MM.  Bousquet,  Emery,  and  Gerardin,  were  commissioned  to  study 
the  case;  and  the  result  was  that  they  obtained  characteristic  cow-pox  by 
inoculating  the  arm  of  a  child  with  matter  taken  from  Madame  Fleury 's 
hand.f 

When  these  inquiries  were  going  on  in  Europe,  Dr.  Macpherson,  in  1833, 
published  his  experiments  on  vaccination,  and  announced  that  he  had  seen 
in  the  neighborhood  of  Calcutta,  in  India,  an  epizootia  of  tag-sore.  He 
found  that  this  affection  could  not  only  be  communicated  by  inoculation 
from  COW  to  COW,  but  also  from  tin-  cow  to  man,  and  afterwards  from  man 
to  man. 

Observers  were  struck  with  the  remarkable  fact  that  transmission  took 
place  more  readily  when  the  virus  was  humanized,  or,  in  other  words, 
when  it  had  been  t  ran-in  i  1 1  <'d  from  man  to  man.  The  action  was  more 
powerful  than  that  produced  by  inoculating  the  human  subject  direct  from 
the  cow.  Dr.  Steinbrenner  has  recorded  a  remarkable  example  of  this 
peculiaritv,  which  1  shall  now  quote  exactly  from  his  Treatise  on  Vacci- 
nation. 

'■On  the  18th  May,  1845,  a  proprietor  informed  me  thai  one  of  hie 
cows  had  an  eruption  on  the  udder  ami  teats.      Upon  examining  the  COW, 

*  Tin-  word  picote  in  the  text  evidently  refers  to  the  vaccine  disease  in  thi 
but  in  Bome  districts  of  Prance,  picote  is  the  current  name  of  small-pox  in  the  human 
Bubject ;  mimI  wherever  French  u  Bpoken,  a  man  marked  with  Bmall-pox  i.-  said 
picote  — Translator. 

t  Snr  le  Cow-pos  decouvert  a  Passy  pres  Paris,  le  22  Stars,  1886. — Mil 
■■  Mtdecine,  t.  v,  p.  600. 


COW-POX.  101 

and  comparing  what  T  saw  with  the  descriptions  of  author?,  I  became 
nearly  certain  that  I  had  at  last  found  picote;  and  although  the  eruption 
was  too  far  advanced  to  justify  the  hope  of  obtaining  very  efficacious  virus, 
I  losl  no  time  in  collecting  a  considerable  quantity  on  tour  plates  of  glass. 
Aluiut  an  hour  afterwards  1  inoculated,  by  sixteen  punctures,  two  unvac- 
cinated  children.  Only  one  of  the  sixteen  punctures  produced  a  vaccinal 
pustule;  hut  it  was  a  very  beautiful  and  large  one,  which  passed  through 
the  different  stages  in  the  most  perfectly  regular  manner.  On  the  eighth 
dav,  two  children  were  vaccinated  from  this  pustule,  the  virus  being  trans- 
ferred direct  from  arm  to  arm  ;  and  this  time  the  sixteen  inoculatory  punc- 
tures produced  sixteen  beautiful  vaccinal  pustules.  Since  that  occurrence 
I  have  only  vaccinated  with  lymph  derived  from  that  source,  and  have 
obtained  precisely  similar  results.  I  sent  supplies  of  lymph  taken  from  my 
first  cases  to  the  Academy  of  Medicine  of  Paris,  through  M.  Bousquet;  to 
the  Medical  Society  of  Strasburg;  and  to  many  brother  physicians,  particu- 
larly to  the  cantonal  physician  of  Saar-Union;  and  to  Drs.  Fodere,  Kuntz, 
Clausing,  &c.  Everywhere  it  produced  a  very  beautiful  vaccine  pock, 
yielding  lymph,  which  was  at  once  substituted  for  that  formally  in  use."* 

Similar  results  have  been  more  recently  obtained  by  physicians  and 
veterinary  practitioners  in  the  department  of  Eure-et-Loir,  by  whom  cow- 
pox  in  the  cow  was  also  found.  Similar  results  are  observed  in  the  vacci- 
nations— particularly  in  the  revaccinations — now  taking  place  in  our  hos- 
pitals, with  vaccinal  lymph  derived  from  the  heifers  of  Dr.  Lanoix.  That 
lymph  gives  rise  to  vaccinal  pustules  much  less  frequently  than  that  taken 
from  the  arm  of  a  child.  With  reference  to  this  point,  I  would  remark, 
that  the  lymph  obtained  from  the  heifers  of  Dr.  Lanoix  is  not  primitive 
lymph,  and  therefore  is  not  more  active  than  that  taken  from  the  human 
subject;  and,  moreover,  it  is  the  virus  of  cow-pox  modified  and  weakened 
by  a  considerable  series  of  successive  generations.  It  appears  to  me  that 
it  has  lost  much  of  its  power  in  passing  successively  from  heifer  to  heifer. 
Whatever  theory  we  adopt,  the  fact  remains,  that  vaccine  lymph  taken 
direct  from  the  heifers  referred  to  is  less  active  than  that  which  has  been 
taken  from  man — than  that  which  has  been  humanized. 

I  must  not  allow  this  opportunity  to  escape  without  explaining  to  you 
the  characteristics  of  cow-pox  in  the  cow  ;  as  it  is  of  the  greatest  impor- 
tance for  physicians,  especially  for  those  practicing  in  country  places,  where 
the  supply  of  vaccine  lymph  may  fail,  to  be  able  to  recognize  the  affection. 
The  eruption  consists  in  pustules  on  the  udder  and  teats  of  the  affected 
animal,  having  a  great  resemblance  to  those  which  we  lately  saw  on  the 
face  of  a  small-pox  patient  who  lay  in  bed  No.  11  ter  of  St.  Agnes's  Ward, 
whose  case  I  have  already  brought  under  your  notice,  as  presenting  a 
remarkable  example  of  the  inoculation-pustule.  The  cow-pox  pustules  are 
at  first  pimples,  varying  in  size  from  that  of  a  lentil  to  that  of  a  common 
round  bean.  They  become  more  and  more  elevated  ;  ou  the  second  or  third 
day  from  their  first  appearance,  they  acquire  a  pustular  character,  are 
filled  with  se  colorless  lymph,  and  are  depressed  in  the  centre.  Toward 
their  centre,  these  pustules  are  of  a  bluish- white,  livid  color,  and  towards 
their  periphery,  where  an  areola  has  already  formed,  they  are  reddish  or 
yellowish-white  ;  they  then  resemble  the  pustules  produced  by  variolous 
inoculation.  In  other  cases,  they  are  of  a  silvery  hue,  of  a  pale  red,  a 
reddish  yellow,  or  a  clear  yellow.  This  difference  in  the  color  of  the  pus- 
tules is  dependent  upon  their  degree  of  development,  and  also,  to  a  certain 
extent,  upon  the  natural  tint  of  the  udder.     On  the  following  days  they 

*  Stejxbrexner  :  Traite  de  la  Vaccine,  p.  534. 


102  cow-pox. 

become  larger,  and  often  attain  the  size  of  a  half-franc  piece ;  and  in  these 
rare  cases  they  are  also  more  numerous,  the  udder  aud  teats  sometimes 
presenting  from  eight  to  twenty  pustules,  which  reach  their  maximum 
development  on  the  ninth  or  tenth  clay  ;  at  this  period  also,  the  areola 
which,  since  the  formation  of  the  pustule,  has  formed  a  narrow  ring, 
becomes  more  extended,  but  in  cows  with  brown  or  black  udders  the 
areola  is  scarcely  visible.  Hardness,  swelling,  increased  heat  of  skin,  and 
sometimes  very  great  tenderness,  are  then  perceptible.  There  is  at  the 
same  time  an  exacerbation  of  the  general  symptoms,  such  as  distaste  for  food, 
restlessness,  and  fever.  The  milk  both  deteriorates  in  quality  and  dimin- 
ishes in  quantity,  and  its  secretion  is  altogether  arrested  when  the  eruption 
is  very  abundant,  and  accompanied  by  an  excess  of  reaction.  Immedi- 
ately after  the  ninth  day,  crusts  form  in  the  centre  of  the  pustules,  while  at 
their  periphery  the  lymph  grows  thicker  and  thicker,  till  at  last  it  becomes 
converted  into  a  cheesy  pus.  The  crusts,  if  not  previously  torn  off,  fall 
between  the  eighteenth  and  twenty-fourth  day,  leaving  in  their  place  ulcer- 
ations, which  in  some  cases  eat  so  deeply  into  the  tissues  as  to  detach  the 
teats.  In  other  cases,  inflammatory  swellings  and  abscesses  of  the  mamma 
supervene,  which  continue  for  three  or  four  months. 

As  I  have  broached  the  history  of  cow-pox,  allow  me,  gentlemen,  to  say 
a  few  words  upon  questions  connected  with  that  subject.  First  of  all : 
What  is  the  origin  of  cow-pox?  Considering  the  immunity  from  small-pox 
which  cow-pox  confers  on  the  human  race,  it  has  been  asked  whether  cow- 
pox  is  not  in  point  of  fact  human  small-pox  modified  by  transmission  to  the 
cow,  just  as  cow-pox  is  modified  by  transmission  from  the  cow  to  man  ?  It 
has  also  been  asked  whether  cow-pox  is  riot  a  distinct  disease,  peculiar  to 
the  animals  in  which  it  is  observed  ?  And,  finally,  it  has  been  asked, 
whether  it  does  not  originate  in  a  disease  peculiar  to  other  kinds  of  animals, 
and  which  is  not  small-pox? 

Jenner,  adopting  the  opinion  generally  received  in  his  own  country,  re- 
garded cow-pox  as  originating  in  a  disease  peculiar  to  horses  termed  grease 
in  England  and  eaux  aux  jambes  in  France.  The  illustrious  discoverer  of 
vaccination  had  remarked  a  fact,  well-known  also  to  the  farmers  and  peas- 
antry, that  cow-pox  was  met  with  only  in  the  dairies  where  the  cows  were 
attended  to  aud  fed  by  men  who  likewise  had  charge  of  horses.  AVhenever 
grease  was  observed  in  stables,  cow-pox  soon  showed  itself  in  the  cow-houses, 
whither  it  was  brought  by  the  men-servants  of  the  farm  who  came  to  milk 
the  cows  with  hands  soiled  by  pus  from  horses  affected  with  grease.  In 
dairies,  where  women  only  were  employed,  as  in  Ireland,  cow-pox  was  very 
rare.  Although  the  proposition  of  Jenner  cannot  be  accepted  as  absolute, 
experiments  have  proved  that  there  is  an  analogy  between,  it'  ool  an  identity 
in,  the  two  maladies.  It  is  one  thing,  however,  to  admit  thai  grease  may 
be  transmitted  from  the  horse  to  the  cow,  and  then  produce  true  eow-pox, 
and  another  to  maintain  that  the  only  source  of  cow-pox  in  cows  is  grease 
in  horses. 

A  recent  case  has  once  more  demonstrated  the  identity  of  the  two  dis- 
eases. Early  in  March,  L856,  Dr.  Pichol  of  La  Loupe,  a  physician  of  the 
department  of  Eure-et-Loir,  was  consulted  professionally  by  a  Barrier's  as- 
sistant; this  individual  had  on  the  hack  of  both  hands  pustules  which  were 
opaline,  confluent,  of  aboul  a  centimetre  in  diameter,  and  depressed  in  the 

centre,  where  a  .-mall  linear  crust  was  visible.  They  had  exactly  the  ap- 
pearand' of  vaccinal  pustules  of  the  eighth  or  ninth  day.  The  man,  who 
hail  never  been    vaccinated,  allirmed    that   he  had   not    been  in  contact  with 

a  diseased  cow,  bul  he  recollected  that  twenty-four  days  previously  he  had 
shod  a  horse  affected  with  grease.    The  horse  in  question  belonged  to  a 


cow-pox.  103 

farmer.     The  veterinary  practitioner  at  La  Loupe,  a  distinguished  pupil  of 

the  schools  of  Al fort  and  Toulouse,  verified  the  disease,  which  still  existed 
when  he  examined  the  horse.  Dr.  Pichot  immediately  collected,  between 
glass  plates,  fluid  from  the  pustules,  and  sent  some  of  it  to  Dr.  Maunoury 
of  Chartres. 

Without  waiting  to  hear  the  result  of  Dr.  Maunoury's  experiments,  Dr. 
Pichot  tried  to  vaccinate  his  patient.  The  operation  produced  no  charac- 
teristic effect,  although  the  lymph  used  was  taken  from  the  arm  of  a  child, 
from  which  at  the  same  time  two  other  children  were  vaccinated,  in  both 
of  whom  the  true  vaccinal  pock  appeared.  There  were  visible  on  the 
sixth  day  from  the  operation,  in  the  situation  of  the  six  punctures  made 
on  the  man's  arm,  only. two  small  rounded  pustules,  which  were  partially 
covered  with  a  crust,  and  bore  no  resemblance  to  the  pustules  on  the 
arms  of  the  children.  An  attempt  was  made  to  inoculate  another  child 
with  liquid  from  these  two  pustules ;  but  on  the  eighth  day  no  result 
whatever  had  taken  place.  On  that  day,  the  same  child  w7as  vaccinated 
with  ordinary  vaccine  lymph,  and  in  seven  days  he  exhibited  four  superb 
vaccine  pocks,  from  which  three  other  children  were  successfully  vaccinated. 

Dr.  Maunoury  inoculated  a  child  with  the  matter  sent  to  him  by  Dr. 
Pichot,  making  five  punctures,  viz.,  three  on  the  right  and  two  on  the  left 
arm.  The  result  was  the  appearance  on  the  eighth  day,  on  the  right  arm, 
of  one  beautiful  clear  pock,  as  large  as  a  lentil,  filled  with  yellowish  serosity 
and  surrounded  by  a  reddish  circle  of  about  a  centimetre  in  diameter.  Dr. 
Maunoury  vaccinated  several  subjects  from  this  pustule.  Three  children 
were  inoculated  with  pus  taken  from  it,  and  all  three  were  fouud  to  be  per- 
fectly vaccinated.  A  fifth  child  was  vaccinated  with  lymph  taken  from 
one  of  the  three,  and  the  lymph  in  this  its  third  generation  was  proved  to 
be  efficacious ;  it  was  found  to  be  equally  efficacious  in  a  fourth  and  fifth 
generation.  It  is  evident,  therefore,  that  it  was  true  vaccine  matter  which 
was  communicated  to  the  first  patient  by  the  horse  affected  with  grease 
which  he  had  shod.  In  this  history,  accordingly,  we  find  a  confirmation 
of  Jenner's  opinion. 

Jenner,  however,  notwithstanding  the  soundness  of  his  theory,  was  never 
able  to  produce  more  than  a  simple  inflammation  in  those  whom  he  inocu- 
lated with  matter  taken  from  horses  affected  with  grease ;  but  then  it  must 
be  remembered,  that  he  always  used  pus  from  the  old  ulcerations,  and  never 
the  clear  lymph  of  the  recent  pock.  After  his  time,  the  same  facts,  confirmed 
at  a  later  period  by  Drs.  Pichot  and  Maunoury,  were  irrefragably  estab- 
lished by  experimentalists.  In  1801,  Dr.  Loy  published  an  account  of  his 
experiments  on  the  origin  of  cow-pox,  in  which  he  mentioned  that  he  had 
inoculated  men  as  well  as  cows  with  matter  taken  from  horses  affected  with 
grease.  Dr.  Loy  having  observed  on  the  hands  of  two  persons,  a  farrier 
and  a  butcher  residing  in  Yorkshire,  a  pustular  eruption  much  resembling- 
cow-pox  and  accompanied  with  great  constitutional  disturbance,  inquired 
into  the  circumstances  and  found  that  one  of  these  individuals,  for  some 
time  previously,  had  had  charge  of  horses  suffering  from  grease.  He  took 
lymph  from  this  person  and  with  it  inoculated  his  brother  and  another 
child  ;  in  both  cases  this  inoculation  produced  pustules  exactly  similar  to, 
those  of  true  cow-pox,  both  in  respect  of  their  appearance  and  the  course 
they  ran.  With  the  same  lymph  with  which  he  inoculated  the  two  children,. 
he  inoculated  a  cow,  producing  thereby  a  very  beautiful  cow-pock,  which 
was  accompanied  by  all  the  accessory  phenomena.  From  that  pock  he  in- 
oculated a  child  in  whom,  in  due  course,  a  beautiful  cow-pock  appeared  ;; 
this  child  was  ascertained  to  be  proof  against  small-pox,  for  on  the  sixth 
day  after  the  vaccinal  inoculation,  variolous  inoculation  was  performed 
without  causing  any  subsequent  result.     It  will  be  seen  that  the  observa- 


104  cow-pox. 

tions  of  Dr.  Loy  bear  a  great  analogy  to  those  made  at  a  later  date  by  Drs. 
Pic-hot  and  Maunoury. 

But,  at  first,  Dr.  Loy  failed  in  bis  attempts  to  inoculate  cows  with  matter 
taken  from  horses  affected  with  grease.  He  repeated  his  experiments 
several  times  without  success,  using  matter  taken  from  other  horses ;  he 
was  also  at  first  equally  unsuccessful  in  his  attempts  to  inoculate  man  from 
the  horse.  At  last,  he  succeeded  in  finding  a  horse  in  which  the  grease 
had  existed  for  only  fifteen  days ;  the  cases  from  which  till  then  he  had 
obtained  his  matter  were  of  older  standing.  With  matter  derived  from 
this  recent  case,  he  inoculated  five  cows,  and  in  all  of  them  cow-pox  was 
the  result.  From  these  cows  he  obtained  lymph  with  which  he  produced 
cow-pox  in  children,  whom  he  subsequently  found  to  be  proof  against  vario- 
lous inoculation.* 

Sacco,  of  Xaples,  who  had  at  first  unsuccessfully  inoculated  twenty-seven 
cows  and  eight  children  with  lymph  taken  from  grease  in  horses,  observed 
pustules  on  the  hands  of  persons  who  had  charge  of  horses  affected  with 
the  disease ;  with  fluid  from  these  pustules,  he  inoculated  nine  children  and 
one  cow ;  in  two  of  the  children  he  produced  normal  cow-pox,  a  result  ex- 
actly similar  to  that  formerly  noticed  as  having  been  obtained  by  the  phy- 
sicians of  the  department  of  Eure-et-Loir. 

Finally,  in  1805,  Viborg,  a  Danish  veterinary  practitioner,  inoculated 
the  udders  of  cows  with  grease-matter,  taken  from  horses,  and  after  several 
failures  obtained  the  desired  result,  viz.,  a  characteristic,  well-developed 
eruption  of  cow-pox  on  the  fifth  and  sixth  days  after  inoculation.  Other 
observers,  among  whom  may  be  mentioned  Professor  Ritter,  of  Kiel,  have 
reported  cases  of  cow-pox  following  inoculation  with  grease-matter,  and 
yielding  a  perfectly  efficacious  vaccine  lymph. 

To  these  statements  I  may  add  facts  observed  in  the  spring  of  1860,  by 
MM.  Sarrans,  of  Rieumes,  and  Lafosse,  of  Toulouse.  During  an  epizootia 
among  horses,  a  man  was  attacked  with  swelling  of  the  hamstrings,  whence 
issued  a  sanious  discharge.  M.  Lafosse  charged  a  lancet  with  this  exuda- 
tion, and  then  therewith  inoculated  in  succession  two  young  cows;  in  both, 
pustules  appeared,  presenting  all  the  characters  of  cow-pox.  With  matter 
taken  from  these  pustules  he  reproduced  vaccine  lymph,  with  all  its  char- 
acteristics and  properties. 

Hitherto  I  have  spoken  of  grease  [eaux  aux  jambes'],  employing  a  term 
in  common  use ;  but,  in  point  of  fact,  observers  have  not  yet  made  out  the 
exact  nature  of  the  disease  of  the  horse,  which,  when  transmitted  to  the  cow 
by  inoculation,  gives  rise  to  cow-pox.  In  a  discussion  at  the  Academy  of 
Medicine,')'  and  afterwards  at  the  Biological  Society  in  1861,  Mr.  H.  Bouley 
pointed  out  at  great  length  that  veterinaries  were  much  divided  in  opinion 
as  to  the  exact  nature  of  the  disease  which  goes  by  the  name  of  eaux  aux 
jambes.  M.  Leblanc,who  went  to  Toulouse  to  study  the  disease  in  the  man' 
which  had  supplied  M.  Lafosse  with  new  vaccine  Jymph,  proved  that  this 
marc  had  not  the  disease  called  eaux  aux  jambes,  but  all  the  veterinaries 
who  observed  the  epizootia  at  Rieumes  were  agreed  thai  it  presented  all  the 
characters  of  an  epidemic  eruptive  fever.  It  is  not  within  my  provin 
give  a  name  tit  a  disease  of  horses  which  has  already  received  a  name  from 

veterinary  physicians.  < 'an  we,  looking  al  it  as  an  eruptive  fever,  compare 
it  with  the  tag-sore  [claveUe~\  of  sheep  ?  ('an  there  exisl  in  the  horse  an 
eruptive  fever,  which,  when  communicated  t<»  man  by  direct  or  indirect 

jUeinbrenner  op.  cit.,  p   608;   and  Loy *s  Account  of  some  Experiments  on  the 
Origin  of  Cow-pox.  8vo.     Whitby,  1801. 

1    Bulletin  de  I'Acadimie  de  U6decine,  1861  62,  t.  xxvii.  p.  s.vi-880. 


cow-pox.  105 

inoculation,  yields  a  virus  which  either  is  vaccine  virus  or  is  analogous  to 
it  in  its  properties?  These  are  questions  which  we  may  at  present  ask,  but 
it  will  only  be  in  the  future  that  they  can  be  answered. 

Alongside  of  the  experiments  conclusively  in  favor  of  the  transmission  of 
the  disease  from  horses  to  the  cow  and  human  species,  others  of  an  opposite 
tendency  are  cited.  In  France  attempts,  made  at  Alfort  and  Rambouillet, 
to  inoculate  cows  with  cow-pox,  by  using  grease-matter,  were  not  till  recently 
attended  with  success,  hut  then  inoculation  of  children  with  matter  from 
the  horse  disease  was  not  tried.  In  explanation  of  these  negative  results, 
it  has  been  urged  that  possibly  the  cows  which  resisted  the  inoculation  by 
grease-matter  from  horses  had  had  cow-pox  at  some  former  period;  and  also 
that  the  malady  is  not  inoculable  at  all  its  stages,  and  that  it  cannot  be 
communicated  by  punctures  made  anywhere.  Finally,  as  was  alleged  by 
Dr.  Loy,  there  are  evidently  several  different  diseases  which  have  been 
confounded  together  under  the  name  of  grease,  only  one  of  which  is  the 
true  disease  capable  of  being  transmitted  to  the  cow,  and  transformed  in 
the  cow  into  cow-pox,  and  in  the  human  subject  into  vaccinia.  The  re- 
searches of  M.  H.  Bouley  have  corroborated  this  opinion  of  Dr.  Loy.  Jenner 
does  not  seem  to  have  been  acquainted  in  an  exact  manner  with  the  disease 
of  horses  which,  when  transmitted  to  cows,  produced  cow-pox;  he  gave  it 
the  vague  name  of  "sore  heels,"  which  means  disease  of  the  heels.  To  the 
"sore  heels"  of  Jenner,  the  "javart"  of  Sacco,  the  "affection  furonculeuse" 
of  Hertwig,  the  "maladie  pustuleuse"  of  M.  Lafosse — all  of  which  it  has 
been  said,  and  of  some  of  which  it  has  been  demonstrated,  that  they  produce 
cow-pox  by  inoculation — to  these  affections  M.  H.  Bouley  has  just  added 
aphthous  stomatitis.  M.  Depaul,  however,  has  shown  that  what  was  sup- 
posed to  be  merely  an  aphthous  affection  of  the  mouth  was  a  general  pus- 
tular eruption  very  analogous  to  small-pox.  In  other  words,  it  was  horse- 
pox,  the  malady  which  gives  cow-pox  to  cows.  But  the  distinctive  characters 
of  horse-pox  have  not  as  yet  been  accurately  determined,  and  it  is  still  a 
disease  without  an  historian. 

There  are  numerous  examples  in  human  pathology  of  inoculable  diseases 
not  inoculable  at  all  their  stages,  and  also  of  diseases  which  can  \>q  set  up 
more  easily  by  introducing  the  virus  at  one  partof  the  body  than  at  another. 
We  know  that  syphilis  can  be  easily  introduced  into  the  system  by  making 
a  puncture,  and  inoculating  with  pus  taken  from  a  chancre ;  and  we  also 
know  that  generally  syphilis  cannot  be  inoculated  by  using  matter  from  a 
pustule  or  muculent  scab  of  ecthyma  syphilitica.  Some  physicians,  wrongly, 
however,  deny  that  it  is  ever  possible  to  effect  this  last-mentioned  kind  of 
inoculation.  It  is  now  beyond  dispute  that,  in  certain  exceptional  circum- 
stances, syphilis  can  be  inoculated  from  secondary  forms  of  the  disease. 
When  we  return  to  this  question  in  treating  of  syphilis  in  new-born  children, 
we  shall  see  that  the  disease  is  transmitted  from  infant  to  nurse  only  under 
very  special  conditions. 

These  conditions  chiefly  consist  in  frequent  and  long-continued  contact 
of  the  syphilitic  virus  of  the  affected  parts  of  the  infant  with  the  absorbing 
surface  in  the  nurse.  They  are  most  favorable  when  the  infant  sucks  with 
power  and  energy,  and  when  the  nipple  is  in  a  state  of  continuous  and  in- 
creasing erection  from  the  time  that  it  is  touched  by  the  lips  of  the  infant. 
The  excitation  of  the  nipple  imparts  to  it  an  anatomical  and  physiological 
state,  in  virtue  of  which  the  skin  covering  it,  in  obedience  to  the  lawrs  of 
endosmosis,  opens  a  door  for  the  absorption  of  the  contagium,  so  that  there 
is  required  neither  denuded  surface,  excoriation,  nor  fissure  of  the  nipple, 
the  more  usual  way  by  which  syphilis  enters  the  system  of  the  nurse  from 
that  of  the  nursling.     If,  then,  we  compare  what  takes  place  in  respect  of 


106  cow-pox. 

the  transmission  of  syphilis  and  grease  in  their  more  advanced  forms,  we 
can  understand  the  unsuccessful  attempts  which  have  been  made  to  inoculate 
the  hitter,  and  can  explain  the  negative  experiments  made  at  Alfort  and 
Rambouillet,  as  well  as  other  negative  experiments,  by  supposing  that  the 
virus  was  taken  at  a  period  when  it  had  lost  its  energy  through  the  too  great 
length  of  time  which  had  elapsed  since  the  primary  development  of  the 
disease.  Is  it  possible  otherwise  to  explain  the  positive  results  obtained  by 
learned  and  conscientious  observers,  such  as  Loy,  Sacco,  Viborg,  Hitter, 
Berndt,  Pichot,  and  Maunoury? 

From  this  brief  statement  of  facts,  I  conclude  with  Steinbrenner,  whose 
opinion  is  also  that  of  AYoodville,  Coleman,  Viborg,  Sacco,  and  others,  that 
cow-pox  may  originate  in  grease :  but  here  I  must  repeat  a  proposition  I 
have  already  carefully  established,  that  this  is  not  equivalent  to  saying  that 
cow-pox  has  an  exclusive  origin  in  inoculation  or  in  contact  with  the  disease 
of  horses:  indeed,  cow-pox  generally  arises  quite  independently  of  grease. 

Although  grease  is  undoubtedly  transmissible  from  horse  to  cow  and  from 
horse  to  man,  it  loses  much  of  its  likeness  to  itself  by  transmission:  and 
cow-pox  in  the  cow  has  not  a  greater  resemblance  to  grease  than  vaccinia 
(or  humanized  cow-pox)  has  to  cow-pox  in  the  cow.  These  modifications 
in  the  form  of  affections,  which  are  essentially  and  fundamentally  identical, 
depend  on  the  nature  of  the  organisms  in  which  they  are  developed ;  and 
similar  modifications  are  not  rare  in  comparative  pathology. 

For  example,  malignant  carbuncle  [sang  de  rate],  a  disease  peculiar  to 
the  ovine  species,  becomes  quarter-evil  [charboii]  in  horned  cattle,  and  ma- 
lignant pustule  [pustule  maligne]  in  man. 

This  typhic,  strange,  general  disease,  frequently  destroys  a  great  number 
of  wool-clad  animals  in  certain  countries  of  Europe,  particularly  in  the 
departments  of  France  which  constitute  the  old  provinces  of  Beauce,  Berry, 
and  Brie.  It  can  be  transmitted  to  sheep,  by  inoculating  them  with  the 
blood  of  an  infected  sheep.  If  a  little  blood,  taken  from  the  spleen  im me- 
diately after  the  animal  has  been  killed  and  before  putrefaction  has  began, 
be  introduced  by  inoculation  into  the  ear,  groin,  or  inguinal  region  of 
another  sheep,  there  is  no  indication  of  any  effect  having  been  produced, 
till  from  twenty-six  to  thirty-six  hours  have  elapsed  :  the  animal  then,  all 
at  once,  loses  appetite,  shows  typhic  symptoms  and,  within  an  hour  or  two, 
dies.  On  dissection,  lesions  similar  to  those  found  in  the  sheep  from  which 
the  blood  used  for  the  inoculation  was  taken  are  observed.  On  inoculating 
with  blood  taken  from  the  second  sheep  a  third  in  a  district  far  away  from 
that  of  the  other  two,  the  malady  is  communicated  ;  and  it  can  in  succession 
be  similarly  transmitted  to  individuals  of  the  same  species,  the  disease  always 
remaining  the  same,  and  identical  in  its  symptoms. 

If,  however,  you  inoculate  an  ox  or  a  cow  with  blond  from  the  spleen  of 
an  infected  sheep,  you  no  longer  produce  the  ovine  malignanl  carbuucle 
[sang  de  rate],  but  a  kind  of  charbon  which,  though  at  first  only  a  local 
affection,  will  soon  become  a  general  disease  attended  by  grave  Bymptoms, 
quickly  proving  fatal,  uuless  it  lie  eradicated  in  its  original  site  by  energetic 
cauterization. 

Again  :  A  Bhepherd,  when  Bkinniug  a  sheep  which  had  died  from  sang 
de  r<itry  was  inoculated  with  the  disease,  cither  by  his  excoriated  hands 
having  been  .-oiled  with  the  animal's  blood,  or  by  his  hands,  perhaps  quite 

free   from  excoriations,  having   remained    t<">  Ion-'   in  contact  with  it-  hide. 

After  a  certain  time,  a  disease  of  special  character  was  developed  in  this 

•nan:    which,  although  Sang  de  rnlr  is  from  the  unset  a  general  malady,  was 

at  firsl  exclusively  local:  it  was  the  affection  called  malignanl  pustule. 
This  malignanl  pustule,  which  is  really  a  small  vesicle,  occasions  tingling 


cow-pox.  107 

in  the  skin  for  a  day  or  two,  soon  followed  by  a  feeling  of  numbness  extend- 
ing along  the  arm,  if  the  pustule  is  situated  on  the  hand  or  forearm:  soon 
after  this  there  appears  in  the  centre  of  the  little  vesicle  a  gangrenous  speck, 

which  resists  the  point  of  the  bistoury,  while  at  the  same  time  general  dis- 
turbance of  the  system  supervenes,  and  the  patients  sink  under  ataxo-ady- 
namic  symptoms,  lasting  sometimes  for  five  or  six  days.  Malignant  pustule 
is  at  first  so  purely  a  local  affection  that  its  constitutional  development  may 
he  prevented,  and  the  patients  saved  by  adopting  the  treatment  now  gener- 
ally followed  in  Beauce,  which  consists  in  vigorous  cauterization,  effected 
more  particularly  by  applying  corrosive  sublimate  to  the  parts  previously 
deeply  scarified.  The  physicians  of  the  department  of  Eure-et-Loir,  as  well 
as  those  of  Perche  and  Berry,  are  well  acquainted  with  this  treatment,  and 
when  called  in  to  a  case  promptly,  that  is  to  say,  sufficiently  early  to  cut 
short  the  progress  of  the  disease,  they  have  little  anxiety  about  the  issue. 
I  am  myself  in  a  position  to  form  an  opinion  on  this  question.  In  1856  one 
of  my  country  servants  contracted  the  disease  when  handling  three  sheep 
which  had  died  of  the  sang  de  rate.  One  Sunday,  just  as  I  came  home,  this 
man  showed  me  his  hand,  on  which  I  saw  a  very  characteristic  malignant 
pustule:  the  beginning  of  the  malady  dated  back  to  the  previous  Wednes- 
day: there  was  already  some  feverishness  and  general  constitutional  dis- 
turbance. I  scarified  the  affected  part,  and  introduced  corrosive  sublimate 
into  the  wound :  in  forty-eight  hours  the  cure  was  ascertained :  on  the  fol- 
lowing Sunday  I  found  my  patient  in  perfect  health,  excepting  that  he  had 
a  painful  scab  on  his  hand. 

When  we  see  a  disease  undergo  such  remarkable  mutations  by  trans- 
mission from  an  animal  of  one  species  to  an  animal  of  another  species  ; 
when  we  see  different  organisms  respond  in  so  different  a  manner  to  the 
same  morbific  cause,  it  ought  not  to  be  looked  on  as  astonishing  that  grease 
should  also  change  its  form  when  transmitted  to  the  human  subject  or  the 
cow;  nor  need  it  any  more  be  considered  wonderful  that  there  is  so  little 
resemblance  between  cow-pox  in  the  cow  and  vaccinia,  although  the  nature 
of  both  is  the  same.  We  can  in  the  same  way  understand  how  the  further 
question  may  be  asked — whether  cow-pox  is  anything  else  than  human 
small-pox  modified  by  development  in  the  organism  of  the  cow,  so  as  to 
lose  its  original  qualities,  and  be  re-transmissible  to  man  with  its  behavior 
wholly  changed.  Let  us  pause  a  moment  to  consider  what  has  been  done 
to  elucidate  this  question,  so  full  of  interest. 

Many  attempts  had  been  made  to  produce  cow-pox  in  cows  by  inoculat- 
ing them  with  virus  of  small-pox  from  the  human  subject,  but  without 
causing  anything  like  cow-pox,  although  the  experiments  were  made  in 
various  ways,  and  upon  animals  of  different  ages,  till  1807,  when  Dr. 
Gassner,  of  Giinzburg,  announced  that  he  had  obtained  the  desired  result. 
He  inoculated  eleven  cows  with  small-pox  virus,  and  obtained  true  cow-pox 
from  them,  with  the  matter  of  which  he  inoculated  children  in  whom  real 
vaccinia  was  thereby  produced.  These  results  were  called  in  question; 
but  in  1839  Dr.  Thiele,  of  Kasan,  having  repeated  the  experiments  of 
Gassner,  stated,  that  after  having  tried  ineffectually  to  inoculate  the  cow 
both  with  vaccine  lymph  and  small-pox  matter  from  man,  he  at  last  suc- 
ceeded with  the  latter,  cow-pox  pustules  being  produced  in  the  cow  :  with 
matter  taken  from  these  pustules,  he  obtained  normal  vaccinia  in  children. 
These  experiments  date  back  to  1836,  from  which  time  Dr.  Thiele  con- 
tinued to  vaccinate  with  the  same  lymph  ;  and  when  he  wrote,  it  had  passed 
through  seventy-five  generations,  and  had  demonstrated  its  efficacy  in  more 
than  3000  persons.  More  recently,  to  put  this  efficacy  to  the  test,  he  in- 
oculated with  small-pox  twenty-one  of  those  he  had  vaccinated,  and  without 


108  cow-pox. 

causing  small-pox  in  any  of  them.  The  cows  upon  •which  Dr.  Thiele  made 
his  experiments  were  between  four  and  six  years  old,  newly  calved,  and 
were,  as  often  as  he  could  find  them,  cows  with  white  teats.  He  confined 
them  to  their  shed,  keeping  the  temperature  there  at  15°  Reaumur:  their 
food  was  not  in  any  way  altered  ;  and  they  continued  to  be  milked.  The 
place  selected  was  shaved  immediately  before  inoculating;  and  the  place 
selected  was  the  posterior  surface  of  the  udder,  so  that  the  cow  was  unable 
to  lick  it.  Punctures  were  there  made,  a  little  deeper  than  is  usual  in 
vaccinating  the  human  subject,  and  were  covered  with  a  linen  cloth  soaked 
in  the  matter.  The  matter  was  taken  from  small-pox  pustules,  nacreous, 
and  bead-like,  before  they  had  lost  their  transparency,  and  containing  very 
clear  lymph  :  that  he  might  proceed  with  still  greater  certainty,  Dr.  Thiele 
kept  the  lymph  for  ten  or  twelve  days  between  glass  plates  before  using  it. 
On  the  third  day  after  inoculation,  a  protuberance  was  formed  under  the 
skin  ;  on  the  fifth,  a  pock  like  the  vaccinal  pock  was  visible,  which,  between 
the  seventh  and  ninth,  contained  a  limpid  lymph  and  presented  a  central 
depression.  Between  the  ninth  and  eleventh  day,  this  pock  began  to 
desiccate,  and  to  form  a  crust  which,  when  it  fell  off,  left  a  small,  smooth 
cicatrix.  Dr.  Thiele  generally  obtained  one  or  two  pocks  from  about  three 
or  six  inoculated  punctures. 

In  1840,  Dr.  Bitter,  of  Munich,  announced  that  he  also  had  inoculated 
cows  with  small-pox.  He  stated  that  during  ten  years  he  had  experimented 
on  more  than  fifty  cows  without  the  least  success,  but  that  at  last,  having 
adopted  Dr.  Thiele's  plan,  he  obtained  his  results.  He  produced  cow-pox 
in  the  cow,  whence  he  derived  matter  which  gave  children  a  perfectly 
normal  vaccinia. 

Concurrently  with  the  publication  of  the  result  of  Dr.  Thiele's  experi- 
ments, Dr.  Ceely,  of  Aylesbury,  met  with  similar  success.  I  shall  not 
relate  the  details  of  his  experiments,  which  you  will  find  in  extenso  in  Dr. 
Steinbrenner's  remarkable  work. 

Dr.  Sunderland,  of  Barmen,  also  tried  to  get  cow-pox  by  inoculating  the 
cow  with  small-pox,  but  he  proceeded  in  a  different  manner  from  Drs. 
Thiele  and  Bitter.  Dr.  Sunderland,  in  Hit/eland's  Journal  for  1830,  has 
described  the  plan  which  he  adopted,  which  consisted  in  covering  cows  with 
a  woollen  blanket  taken  from  the  bedding  of  a  man  who  had  died  in  the 
suppurative  stage  of  a  severe  case  of  small-pose.  The  blanket  was  imme- 
diately taken  from  the  dead  man's  bed,  rolled  up  in  a  sheet,  and  carried  t<> 
a  shed  where  there  were  young  cows:  it  was  carefully  fixed  successively  on 
the  backs  of  the  animals,  ami  allowed  to  remain  on  each  for  twenty-four 
hours.  Not  only  did  each  of  the  cows  wear  the  blanket  for  twenty-four 
hours,  but  it  was  after  that  fixed  along  their  manger,  SO  that  they  could  not 
avoid  breathing  the  miasmata  which  it  exhaled.  After  some  days  the  cows 
ceased  eating,  drank  a  great  deal,  and  had  fever:  about  the  fourth  <>r  fifth 
day,  pustules  appeared  upon  the  udder  and  other  sofl  parts.  These  pustules 
followed  the  usual  course  of  cow-pox,  and  between  their  fourth  and  eighth 
day  they  yielded  lymph  which  Berved  for  vaccination. 

This  marvel  loo-  discovery  could  not  fail  to  command  attention  :  eagerness 
was  shown  to  repent  Dr.  Sunderland's  experiments.  The  results  which  he 
announced  had  been  now  here  obtained,  neither  in   I  )enmark.  where,  in  L833, 

the  Government  requested  physicians  to  investigate  the  subject,  nor  at 
Berlin,  Weimar,  Dresden,  nor  Calcutta.  In  Prance,  the  success  was  no 
greater.  M.  Miquel of  Amboise made  several  fruitless  attempts  to  inoculate 
the  cow  with  a  view  to  produce  cow-pox  from  the  virus  of  small-pox,  Cur 
learned  brother  of  Touraine,  however,  experimented  under  apparently  the 
mosl  favorable  conditions.     Those  who  have  visited  the  hanks  of  the  Loire 


cow-pox.  109 

between  Blois  and  Angers  musl  have  .-ecu  dwellings  excavated  in  the  rocky 
slopes  wherein  herds  of  peasants  live  crowded  together,  and  only  separated 
from  their  cattle  by  slight  partitions.  Well!  M.  Miquel  had  occasion  to 
see  an  epidemic  of  confluent  small-pox  prevailing  amid  that  population. 
It  being  winter,  the  cows  were  shut  up  in  their  sheds  day  and  night,  .so 
that  they  actually  lived  among  the  sick  people.  Still,  under  these  circum- 
stances M.  MitpK'l  was  unable  to  find  small-pox  among  the  rows  :  he  wrapped 
them  up  in  the  blankets  of  th<)  sick  people,  but  was  not  able  in  a  single 
cow  to  detect  the  most  minute  cow-pock.  The  plan  of  Dr.  Sunderland, 
then,  only  yielded  satisfactory  results  when  put  in  force  by  himself,  unless 
we  take  into  account  circumstances  mentioned  in  the  narrative  of  John 
Webb  which  I  quoted  from  the  London  Lancet,  and  which  certainly  cor- 
roborate the  experiments  of  the  physician  of  Barmen. 

M.  Depaul  has  recently  supported  the  proposition  that  small-pox  and 
cow-pox  are  identical,  and  that  cow-pox  is  human  small-pox  transmitted  to, 
and  modified  by  the  cow,  or  in  other  words,  that  it  is  nothing  more  than 
mitigated  small-pox.  An  epidemic  of  small-pox  would  in  his  opinion  be 
sufficient  to  explain,  on  the  principle  of  contagion,  the  development  of  that 
disease  in  horses,  and  the  inoculation  of  the  cow  with  horse-pox  would  in 
all  probability  give  rise  to  a  modified  form  of  small-pox — that  is,  to  cow- 
pox.  He  says  :  "  Cow-pox  when  transmitted  to  man  will  reproduce  itself 
with  its  characteristics,"  that  is,  with  its  vaccinal  characteristics;  and 
finally,  that  "tag-sore  [clavelee]  is  nothing  more  than  small-pox  in  the 
sheep,  aud  is  probably  the  same  as  small-pox  in  the  horse,"  whence,  he 
adds,  "  it  follows  that  the  true  secret  for  mitigating  small-pox  in  the  human 
race  consists  in  causing  the  disease  to  pass  through  another  species  of 
animal  and  in  then  communicating  it  to  man  by  inoculation."* 

I  have  quoted  the  opinions  of  my  learned  colleague  in  his  own  words — 
opinions  which  he  supported  by  experiments  which  seemed,  for  the  moment, 
to  prove  that  his  views  were  right.  In  point  of  fact,  small-pox  can  be 
transmitted  by  inoculation  to  oxen  and  horses :  the  inoculation  originates 
in  them  a  pustular  affection  analogous  to  cow-pox,  but  only  analogous,  for 
the  disease  imparted  to  them  is  really  small-pox.  This  question  ought  to 
be  considered  as  definitely  settled  by  the  experiments  of  a  commission 
appointed  by  the  Society  of  the  Medical  Sciences  at  Lyons. 

As  we  have  here  to  do  with  a  doctrine  in  which  theory  is  intimatelv 
associated  with  practice,  and  regarding  which  the  holding  of'  unsound  con- ' 
elusions  may  lead  to  and,  as  you  shall  see,  has  led  to  irreparable  mischiefs, 
I  ask  you  to  allow  me  to  read  to  you  some  of  the  salient  passages  of  the 
report  made  by  M.  Chauveau  in  the  name  of  the  Lyons  Commission. 

The  learned  reporter  has  first  shown  that  small-pox  can  be  perfectly  well 
communicated  to  the  bovine  species  by  inoculation,  to  which  species  it 
stands  in  the  same  relation  as  vaccinia  to  man ;  that  is  to  say,  that  when 
an  ox  is  inoculated  with  small-pox  it  is  thereby  made  proof  against  cow-pox, 
just  as  a  vaccinated  man  is  proof  against  small-pox.  But  a  much  more 
important  practical  point  is,  that  "smallpox  in  Us  passage  through  the  system 
of  a  cotv  is  not  transformed  Into  vaccinia:  it  remains  small-pox,  and  returns  to 
the  original  state  of  small-pox  when  reintroduced  into  the  human  species." 
The  experiments  of  the  Lyons  Commission  upon  solipeds  gave  results  similar 
to  those  obtained  from  bovine  ruminants.  There  is  only  a  difference  in 
form.  Thus  in  the  cow,  the  eruption  of  small-pox  consists  of  pimples  so 
minute  as  to  escape  notice  unless  one  is  on  the  outlook  for  them.  Cow-pox, 
on  the  other  hand,  engenders  an  eruption  of  the  vaccinal  type  with  its 

*  Depaul  :  Bulletin  de  1'Academie  de  Medecine,  1863-04,  t.  xxviii. 


110  COW-POX. 

large  and  very  characteristic  pocks.  In  the  horse,  also,  the  inoculation  of 
small-pox  engenders  a  papular  eruption  in  which  there  is  neither  secretion 
nor  crust ;  and  although  this  eruption  is  much  more  formidable  than  that 
produced  in  the  cow,  it  need  never  be  confounded  with  horse-pox  eruption, 
so  remarkable  for  the  abundance  of  the  secretion  and  the  thickness  of  the 
crusts.  Hence  it  follows,  that  small-pox  and  cow-pox,  or  horse-pox,  are 
different  diseases,  and  that  when  we  vaccinate  after  the  method  of  Thiele 
and  Ceely  we  in  reality  inoculate  smallpox. 

This  kind  of  inoculation  of  small-pox  may  possibly  be  free  from  clanger, 
the  disease  being — according  to  hypothesis — modified  in  its  passage  through 
the  cow  or  horse.  Some  even  believe  in  a  mixed  virus,  to  which  the  epithet 
vaccino-variolic  has  been  given.  Experiment,  however,  utterly  demolishes 
this  theory.  Here,  again,  we  are  indebted  to  M.  Chauveau  for  demonstra- 
tive evidence.  The  facts  are  as  follows:  A  girl  of  two  and  a  half  years  of 
age  was  inoculated  with  the  so-called  vaccino-variolic  virus — that  is  to  say, 
with  matter  taken  from  pustules  in  a  cow  which  had  been  inoculated  with 
small-pox.  This  child  had,  on  each  arm,  three  magnificent  primitive  pus- 
tules, and  at  a  later  period,  a  disseminated  eruption  of  about  fifteen 
pimples.  The  pustules  on  the  arm  furnished  virus  with  which  two  very 
healthy  children  were  inoculated.  "  On  the  tenth  day,  both  took  simulta- 
neously very  severe  general  small-pox :  the  eruption  was  as  confluent  as  it 
was  possible  to  be,  the  fever  was  very  intense,  and  there  were  convulsions 
and  vomiting.  One  of  these  two  children  died  from  the  severity  of  the 
attack."  But  this  is  not  all :  another  child  was  inoculated  with  the  vaccino- 
variolic  virus  taken  direct  from  the  cow  :  on  the  eleventh  day,  there  was  a 
well-marked  local  eruption,  and  three  days  later  confluent  small-pox,  which 
for  several  days  placed  the  life  of  the  child  in  imminent  jeopardy.  Finally, 
in  this  case  there  was  indelible  variolic  cicatrices.  Here,  inoculatiou  only 
disfigured  the  child  :  but  I  have  now  to  mention  another  case  in  which  it 
was  a  homicidal  act.  The  virus  was  taken  from  the  horse :  the  inoculated 
child  had  an  anomalous  form  of  small-pox,  from  which  it  died.  Influenced 
by  highly  commendable  prudential  motives,  M.  Chauveau  does  not  give 
more  circumstantial  details  of  this  case,  but  the  details  which  he  furnishes 
are  quite  sufficient. 

By  the  evidence  now  adduced,  I  hold  that  the  question  is  definitively 
settled.  Both  in  France  and  foreign  countries,  however,  successful  and 
unsuccessful  experiments  may  be  quoted.  Bretonneau  in  his  experiments, 
which  he  repeated  several  times,  never  obtained  any  result  when  he  operated 
on  heifers,  to  which  he  gave  the  preference  from  not  wishing  to  dry  up  the 
milk  of  nursing  cows.  But  other  experimentalists  were  more  fortunate. 
Drs.  Haussmann  of  Stuttgard,  Numann,  Billing,  professor  of  the  veterinary 
school  of  Stockholm,  Magliari  of  Naples,  Heim  of  Meschede;  Drs.  Zybel, 
Nicolai,  and  Leutin;  MM.  With,  professor  at  the  veterinary  school  of 
Copenhagen,  IVinz  of  Dresden,  &c. ;  lastly,  Dr.  Bousquet,  member  of  the 
A.cademy  of  Medicine,  who  has  paid  much  attention  to  the  subjeel  of  cow- 
pox,*  Dr.  Bteinbrenner,  M  M.  Boutet,  Maunoury  of  <  'hurt res,  have  produced 
true  cow-pox  by  vaccinating  cows  with  the  human  vaccine  lymph  with  which 
they  were  vaccinating  infants. 

When  confronted  with  these  contradictory  facts,  we  are  obliged  to  ask  : 

What  is  the  explanation  of  the  successes  and  failures  ?  The  solution  of  the 
problem  is  not  devoid   of  difficulty.      Must   we,  to   explain    the   diversity  of 

results,  invoke  assistance  from  the  question  of  morbid  susceptibility — 


*  Bousquet:    Nouveau   Traits  <\<k   In    Vaccine  el   des    Eruptions   Varioleuses. 

Paris,  1848. 


COW-POX.-  Ill 

opportunity  morbide  f  Let  us  take  an  example.  I  assume  that  some  par- 
ticular disease — say  influenza — is  prevailing.  One  individual,  living  in  the 
midst  of  the  epidemic,  is  seized  with  influenza  under  influence  of  the 
slightest  cause,  while  another  escapes  who  is  living  close  to  the  first,  and 
exposed  to  the  same  morbific  causes,  as  well  as  to  others  more  powerful. 
During  the  whole  of  the  course  of  the  epidemic,  this  individual  may  be 
exposed  with  impunity,  and  then,  at  some  future  time,  take  influenza 
without  any  appreciable  cause.  There  are  times  when  an  individual  is 
proof  against  morbific  influences,  in  virtue  of  I  know  not  what,  in  virtue  of 
a  special  condition,  of  a  peculiar  state  of  the  organism  ;  but  whenever  this 
special  state  ceases,  the  same  organism  is  easily  affected  by  the  smallest  of 
the  influences  which  it  formerly  resisted.  Is  it  to  special  states  of  the 
organism  we  ought  to  look  for  the  explanation  of  the  different  results  which 
have  followed  vaccination  of  the  cow  ?  Or  ought  we  to  call  in  question  the 
virus  employed  in  the  experiments?  Shall  we  say  with  Steinbrenner,  that 
the  total  absence  of  results  observed  at  a  certain  period  .after  the  early 
days  of  the  Jennerian  discovery,  in  which  successful  were  in  excess  of 
unsuccessful  cases,  depended  on  the  lymph  having  in  its  descent  become 
much  weakened  in  power  ?  The  observations  of  Fiard  and  those  of  Boutet 
and  Maunoury  seem  to  give  support  to  that  view  :  the  inoculations  of  cows 
which  they  made  with  matter  of  old  descent  never  succeeded,  but  when 
they  used  the  matter  regenerated  in  their  experiments,  they  obtained  a 
pock  from  which  they  were  enabled  advantageously  to  vaccinate  children. 
With  Steinbrenner  we  further  ask  whether  vaccinal  matter  in  its  first 
generation  in  the  cow  produces  more  than  local  results,  and  whether,  after 
successive  generations  in  animals,  it  does  not  gradually  acquire  the  proper- 
ties of  cow-pox  such  as  they  were  found  by  Jenner  ? 


Transmission  of  Cow-pox  from  Man  to  Man. — Circumstances  favorable  to 
Successful  Vaccination. —  The  lymph  ought  to  be  taken  between  the  Fifth 
and  Seventh  Days. — Selection  of  Subjects  from  whom  the  lymph  ought  to 
be  taken. — Health  of  Persons  who  are  to  be  Vaccinated. — Transmission 
of  Syphilis  in  Vaccination. —  Vaccinal  Eruptions. 

Whatever  explanation,  gentlemen,  may  be  given  of  the  facts  which  I 
have  now  laid  before  you,  it  is  very  remarkable  that  cow-pox  when  first 
introduced  had  a  much  greater  activity  than  it  manifests  in  the  present 
day.  Jenner  foresaw  this  degeneration :  he  foresaw  it,  because  he  suspected 
that  the  virus  would  lose  its  power  in  successive  transmissions,  and  also 
because  he  reckoned  on  the  shortcomings  of  vaccinators.  The  first  propo- 
sition is  to  a  certain  extent  established  by  what  I  have  already  told  you 
of  the  enfeebling  of  cow-pox  in  the  bovine  species  itself,  which  took  place 
by  transmission  from  heifer  to  heifer.  What  I  am  about  to  say  of 
the  manner  in  which  vaccination  is  too  often  performed  will  prove  the 
second  proposition.  Forgetful  of  the  rules  laid  down  by  Jenner,  vaccina- 
tors in  place  of  taking  lymph  before  the  eighth  day,  and  by  preference  on 
the  fifth,  waited  till  the  eighth  day :  that  was  the  general  practice,  but 
some  physicians  did  not  scruple  to  use  lymph  taken  even  as  late  as  the 
ninth  day.  Moreover,  no  attention  was  paid  as  to  whether  the  individual 
to  be  vaccinated  was  or  was  not  in  a  favorable  state  for  the  development  of 
cow-pox.  This  state  of  fitness,  however,  is  a  consideration  of  the  highest 
importance,  and  the  frequency  with  which  it  has  been  neglected  is  the 
reason  why  we  have  to  deplore  many  disappointments  in  the  present  day. 

Let  us,  then,  study  the  conditions  necessary  for  the  reproduction  of  a 


112  "cow-pox. 

vaccine  lymph,  which  will  retain  its  an ti- variolous  power  to  the  greatest 
possible  extent,  and  be  transmissible  from  age  to  age.  Jenner  pointed  out 
these  conditions :  Dr.  Truchetet  has  restated  them  in  his  inaugural  thesis, 
basing  his  conclusions  upon  experiments  which  he  made  in  my  clinical 
wards.*  Some  of  these  conditions  pertain  to  the  virus,  others  to  the  subject 
into  whose  system  it  is  introduced.  If  the  virus  has  degenerated,  it  is,  as 
Steinbrenner  says,  because  the  lymph  employed  has  been  taken  indiscrimi- 
nately from  any  individual  provided  the  pocks  were  normal,  no  inquiry 
being  made  as  to  the  beauty  of  the  pock,  its  progressive  development,  or 
its  age.  Upon  reflection,  however,  it  is  evident,  that,  as  the  laws  of  biology 
are  equally  applicable  to  the  life  of  animals  and  plants,  physicians  ought 
always  to  act  in  this  matter  upon  principles  similar  to  those  which  influence 
the  selection  of  seed  by  agriculturists,  who  know  that  by  sowing  their  fields 
with  the  finest  grain,  they  will  in  return  reap  from  them  grain  of  the  finest 
quality.  And,  without  leaving  the  domain  of  pathological  biology,  it  is  a 
well-known  fact  that  after  a  certain  period  in  the  development  of  the  pus- 
tule, the  variolous  virus  is  inert.  In  1784,  Earle,  an  English  physician, 
communicated  his  observations  on  this  subject  to  Jenner,  stating  that  when 
he  had  inoculated  with  matter  from  too  advanced  small-pox  pustules  no 
effect  was  produced. 

The  selection  of  vaccinal  lymph  is,  therefore,  a  matter  of  great  impor- 
tance. Its  activity  is  far  from  being  the  same  at  all  its  ages.  Twenty- 
four  or  thirty  hours  after  introduction,  it  is  powerless  ;  in  from  forty-eight 
to  seventy-two  hours,  it  has  begun  to  develop  power ;  and  on  the  fourth, 
fifth,  and  sixth  days,  it  possesses  its  maximum  energy  ;  on  the  seventh  day, 
it  has  decreased  in  power,  and  after  from  the  eleventh  to  the  fourteenth,  it 
is  absolutely  powerless. 

Jenner,  who  at  first  employed  lymph  taken  on  the  eighth  day,  then  be- 
lieved that  that  was  the  most  favorable  time,  but  he  afterwards  discovered 
that  on  and  after  the  fifth  day,  the  pock  contained  a  lymph  perfectly  inocu- 
lable  and  of  great  energy:  he  said  that  this  energy  diminishes  from  the  time 
that  the  inflammatory  areola  begins  to  appear:  and  not  only  did  he  abstain 
from  employing  lymph  taken  after  the  eighth  day, when  he  could  do  other- 
wise, but  he  preferred  to  obtain  it  on  the  fifth.  This  was  likewise  the  opinion 
of  Delaroque,  the  French  translator  of  the  English  physician's  work  ;  it  is 
the  opinion  of  a  certain  number  of  the  most  notable  practitioners;  it  is  Dr. 
Bousquet's  opinion  ;  and  it  is  also  mine. 

These  opinions,  gentlemen,  have  been  beautifully  expressed  in  verse  by 
one  of  our  most  illustrious  poets.  Casimir  Delavigne,  in  his  poem  on  Vac- 
cination, says : 

"Puiscz  le  germe  heureuz  dans  sa  frafcbeur  premiere, 
Quand  le  Boleil  cinq  foia  a  fourrii  sa  carriere." 

[Draw  forth  the  auspicious  germ  in  its  first  freshness,  when  the  sun  has  five 
times  completed  his  course.]  Casimir  Delavigne,  in  the  poem  from  which 
I  quote,  gives  with  singular  felicity  and  elegant  precision  the  symptoms  of 
cow-pox  which  he  had  observed  along  with  Dr.  Pariset,  Secretary  ol  the 
A.caaemy  of  Medicine. 

[f  then  you  wish  to  have  vaccine  lymph  possessed  of  all  its  power,  and 
of  the  greatest  possible  amount  of  efficiency  as  a  protection  from  small-pox, 
you  must  take  it  at  a  sufficiently  earl  y  stage  of  the  pock:  you  mual  take  it 
between  the  fifth  and  seventh  days  inclusive.     Matter  taken  at  thai  period 


*  Tbuciiktkt:   nuel'jii's  Rrdicrdn's  stir  l.i  Vnrdnc.      [ThdseB  dc  Paris,  1856   | 


cow-pox.  113 

produces  a  large  pock,  which  becomes  surrounded  by  a  large  and  more  last- 
ing areola  of  inflammation  :  in  a  word,  a  cow-pock  is  obtained  more  vigorous 

than  if  the  virus  used  had  been  taken  at  a  more  advanced  stage. 

During  an  epidemic  of  small-pox,  if  you  can  procure  no  better  vaccinal 
matter,  you  may  vaccinate  with  lymph  taken  from  a  forty-eight  hours'  old 
pimple  :  its  activity  will  be  less  than  if  taken  some  days  later,  but  greater 
than  at  the  eighth  day.  When  eight-day  lymph  is  used,  evolution  proceeds 
more  slowly,  the  papule  not  appearing  till  the  third  day,  whereas,  when 
use  is  made  of  lymph  taken  between  the  fifth  and  seventh  days  inclusive, 
the  papule  is  visible  on  the  second  day.  In  the  former  case,  the  areola 
appears  on  the  seventh  or  eighth  day,  and  in  the  latter,  on  the  fifth  or  sixth. 
The  one  begins  to  dry  up  on  the  eleventh  or  twelfth,  and  the  other  on  the 
twelfth  or  thirteenth.  Finally,  while  the  period  for  maturation  is  from 
eight  to  nine  times  forty-eight  hours  for  eight-day  lymph,  it  is  prolonged 
to  eleven  or  twelve  nyqthemera  when  the  lymph  used  has  been  taken  be- 
tween the  fifth  and  seventh  days. 

The  choice  of  the  subjects  from  whom  the  supply  of  vaccine  lymph  is 
derived,  and  the  health  of  the  persons  to  be  vaccinated  are  also  matters  of 
importance ;  for  if  the  conditions  favorable  to  the  perfect  development  of 
a  germ  are  inherent  in  the  germ  itself,  so  likewise  are  they  in  the  soil 
wherein  it  germinates  and  grows.  In  respect  of  the  selection  of  persons 
from  whom  to  take  vaccine  lymph,  it  has  been  shown  that  they  ought  to  be 
in  good  health  and  of  vigorous  constitution,  as  the  pock  is  much  better 
developed  in  them  than  in  sickly  drooping  persons. 

But,  gentlemen,  there  is  a  point  to  which  I  desire  to  call  your  special 
attention  to-day ;  it  is — never  to  vaccinate  with  lymph  taken  from  one  under 
the  influence  of  the  syphilitic  diathesis.  The  transmission  of  the  great-pox  by 
vaccination  is  a  fact  which  now  seems  to  have  been  demonstrated.  Since 
the  beginning  of  this  century,  and  particularly  in  later  years,  cases  of  this 
kind  have  been  recorded  both  in  France  and  in  foreign  countries ;  to  them 
I  can  add  one  which  you  have  seen  in  the  clinical  wards,  and  which  I  shall 
now  briefly  recall  to  your  recollection. 

The  patient,  a  young  woman  of  eighteen  years  of  age,  came  into  the 
Hotel-Dieu  for  a  uterine  affection.  As  we  had  at  the  time  some  cases  of 
small-pox,  I  recommended  that  she  should  have  herself  vaccinated.  The 
lymph  was  taken  from  a  child  apparently  in  perfect  health,  and  from  the 
same  lymph  four  infants  in  the  nursery  ward  were  also  vaccinated.  •  Cow- 
pox  was  regularly  developed  in  the  children,  and  during  their  residence  in 
hospital  nothing  anomalous  was  noticed,  but,  unfortunately,  when  they  left 
we  lost  sight  of  them.  The  young  woman  had  false  cow7-pox :  on  the  day 
after  vaccination  the  punctures  became  salient ;  they  were  surrounded  by 
an  inflamed  areola,  and  accompanied  by  great  itching  of  the  skin  ;  in  four 
or  five  days  no  trace  of  puncture  remained.  The  patient  then  left  us,  but 
it  was  agreed  that  she  should  return  once  a  fortnight  to  follow  out  the  treat- 
ment of  the  uterine  affection.  On  her  first  return,  twenty-three  days  after 
vaccination,  she  drew  attention  to  the  punctures  on  both  arms  :  two  of  those 
on  the  left  arm  seemed  to  have  taken  :  I  observed  that  the  pustules  were 
ecthyma.  At  her  next  visit,  a  fortnight  later,  the  pustules  of  ecthyma  were 
observed  to  have  become  transformed  into  scabs  of  rupia  indurated  at  the 
base :  in  the  axilla  we  found  some  of  the  lymphatic  glands  in  a  state  of 
indolent  turgescence ;  finally,  an  eruption  of  roseola  clearly  showed  that 
the  woman  was  under  the  influence  of  syphilitic  poisoning,  and  that  the 
starting-point  of  the  poison  was  iucontestably  the  vaccination  pustules. 

Gentlemen,  you  know  how  many  questions  have  been  recently  raised  in 
relation  to  cases  of  this  kind  :  the  subject  is  one  of  grave  importance,  and 


114  .  cow-pox. 

its  discussion  is  not  yet  closed.  If  some  physicians  still  doubt  the  possibility 
of  syphilis  being  communicated  in  vaccination,  the  majority  are  open  to 
the  logic  of  facts,  and  remain  on  the  alert.  But  among  those  who  constitute 
this  majority,  what  diversity  of  opinion  exists?  Some  hold  that  syphilis  is 
transmissible  and  inoculable  through  the  medium  of  the  vaccine  virus  ; 
others,  absolving  the  vaccine  virus  from  all  blame,  hold  that  the  syphilitic 
virus  passes  with  the  blood  which  has  accidentally  been  drawn  in  taking 
the  lymph  from  the  pock. 

I  shall  not  stop  to  discuss  the  two  classes  of  facts  by  which  these  views 
are  respectively  supported,  as  my  own  experience  is  insufficient  to  solve  the 
difficulty.  The  fact  which  I  wish  to  impress  upon  you  is  this, — that  syphilis 
has  in  numerous  cases  been  transmitted  in  vaccination.  I  cannot  better 
bring  my  remarks  on  this  subject  to  a  close,  than  by  cpioting  some  of  the 
conclusions  in  relation  to  it  which  have  been  arrived  at  by  Dr.  Viennois,  of 
Lyons.* 

I  agree  with  Viennois  that  one  ought  never  to  use  vaccine  lymph  taken 
from  a  suspected  subject,  and  that  in  respect  of  infants  one  ought  not  to 
take  it  unless  the  infant  has  passed  four  or  five  months,  the  age  at  which 
hereditary  syphilis  usually  shows  itself  by  visible  signs ;  for  infantile  syphilis, 
even  before  it  appears  on  the  exterior  parts  of  the  body,  is  transmissible. 
But  I  cannot  in  any  degree  adopt  the  conclusions  of  this  author  when  he 
adds :  "  If  special  circumstances  make  it  necessary  to  take  vaccination 
lymph  from  a  syphilitic  patient,  great  care  must  be  observed  so  as  to  draw 
the  pure  lymph  without  the  slightest  admixture  of  blood  or  syphilitic 
humor."  I  cannot  in  any  circumstances  whatever  sanction  vaccine  matter 
being  taken  from  a  syphilitic  subject.  It  is  more  a  matter  of  hypothesis  than 
of  demonstration,  that  it  is  only  by  the  blood  that  syphilis  is  transmitted  in 
this  class  of  cases.  Besides,  it  is  rather  difficult  to  understand  how  that 
which  is  contained  in  the  serum  of  the  blood,  that  is  the  syphilitic  virus, 
should  not  also  be  contained  in  the  serosity  of  the  vaccinal  pock.  Finally, 
it  is  so  difficult  to  draw  off  the  vaccine  lymph  free  from  "  the  slightest 
admixture  of  blood  or  syphilitic  humor,"  that  the  recommendation  of  the 
required  precaution  amounts,  so  far  as  I  am  concerned,  to  a  prohibition. 
Mv  opinion  on  this  point  admits  of  no  modification.  Abstain  always  from 
raking  lymph  from  a  syphilitic  subject. 

In  the  discussion  which  took  place  in  1864  and  1865  in  the  Academy  of 
Medicine,  upon  the  transmission  of  syphilis  in  vaccination,  MM.  Depaul 
and  Bouvier  demonstrated  the  relative  frequency  of  cases  of  transmission, 
and  showed  that  vaccination  carried  out  with  Lymph  derived  from  a  syphilitic 
child  may  sometimes  assume  the  character  of  a  real  social  calamity.  Thus 
in  1856,  at  Lupara  in  the  Neapolitan  territory,  Dr.  Marone  vaccinated  in 
the  beginning  of  November  a  certain  number  of  children  with  lymph  in 
tube.-  which  came    from  Campo-BasSO :   it  was  slightly  colored  with    blood. 

though  as  clear  and  transparent  as  usual.  The  first  child  vaccinated  with 
this  lymph  was  Philomene  Lietori,  aged  eight  months,  and  Gram  her  the 

others  were  vaccinated,  of  whom,  besides  Philomene  Listori,  twenty-two, 
being  Dearly  the  entire  number  vaccinated,  took  syphilis,     'I 'hoe  children 

..(■re  horn  of  healthy  parent,-,  and  all  had,  from  their  birth  to  the  date  of 
vaccination,  been  i'vvv  from  venereal  symptoms.  In  m08<  of  them  vaccina- 
tion took  effect  on  the  firet  trial,  but  in  some  the  operation  required  to  be 
repeated.  The  vaccinal  pock  was  followed  by  characteristic  venerea]  ulcera- 
tions, accompanied  by  swelling  of  the  axillary  glands.     Then,  a  little  sooner 


*  Viennois:    Archives  Generalcs  *l . -    M.,i(>cine,  Juin,  Juillet,  el   Septembre, 
Paris,  I860. 


cow-pox.  115 

in  sonic,  and  a  little  later  in  others,  but  in  the  majority  about  the  middle  of 
January,  L857,  there  appeared  eruptions  of  roseola,  impetigo,  syphilitic 
papules,  and  oven  pemphigus:  those  eruptions  were  soon  succeeded  by  mu- 
cinous scabs  on  the  lips,  the  interior  of  the  mouth,  on  the  parts  around  the 
anus,  on  the  vulva  and  on  the  scrotum,  with  consecutive  enlargement  of  the 
posterior  cervical  and  inguinal  glands;  loss  of  flesh,  and  a  disturbance  of 
the  general  health,  proportionate  to  the  severity  of  the  case.  The  mothers, 
mosl  of  whom  suckled  their  infants,  contracted  syphilis  from  them.  A  series 
of  venereal  symptoms,at  first  local, and  which  Dr.Marone  has  well  described, 
manifested  themselves  in  these  unfortunates.  Some  of  them  communicated 
the  disease  to  their  husbands.  From  fathers  and  mothers  it  extended  to 
other  members  of  the  family,  to  children  under  puberty  of  both  sexes,  and 
sometimes  to  entire  families.  Almost  all  the  women  who  became  pregnant 
miscarried,  bringing  forth  syphilitic  infants,  or  dead  foetuses,  presenting  in 
some  cases  traces  of  syphilis.  Most  of  the  patients  were  cured  by  specific 
treatment :  there  was,  however,  a  great  tendency  to  relapses ;  and  in  some 
two  years  and  a  half  had  elapsed  before  the  disease  was  eradicated. 
Some  of  the  infants  died,  and  several  of  the  adults  were  in  jeopardy.  Dr. 
Marone  had  taken  lymph  from  the  first  series  he  vaccinated  for  the  purpose 
of  vaccinating  others.  Eleven  of  this  second  series  contracted  syphilis  like 
the  first,  and  communicated  it  to  their  mothers,  who  gave  it  to  eleven  nurs- 
lings who  had  not  been  vaccinated.  Some  of  the  women  gave  the  disease 
to  their  husbands,  and  all  the  young  girls  Avere  also  affected  through  their 
contact  with  the  nurses  and  children.  It  appears,  therefore,  that  at  Lupara 
thirty-four  children  were  inoculated  with  syphilis  in  being  vaccinated  ;  and 
that  a  great  number  of  individuals  of  different  ages  were  directly  or  indi- 
rectly contaminated  by  these  children.  At  Rivalta  there  were  eighty  vic- 
tims. 

The  details  now  laid  before  you  are  given  by  M.  Bouvier.  I  have  now 
to  add,  on  the  authority  of  M.  Depaul,  the  history  of  forty  infants  con- 
taminated with  syphilis  out  of  forty-six  vaccinated  in  1821.  According  to 
the  report  of  M.  Cerioli,  there  were  thus  from  four  original  cases  155  chil- 
dren directly  infected  with  syphilis  by  vaccination,  and  there  were  others 
secondarily  infected  through  them,  bringing  up  to  300  the  total  number  of 
syphilitic  contaminations.  I  cannot,  therefore,  too  earnestly  recommend 
you  to  examine  with  the  greatest  possible  minuteness  the  subject  from 
which  you  take  the  lymph  for  your  vaccinations,  and  to  abstain  from  taking 
it  not  only  from  syphilitic  persons,  but  likewise  from  all  who  present  the 
slightest  ground  for  your  suspecting  that  they  have  venereal  contamination. 

With  respect  to  those  xohom  it  is  wished  to  vaccinate,  we  have  to  bear  in 
mind  age,  constitution,  certain  antecedent  diseases,  and  also  the  diseases 
which  supervene  during  the  progress  of  cow-pox.  Vaccination  succeeds 
better  in  childhood  than  in  adult  age :  it  must  not,  however,  be  supposed 
that  the  younger  the  infant  the  greater  is  the  fitness.  At  the  age  of  some 
months,  vaccination  does  much  better  than  in  the  new-born  infant.  The 
cow-pock  will  be  much  finer  in  an  individual  of  good  health  and  sound  con- 
stitution that  in  one  who  is  weak  and  drooping.  In  the  latter,  the  vaccinal 
pimple  is  softer  and  less  prominent,  its  areola  is  smaller,  of  a  dull-red 
color,  and  desiccates  at  an  earlier  date.  M.  Truchetet,  finding  by  experi- 
ment that  lymph  taken  from  persons  of  unsound  health  became  very  feeble 
in  its  third  generation,  abandoned  the  use  of  it  after  two  transmissions. 

Acute  antecedent  diseases  have  no  effect  on  vaccination,  provided  the 
child  has  recovered  its  health.  Small-pox  and  cow-pox,  however,  are 
exceptions  to  this  law ;  it  may  be  superfluous  to  say  so,  after  what  I  have 
several  times  repeated,  to  the  effect  that  there  is  an  antagonism  between 


116  cow-pox. 

the  two  diseases,  and  that  they  reciprocally  confer  immunity  from  one 
another.  Nevertheless,  cases  have  heen  cited,  and  I  have  also  seen  cases, 
in  which  vaccination  took  effect  in  persons  who  had  had  small-pox  previ- 
ously ;  but  such  cases  are  very  rare,  and  wheu  they  are  looked  into,  it  is 
generally  found  that  the  cow-pox  was  of  a  feeble,  spurious  kind  :  regular 
cow-pox  after  small-pox  is  exceedingly  uncommon.  Examples  of  antece- 
dent vaccination  not  preventing  a  subsequent  vaccination  from  producing 
cow-pox  have  been  occasionlly  noticed  from  the  date  of  Jenner's  discovery 
downwards ;  indeed  two  cases  of  this  class  are  recorded  by  Jenner  himself, 
in  which  vaccinated  persons  went  through  normal  cow-pox  a  second  or 
even  a  third  time,  but  at  long  intervals.  Such  cases,  however,  are  at  least 
quite  as  exceptional  as  the  occurrence  of  cow-pox  in  persons  who  have  pre- 
viously had  small-pox. 

Is  there  anything  surprising  in  these  returns  of  the  disease  ?  Was  it  not 
known  that  small-pox  might  attack  the  same  person  more  than  once? 
Why  then,  may  not  its  congener  cow-pox  likewise  offer  sometimes  an  excep- 
tion to  the  general  rule '?  Such  exceptions  were,  moreover,  much  more 
uncommon  formerly  than  now  that  the  vaccine  lymph  in  general  use  has 
undoubtedly  become  degenerated.  But  before  pronouncing  any  opinion 
on  the  number  and  value  of  these  second  attacks,  it  is  important  among 
other  things  to  ascextain  whether  the  persons  in  whom  vaccination  has  taken 
effect  more  than  once  have  ever  had  previously  the  legitimate  cow-pock,  in 
what  condition  it  was  developed,  in  what  manner  vaccination  was  per- 
formed, and  what  was  the  date  of  the  first  vaccination  ;  it  is  particularly 
important  to  ascertain  positively  that  the  second  vaccinal  eruption  is  not 
that  which  is  called  false  cow-pox,  which  may  sometimes  be  mistaken  for 
the  true,  and  to  which  I  shall  return,  as  it  is  indispensable  to  be  acquainted 
with  the  differential  diagnosis  of  the  two  affections. 

It  has  been  also  asked,  gentlemen,  whether  cow-pox,  an  affection  which 
so  radically  modifies  the  economy,  aud  is  iu  the  opinion  of  some  observers 
only  a  form  of  small-pox,  does  not  sometimes  declare  its  presence  by  a 
general  eruption  :  indeed,  there  is  room  for  surprise  that  such  is  not  ordi- 
narily its  mode  of  manifestation.  I  have  often  recalled  to  your  attention  a 
case  which  I  saw  in  the  Xecker  Hospital,  and  I  am  not  the  only  vaccinator 
who  has  observed  cases  of  this  kind.  I  vaccinated  a  strong  young  child, 
making  eight  punctures.  Eleven  days  afterwards,  to  my  great  astonish- 
ment,! saw  on  the  face,  trunk  and  limbs  twenty-seven  pocks  having  exactly 
the  appearance  of  cow-pox.  I  confess  that  at  first  I  believed  in  a  general 
eruption,  like  that  which  follows  variolous  inoculation,  but  on  a  closer 
examination  I  abandoned  that  idea,  or  at  least  I  entertained  great  doubts 
as  to  its  correctness.  Before  vaccination,  the  child  had  sudamina  all  over 
the  body.  It  was  summer.  He  scratched  the  vaccinal  pimples  which 
were  excoriated,  and  thus  he  carried  the  virus  on  his  nails  to  parts  denuded 
of  epidermis,  and  so  produced  on  these  parts  vaccinal  pocks.  Inoculation 
of  cow-pox  in  a  recently  vaccinated  child  lakes  place  readily,  but  the  time 
come- when  attempts  ai  this  kind  of  secondary  vaccination  prove  abortive. 

You  have  often  seen  the  experiment-  which  1  have  made  in  the  wards 
in  relation  to  this  point.  I  vaccinate:  in  four  days  I  make  a  new  punc- 
ture with  a  lancet  charged  from  one  of  the  incipient  pustules  J  I  continue 
to  do  this  daily  :  and  you  baveseen  that  up  to  the  ninth  ami  sometimes  till 
the  tenth  day — hut  not  later  than  that-  there  i-  a  cow-pock  developed  at 
each    new  puncture.      The  secondary  pock-,  however,  do  not    attain    to   the 

size  of  the  primary  pock,  ami  it  is  observed  that  the  secondary  pocks 
earliesl  in  date  are  the  besi  developed,  and  that  in  succession,  as  the  date 
of  the  puncture  from  which  they  proceed  becomes  more  distant  from  that 


cow-pox.  117 

of  the  original  vaccination,  they  lose  the  normal  appearance,  those  of  the 
ninth  and  tenth  days  aborting  soon  after  being  slightly  inflamed  ;  whilst 
after  the  tenth  day,  the  prick  produces  no  more  effect  than  if  the  lancet 
were  charged  with  the  pus  of  an  ordinary  boil.  Our  little  patient  of  the 
Necker  Hospital  must  therefore,  have  secondarily  vaccinated  himself,  at 
latest,  seven  or  eight  days  after  the  primary  vaccination. 

The  general  pustular  eruption  of  which  I  have  just  spoken,  and  the 
occurrence  of  which  is  altogether  exceptional,  must  not  be  confounded  with 
a  secondary  eruption  very  common  in  small-pox,  and  of  which  physicians 
give  different  explanations.  On  the  seventh,  or  at  latest  on  the  eighth  day 
after  vaccination,  fever  is  lighted  up,  analogous  to  the  fever  of  maturation 
in  small-pox.  It  is  generally,  and  I  think  correctly  believed  that  this 
fever  is  symptomatic  of  the  very  acute  inflammation  going  on  around  each 
pock,  and  of  the  swelling  of  the  axillary  lymphatic  glands.  Another 
interpretation  is,  that  it  is  simply  the  general  fever  of  invasion  dependent 
on  the  disturbance  of  the  system  caused  by  the  reception  of  the  vaccine 
virus,  just  as  the  fever  of  the  eighth  and  ninth  day  after  variolous  inocula- 
tion is  nothing  more  than  the  invasion-fever  of  the  small-pox  then  becom- 
ing developed  in  the  system,  and  not  at  all  a  symptom  of  the  inflammation 
manifested  around  the  pustule  of  inoculation.  Looking  at  it  from  this 
point  of  view,  we  are  obliged  to  hold  that  the  vaccinal  fever  is  not  the 
necessary  consequence  of  the  general  cutaneous  eruption,  differing  in  this 
respect  from  the  eruptive  fever  in  small-pox  and  measles.  But  as  the 
secondary  vaccinal  eruption  occurs  very  often,  and  as  in  summer  as  many 
children  have  it  as  escape  it,  the  question  may  be  asked,  whether  the  initia- 
tory vaccinal  fever  may  not,  up  to  a  certain  point,  be  analogous  to  scar- 
latinous fever,  which,  as  I  shall  have  to  tell  you  on  some  future  occasion,  is 
not  always  followed  by  the  specific  exanthem.  Finally,  without  going  in 
search  of  explanations  more  or  less  hypothetical,  we  may  consider  the  erup- 
tion frequently  seen  about  the  tenth  or  eleventh  day  after  vaccination  to 
be  nothing  more  than  that  exanthem  so  common  in  children  having  sup- 
puration going  on  in  some  part,  and  at  the  same  time,  fever  and  copious 
sweating.  In  point  of  fact,  gentlemen,  the  secondary  vaccinal  eruption 
differs  in  no  respect  from  that  which  I  have  called  sudoral  eruption, 
regarding  which  it  is  my  intention  to  spea"k  in  an  early  lecture.  It  is  a 
measly  or  scarlatiniform  exanthem,  almost  always  very  transitory,  some- 
times, however,  taking  the  more  severe  form  of  acute  eczema,  or  impetigin- 
ous eczema,  and  constituting  the  first  link  in  the  very  long  chain  of  sup- 
purations of  the  skin  and  mucous  membranes  which  have  caused  a  sort  of 
reprobation  of  vaccination  still  existing  among  prejudiced  and  ignorant 
people. 

Let  us  now  return,  gentlemen,  to  other  conditions  which  modify  cow-pox. 

Chronic  diseases,  by  reducing  the  vital  powTer  of  the  economy  and  weak- 
ening the  constitution,  necessarily  produce  a  condition  unfavorable  to  the 
development  of  cow-pox.  Infants  with  hereditary  syphilis  readily  take  the 
cow-pox,  whether  the  syphilis  be  still  latent,  or  whether  it  has  showed  itself 
by  unmistakable  visible  signs.  Without  entering  into  too  much  detail,  I 
would,  in  proof  of  this  assertion,  remark  that  you  have  often  seen  in  my 
wards  the  normal  development  of  cow-pox  in  infants  who  at  a  later  period 
showed  symptoms  of  hereditary  syphilis,  as  well  as  in  other  infants  who 
were  admitted  to  be  treated  for  syphilitic  psoriasis,  rupia,  and  other  vene- 
real affections.  Syphilis,  then,  does  not  constitute  an  obstacle  to  the 
development  of  cow-pox.  It  is  not  so  with  the  eruptive  fevers.  For 
example,  when  measles  or  scarlatina  supervene  during  an  attack  of  syphilis, 


118  cow-pox. 

the  progress  of  the  latter  is  arrested,  and  is  not  resumed  till  the  exanthem- 
atous  disease  has  run  its  course. 

As  small-pox  and  cow-pox  mutually  exclude  one  another,  it  seems  ra- 
tional to  believe  that  the  two  diseases  cannot  coexist.  Again,  it  has  been 
demonstrated  that  the  incompatability  of  the  two  is  not  declared  till  the 
fifth,  sixth,  or  seventh  day  of  normal  cow-pox.  If  the  system  is  under  the 
influence  of  the  variolous  poison  during  a  few  days  immediately  succeeding 
vaccination,  the  small-pox  and  the  cow-pox  both  germinate  and  become 
simultaneously  developed  without  in  any  way  influencing  one  another.  The 
experiments  of  Woodville  leave  no  room  for  doubting  this,  and  M.  Bous- 
quet  states  that  Professor  Leroux  has  seen  a  vaccinal  pock  implanted,  as  it 
were,  in  the  centre  of  a  variolous  pock.  "  He  separately  inoculated  the 
two  viruses:  vaccination  produced  cow-pox  with  all  its  advantages,  and 
variolation  produced  small-pox  with  all  its  dangers."  I  have  seen  the  two 
diseases  develop  themselves  simultaneously.  I  am  well  aware,  and  I  ought 
to  tell  you,  that  statements  have  been  published  in  contradiction  to  the 
cases  I  now  refer  to  as  having  seen.  Thus,  a  physician  of  Dunkirk,  Dr. 
Zandyck,  concluded  from  experiments  which  he  made  during  an  epidemic 
of  small-pox,  that  persons  vaccinated  during  the  incubation  of  small-pox 
always  had  modified  small-pox  with  its  symptoms  and  characteristics. 
Similar  results  were  obtained  in  experiments  made  by  MM.  Rayer,  Herard, 
and  Tardieu.  The  latter  has  even  recorded  a  case  in  which  he  saw  success 
attend  vaccination  performed  at  the  beginning  of  a  variolous  eruption. 
Although  this  case  is  unique,  Dr.  Zandyck  does  not  the  less  decidedly  give 
his  opinion  that  vaccination  ought  to  be  practiced  under  these  circum- 
stances, inasmuch  as  the  dangers  never  originate  in  the  cow-pox,  but  in  the 
small-pox  simple  or  complicated  :  most  assuredly  he  is  right.  Dr.  Zandyck 
is  of  opinion  that  the  affection— cow-pox  or  small-pox — which  is  first  in 
possession,  influences,  but  is  not  influenced  by  the  other.*  I  have,  however, 
told  you  that  the  experiments  of  Woodville  and  Bousquet,  as  well  as  my 
own,  demonstrated  that  cow-pox  and  small-pox  become  simultaneously 
developed,  without  exerting  any  influence  on  one  another:  and  my  obser- 
vations have  been  confirmed  by  the  paper  of  M.  Mare  d'Espine,  published 
in  the  Archives  Generates  de  Medecine  for  June  and  July,  1859. 

You  have  recently  had  under  your  observation  a  new  proof  of  the  cor- 
rectness of  this  opinion.  A  mother  and  her  infant  of  two  months  old 
simultaneously  took  small-pox  in  our  wards.  The  mother,  though  never 
vaccinated,  bad  the  distinct  form  of  the  disease,  which  ran  a  course  like 
that  of  modified  small-pox  ;  hut  the  infant  bad  a  confluent  eruption,  and 
died  on  the  eleventh  day.  This  infant  had  nevertheless  been  vaccinated 
on  the  second  or  third  day  of  small-pox  incubation  :  the  vaccination  ran  a 
perfectly  normal  course,  there  being,  however,  only  one  pock  from  -ix 
punctures.      On   the  eighth  day,  a  period  at  which  there  was  no  ground  for 

supposing  that  the  child  was  breeding  Bmall-pox,  two  new  punctures 

made  belOW  the  pock,  when  two  other  pocks  developed  themselves  in  a 
regular   manner.      It  was   QOl    till    the   third  day  of  the  variolous   eruption 

that  all  the  vaccinal  pocks  appeared  modified  in  their  mode  of  evolution : 
they  were  then  the  seat  of  hemorrhage  which  extended  to  the  surrounding 
cellular  tissue,  ami  the  sub  vaccinal  ecchymosis  became  very  hard.  You 
bave  seen  that  in  thi-  case  the  patient  derived  no  benefit  from  the  cow-pox, 
which  did   not   prevenl  death  from  confluenl  small-pox.     It   is  but   fair, 

however,  to   remark    that    this  child  Was  only  two  months  "Id,  and  that  the 

■   Zandyck:   Essai  sur  I'Epideoiie  de  Variole  <-t  de  Varioloids  qui  :i  rej 
Dunkerke  en  18ts,  el  1849.     Paris,  I 


cow-pox.  119 

termination  of  small-pox,  as  well  a<  of  erysipelas,  is  almost  always  fatal  ;it 
that  early  age. 

As  a  set-off  to  this  unfortunate  history,  I  must  mention  a  case  which 
several  of  you  had  an  opportunity  of  seeing  in  1861,  and  which  tends  to 
support  the  opinou  of  MM.  Zandyck,  Etayer,  Herard,  and  Tardieu.  The 
patient  was  a  male  infant  of  eleven  months,  whom  I  had  vaccinated  during 
tin-  incubation  of  small-pox.  The  progress  of  the  cow-pox  was  retarded  up 
to  the  eighth  day  ;  that  is  to  say,  the  pimples  did  not  show  themselves  till 
the  fifth  day,  and  the  pustular  development  proceeded  exceedinglv  slowly. 
On  the  eighth  day,  the  child  was  seized  with  fiver,  vomiting,  and  diarrhoea, 
which  continued  for  two  days,  and  on  the  following  day  the  variolous  erup- 
tion appeared.  It  pursued  its  normal  course  till  the  fifth  day,  when  the 
pustules  became  dry  and  crusted.  The  small-pox  had  then  been  modified 
by  the  cow-pox,  which,  on  the  very  day  of  the  appearance  of  the  small-pox 
eruption,  showed  itself  in  beautiful  pocks  which  followed  a  regular  course. 

To  sum  up  what  I  have  said  on  this  subject :  If  you  wish  to  propagate 
efficient  cow-pox,  you  must  select  your  virus  under  circumstances  as  favor- 
able as  possible  for  securing  its  activity,  you  must  take  it  from  children 
who  are  healthy  and  of  sound  constitution,  you  must  choose  pocks  which 
are  large,  beautiful,  in  full  bloom  [bien  fleuries],  if  I  may  be  allowed  the 
expression,  and  which  are  from  five  to  seven  days  old. 

However  we  may  explain  it,  gentlemen,  taking  into  account  all  the 
conditions  and  circumstances  to  which  I  have  directed  your  attention,  it 
cannot,  in  the  first  place,  be  denied  that  it  is  much  more  common  nowadays 
than  at  the  commencement  of  the  century,  to  meet  with  anomalous  cow-pox, 
which  bears  the  same  relation  to  cow-pox  as  modified  small-pox  bears  to 
small-pox:  and  in  the  second  place,  all  vacinnators  have  seen — as  I  have 
seen — a  very  considerable  number  of  persons  with  cow-pox  who  had  been 
previously  vaccinated.  The  normality  of  the  first  vaccination  had  been 
proved  by  insusceptibility  to  revaccination  lasting  for  a  number  of  years, 
by  immunity  from  epidemics  of  small-pox,  and  also  by  the  length  of  time 
which  elapsed  before  successful  revaccination  was  possible. 

By  vaccinating  from  arm  to  arm,  there  is  certainly  the  least  risk  of 
failure;  but  as  we  cannot  always  have  recourse  to  the  pock  itself,  we  are 
frequently  compelled  to  use  preserved  lymph.  I  do  not  propose  to  enumerate 
the  different  plans  of  preservation  which  have  been  devised.  You  are 
acquainted  with  the  method  of  placing  the  lymph  between  two  perfectly 
smooth  plates  of  glass  of  about  twro  or  three  square  centimetres :  the  dried 
lymph  between  the  glass  plates  (which  are  closely  applied  the  one  upon 
the  other),  may  be  kept  in  this  way  protected  from  air  and  light,  provided 
the  plates  are,  as  is  usual,  enveloped  in  tin-foil.  The  method  which  I  prefer 
consists  in  shutting  up  the  lymph  in  capillary  tubes — not  in  vial  tubes, 
which  are  most  objectionable,  as  it  is  impossible  to  fill  them  with  the  virus, 
which  consequently  is  left  in  contact  with  air,  and  so  does  not  keep.  The 
tubes  which  I  recommend  are  in  the  strictest  sense  capillary :  as  you  have 
often  seen  them  employed,  you  know  that  the  proceeding  is  simplicity  itself. 
When  you  wish  to  fill  them,  you  open  a  vaccinal  pock  by  making  very 
slight  scarifications,  in  the  elevated  epidermis ;  forthwith,  an  exudation  of 
minute  drops  of  serosity  is  seen  :  this  lymph  is  collected  by  moving  over 
the  surface  of  the  pock  the  extremity  of  the  tube,  which  ought  to  be  held 
almost  horizontally:  the  liquid  is  drawn  into  the  tube  by  capillary  attrac- 
tion. The  proceeding  is  continued  till  the  tube  is  nearly  full,  when  it  is 
closed  by  holding  in  the  flame  of  a  candle,  first,  the  end  by  which  the 
lymph  entered,  and  then  the  other.  When  you  wish  to  use  the  lymph,  you 
break  off  both  extremities  of  the  tube,  place  one  of  them  between  the  lips 


120  cow-pox. 

and  blow  through  the  tube,  placing  the  other  extremity  upon  the  thumb- 
nail or  the  blade  of  a  lancet ;  a  small  drop  is  then  deposited. 

I  need  not  describe  the  operation  of  vaccination.  You  all  know  how  to 
perform  it,  and  you  likewise  know  the  place  which  ought  to  be  generally 
selected.  There  are  just  two  matters  of  detail  to  which  I  wish  to  refer;  the 
one  is  the  number  of  punctures  which  ought  to  be  made,  and  the  other,  the 
circumstances  under  which  it  is  expedient  to  select  another  than  the  usual 
place  for  operating. 

How  many  punctures  ought  to  be  made?  This  is  not  an  unimportant 
question.  Although  the  production  of  a  single  pock  is  generally  sufficient 
to  confer  immunity  from  small-pox,  the  labors  of  Eichborn  have  demon- 
strated that  it  is  not  always  sufficient.  Dr.  Marson,  an  English  physician, 
has  lately  conclusively  confirmed  this  opinion  of  the  German  pathologist. 
He  has  shown,  from  excellently  handled  statistical  data,  that  of  the  vac- 
cinated persons  who  take  small-pox,  those  have  it  in  the  mildest  and 
most  modified  form  who  bear  more  than  one  vaccinal  cicatrix.  Here  is  a 
summary  of  Dr.  Marson's  observations  as  given  by  my  friend  Dr.  Lasegue. 
Of  768  small-pox  patients  with  one  cicatrix,  550  had  the  disease  in  a  mod- 
ified form,  and  3  died,  giving  a  mortality  of  3.9  per  1000.  Of  608  with 
two  cicatrices,  486  had  modified  small-pox,  and  1  died,  giving  a  mortality 
of  1.6  per  1000.  Of  187  with  three  cicatrices,  156  had  modified  small-pox. 
Finally,  of  202  individuals  presenting  four  or  more  vaccinal  cicatrices,  182 
had  modified  small-pox,  and  none  of  them  died.  These  figures  speak  with 
emphasis,  and  taken  along  with  others  less  decisive,  though  valuable, 
demonstrate  that  the  number  of  punctures  made  in  vaccinating  is  a  matter 
of  importance. 

There  is  a  prejudice  against  which  I  wish  to  put  you  on  your  guard,  viz., 
prohibiting  the  washing  or  bathing  of  the  infant  on  the  day  of  vaccination, 
and  for  some  days  afterwards.  The  uselessness  of  these  precautions  was 
shown  by  experiments  made  in  1863  by  Dr.  Peter,  then  my  chef  de  clinique, 
now  my  colleague  in  the  hospitals,  and  Professor  agrir/e  of  the  Faculty. 
Acting  on  my  recommendation,  Dr.  Peter,  after  vaccinating  a  child  by 
means  of  three  punctures  on  each  arm,  immediately  washed  the  right  arm 
with  a  copious  splash  of  water,  at  the  same  time  rubbing  it  vigorously. 
The  vaccinal  eruption  not  only  appeared  on  the  right  arm  of  all  the  infants 
thus  treated,  but,  by  a  strange  chance,  the  pustules  were  must  numerous  and 
most  beautiful  on  the  washed  arm.  This  experiment  was  repealed  on  more 
than  sixty  infants,  and  as  the  results  were  always  similar,  it  is  evident  thai 
we  ought  to  give  no  countenance  to  the  puerile  prohibition  of  ablution  for 
some  days  alter  vaccination.  Besides,  how  can  one  believe  in  the  absorption 
of  the  virus  being  hindered  by  bathing  or  washing,  when  the  experiments 
made  in  18(52  by  Dr.  Martin  demonstrated  that  it  was  not  prevented  by 
cauterization.  This  young  physician,  who  was  an  interne  at  Saint  Lazarus 
Hospital  when  he  made  the  experiments,  applied  potassa  fusa  [cauxbique  dt 
Vienne]  to  the  punctures  of  vaccination  some  minutes  alter  he  made  them, 
and  the  deep  cauterization  thus  produced  did  not  prevent  absorption  of  the 
virus,  although  it  prevented  vaccinal  pocks  from  appearing :  it  was  found 
that  the  subject  bo  treated  acquired  immunity,  and  that  subsequent  attempts 
to  produce  cow-pox  were  ineffectual.* 

The  consideration  of  the  rule  to  he  followed  in  selecting  the  punctures, 

and  the  modifications  which  may  he  required  in  that  ride,  lead  me  to  Speak 
of  vaccination  as  a  mean.-  of  Curing  vascular  Q82VU8  ma  tern  us.      This  method 

of  treating  erectile  tumors  has  been  practiced  in  England  by  Hodgson, 


I'i.im;     I).--  Maladies  Virulentea  C pair,..  1868,  p.  IT. 


cow-pox.  121 

Earle,  and  dimming ;  and  is  mentioned  by  numerous  French  practitioners, 
some  of  whom  have  also  employed  it,  particularly  Baudelocque,  Rayer, 
Velpean,  Bousquet,  Paul  Gruersant,  Pigeaux,  Lafargue  of  St.  Emilion, 
tilhes,  Laboulbene,  Marjolin,  Blache,  &c.  It  offers  the  double  advantage 
of  conferring  vaccinal  immunity,  and  of  getting  rid  of  an  affection  which, 
at  a  later  period,  by  assuming  increased  development,  might  become  at  Least 
a  serious  infirmity,  though  not  exactly  a  disease.  Legendre  has  published 
a  note  on  this  eminently  practical  subject  in  the  Archives  Generates  dt  M*'<li- 
eint  for  May,  1856.  Our  lamented  colleague,  in  publishing  a  case  which 
had  come  under  his  observation,  has  formulated  some  practical  rules.  He 
says,  that  before  vaccinating  an  infant,  inquiry  ought  to  be  made  a-  to 
whether  it  has  nsevus,  for  it  is  obvious  that  if  this  method  of  cure  is  to  be 
employed,  it  must  be  had  recourse  to  uninterfered  with  by  antecedent  vac- 
cination. When  the  existence  of  an  erectile  tumor  is  ascertained,  it  ought 
forthwith  to  be  treated  by  vaccination.  This  rule  extends  even  to  those 
which  are  likely  to  disappear  spontaneously,  as  the  proceeding  involves  no 
risk,  and  as  it  often  happens  that  simple  vascular  stains  on  the  skin  hardly 
causing  the  slightest  elevation,  and  resembling  flea-bites  in  appearance, 
ultimately  become  bulky  tumors. 

As  vaccination  cures  nsevi  by  the  inflammatory  process  set  up  in  connec- 
tion with  the  development  of  the  pock,  it  follows,  that  in  proportion  to  the 
size  of  the  erectile  tumor  ought  the  vaccinal  punctures  to  be  more  or  less 
numerous.  For  the  same  reason  it  is  important  that  all  the  pocks  should 
be  freely  developed,  and  to  secure  this  the  vaccination  should  be  made  from 
arm  to  arm  on  the  fifth  or  sixth  day  of  the  pock,  so  that  virus  employed 
may  be  at  its  maximum  of  activity.  The  punctures  ought  to  be  so  made  as 
only  to  involve  the  superficial  lymphatic  network  of  the  skin,  and  the  lancet 
must  be  newly  charged  for  each  puncture.  To  avoid  bleeding,  of  which 
there  is  risk  when  the  tumor  is  very  vascular,  it  may  be  well  to  substitute 
for  the  lancet  a  needle,  or  an  exceedingly  fine-pointed  instrument,  such  as 
several  practitioners  have  had  made  for  this  particular  operation.  Some 
have  recommended  that  the  vaccinal  punctures  be  made  around,  and  not 
in  the  erectile  tumor.  By  adopting  that  plan  there  is  obtained  a  series  of 
pocks  which,  being  partly  on  the  sound  skin  and  partly  on  the  mevus, 
circumscribe  and  invade  the  latter,  determining  an  inflammation  which 
accomplishes  a  complete  cure.  When  the  vaccinal  crusts  fall  off,  the  place 
of  the  tumor  is  found  to  be  occupied  by  a  smooth  cicatrix,  which  is  either 
perfectly  white  or  still  dotted  with  a  few  red  points:  these  red  points  are 
isolated,  not  elevated,  in  size  not  larger  than  a  small  pin's  point,  and  their 
increase  in  volume  is  rendered  impossible  by  their  being  situated  on  cicatrix- 
tissue.  This  method  of  treatment  is  applicable  when  the  nsevi  are  situated 
on  the  trunk  and  limbs,  but  not  when  they  are  on  the  face,  as  in  the  latter 
situation  the  cicatrix  will  be  very  extensive,  and  may  even  be  larger  than 
the  naevus. 


Modified   Cow-pox. — -Regeneration  of  Lymph. — Revaccination. —  Vaccination 
at  the  Bar  of  Public  Opinion. 

I  said  that  I  should  return  to  the  subject  of  false  cow-pox,  an  affection 
which  it  is  necessary  to  be  able  to  recognize,  so  that  it  may  not  be  mistaken 
for  true  cow-pox.     It  has  been  thus  described  by  M.  Bousquet : 

"  True  cow-pox  hardly  begins  to  show  itself  at  the  end  of  the  third  day, 
but  the  false  is  much  earlier,  and  may  be  seen  from  the  first  to  the  second 
day  after  introduction  of  the  virus,  a  circumstance  which  from  the  first 


122  cow-pox. 

constitutes  a  distinction  between  the  two  affections.  But  this  precocity  is 
not  by  itself  sufficient  to  establish  a  differential  diagnosis.  False  cow-pox 
is  sometimes  so  rapid  in  its  course  as  only  to  appear  that  it  may  disappear : 
at  other  times  it  shows  itself  in  the  form  of  a  small  pimple,  more  appreciable 
by  the  eye  than  by  the  sense  of  touch.  This  pimple  goes  on  increasing  in 
size  till  the  fourth  or  fifth  day,  leaving  the  physician  uncertain  as  to  its 
future  progress ;  but  on  the  sixth  or  seventh  day,  in  place  of  becoming 
developed,  its  progress  is  arrested,  it  grows  pale,  and  dries  up:  at  other 
times  it  advances  farther,  always  preserving  in  its  rapid  development  a 
conical  and  globular  shape,  which  I  look  upon  as  an  unerring  a  sign  of  false 
cow-pox  as  the  flattening  and  central  depression  of  the  pock  are  signs 
specifically  characteristic  of  the  true." 

"  The  false  pock  is  sometimes  red  and  sometimes  yellowish.  It  never 
assumes  the  brilliant  silvery  lustre  which  distinguishes  the  prophylactic 
cow-pock.  Though  not  exactly  irregular  in  shape,  it  has  an  ill-defined 
margin.  Some  time  between  the  fourth  and  seventh  clay — for  the  false 
cow-pock  has  nothing  fixed  or  normal  in  its  course — it  becomes  yellow, 
suppurates,  and  dries  up." 

To  this  description  it  may  be  added,  that  false  cow-pox  is  often  accom- 
panied, as  local  symptoms,  by  inflammatory  induration  of  the  subjacent 
cellular  tissue,  disagreeable  itchiug  in  the  affected  parts,  swelling  and  pain 
in  the  axillary  glands ;  and,  as  general  symptoms,  by  restlessness,  headache, 
and  sometimes  by  fever. 

There  is  another  kind  of  false,  or,  to  speak  more  correctly,  of  aborted, 
cow-pox.  It  is  met  with  when  the  pustules  of  true  cow-pox  have  their 
development  arrested  or  impeded  by  excoriations  caused  by  the  scratching 
of  the  infant,  by  the  pressure  of  too  tight  clothes,  or  by  the  irritation  of 
unnecessary  handling.  Under  such  circumstances  the  suppuration  begins 
at  once:  the  pustule  becomes  yellow,  swells,  and  its  virulent  lymph  disap- 
pears. 

The  term  false  cow-pox  which  I  have  employed  is  not  quite  a  correct 
term.  Gentlemen,  neither  false  cow-pox  nor  false  small-pox  has  any  exist- 
ence.  When  the  economy  is  in  no  state  of  aptitude  for  receiving  or  devel- 
oping the  virus  of  small-pox  or  cow-pox,  the  puncture  made  in  vaccinating 
produces  no  more  effect  than  if  the  lancet  had  been  charged  with  pus  from 
a  common  boil;  when  there  is  some  partial  aptitude,  the  result  is  abortive 
cow-pox  at  the  end  of  some  days ;  when  there  is  a  state  of  still  greater  apti- 
tude, the  pock,  quicker  in  its  evolution  than  in  the  normal  order  of  events. 
closely  resembles  that  of. regular  cow-pox  ;  but  it  passes  away  more  rapidly. 
In  a  word,  we  have  modified  cow-pox,  just  as  we  have  modified  small-pox. 

I  have  described  the  manner  of  propagating  that  legitimate  cow-pox, 
which  will  confer  immunity  from  small -pox,  and  have  pointed  out  the  man- 
ner of  preventing  degeneration  of  the  virus.  But  is  it  possible  to  regenerate 
virus  which  has  losl  its  original  energy?  It  certainly  would  not  bedifficu.il 
to  do  SO  if  one  could  always  go  hack  to  the  original  source — provided  we 
could  always  obtain  cow-pox  from  the  cow.  Unfortunately,  thai  is  impos- 
sible. The  question  then  is,  Can  we,  in  the  circumstances  in  which  we  are 
placed,  by  any  means  accomplish  that  object  so  much  to  be  desired,  the 
regeneration  of  vaccine  lymph?  Cannot  we,  by  taking  lymph  of  the  besl 
quality  and  propagating  it  through  a  succession  of  the  most  favorable  sub- 
jects, do  the  same  for  it   «  hich  horticulturists  do  for  plants,  w  hen.  from  seeds 

.if  the  mosl  commonplace  kinds,  they  obtain,  after  a  succession  of  genera- 
tions, the  most  beautiful  varieties,  by  always  sowing  chosen  seed  in  chosen 
soil  ? 

The  observations  which  I  made,  along  with  M.  Delpech,  on  the  inocula- 


cow-pox.  123 

tion  of  small-pox,  give  credibility  to  this  supposition.     A  girl  of  17,  whom 

I  hud  vaccinated  in  her  infancy,  was  admitted  into  my  wards  at  the  Necker 
Hospital,  with  mild  modified  small-pox.  With  variolous  matter  taken  from 
this  young  girl  I  inoculated  a  child,  making  only  one  puncture:  the  pustule 

of  inoculation  became  developed, without  any  other  eruption  being  produced. 
A  second  child  was  inoculated  with  matter  from  the  first:  in  this  case, 
besides  the  development  of  the  inoculation-pustule,  there  was  a  secondary 
variolous  eruption  in  the  distinct  form.  A  third  child  was  inoculated  with 
matter  from  the  second  :  in  this  case  the  eruption  was  more  abundant.  Last 
of  all,  in  the  fifth  generation,  the.  variolous  eruption  was  confluent:  the 
small-pox  had  become  regenerated. 

Why  has  not  a  similar  plan  been  pursued  with  vaccine  lymph  ?  Experi- 
ments were  instituted  under  my  observation  by  M.  Truchetet  in  the  wards 
now  under  my  charge.  We  employed  lymph  taken  on  the  sixth  day,  that 
is  to  say  weak  lymph  which  did  not  become  papular  till  the  third  or  fourth 
day,  nor  pustular  till  the  sixth,  nor  surrounded  by  an  areola  till  the  seventh, 
nor  desiccated  till  the  tenth  ;  nor  did  the  crusts  fall  till  about  the  fifteenth 
day.  We  inoculated  a  healthy  child  :  w^e  took  matter  on  the  fourth  or 
fifth  day  from  this  child,  and  successively  transmitted  it  to  other  children 
in  the  best  possible  state  of  health.  After  a  certain  number  of  genera- 
tions, the  lymph  appeared  to  us  to  have  become  more  energetic,  to  mani- 
fest its  effects  more  quickly,  and  to  take  a  longer  time  to  complete  its  evo- 
lution, than  the  lymph  with  which  we  commenced  the  series  of  inoculations. 
Not  wishing  to  put  too  much  reliance  in  our  own  impressions,  a  child  was 
sent  to  the  mairie  of  the  eleventh  arondissement  to  be  vaccinated.  On  the 
eighth  day,  lymph  was  taken  from  this  child,  and  with  it  the  left  arm  of  a 
healthy  child  was  vaccinated,  while,  at  the  same  time,  the  right  arm  was 
vaccinated  with  lymph  taken  from  a  subject  in  our  wards.  Several  other 
children  were  vaccinated  in  the  same  manner,  and  our  impression  was  that 
our  "  regenerated"  lymph  was  more  energetic  than  the  lymph  used  in  the 
town. 

As  the  results  of  these  experiments  challenge  a  positive  admission  of  the 
doctrine  that  vaccine  lymph  can  be  regenerated,  they  ought  to  be  repeated 
and  generalized.  Unfortunately,  it  cannot  be  denied,  that  the  lymph  in 
common  use  has  become  degenerated  ;  and  this,  as  I  have  pointed  out,  is 
perhaps  exclusively  due  to  the  unfavorable  circumstances  under  which  the 
practice  of  vaccination  is  carried  out.  As  in  the  present  day,  vaccination 
gives  in  many  cases  only  temporary  immunity  in  place  of  the  absolute 
immunity  which  it  seems  to  have  imparted  at  the  beginning  of  the  century, 
it  is  incumbent  on  us  to  revert  to  revaccination,  a  practice  wdiich  has  been 
long  ago  lauded. 

Immediately  after  the  promulgation  of  Jenner's  discovery,  as  I  have 
already  had  occasion  to  remark,  doubts  arose  in  England  regarding  the 
value  of  vaccination  :  even  then,  many  physicians,  had  proclaimed  the 
necessity  of  revaccination  after  the  lapse  of  a  certain  time.  In  France,  at 
a  later  period,  Drs.  Berland,  Boulu,  Caillot,  and  Genouil  stated  their 
belief  that  the  prophylactic  power  of  vaccination  was  limited  to  ten,  twelve, 
fourteen,  fifteen,  seventeen,  eighteen,  twenty,  and  twenty-five  years.  In 
1825,  M.  Paul  Dubois  undertook  the  refutation  of  these  statements,  and 
rejected  revaccination  as  a  useless  practice,  although  he  admitted  the 
apparently  conclusive  character  of  the  facts  on  which  it  rested.  In  1838, 
this  important  question  wTas  submitted  to  formal  discussion  in  the  Academy 
of  Medicine,  where  revaccination  encountered  numerous  adversaries,  but 
where  it  also  had  most  eminent  defenders,  such  as  Chomel  and  Bouillaud. 
The  Academy  adopted  the  conclusions  of  the  commission  appointed  to 


124  cow-pox. 

report  on  the  subject,  which  conclusions  were  adverse  to  the  practice  of 
revaccination.  This  decision,  supposed  to  have  been  a  definitive  settle- 
ment of  the  question,  was  warmly  defended  by  M.  Dezeimeris,  in  his  jour- 
nal, the  Experience.  He  based  his  arguments  upon  numerous  facts  observed 
in  France,  and  on  rigorous  statistics  collected  in  Northern  Germany.  On 
the  other  side,  Drs.  Fiard  and  Hardy  protested  against  the  decision  of  the 
Academy — Dr.  Fiard  in  a  letter  addressed  to  that  scientific  body,  and  Dr. 
Hardy  in  a  paper  published  in  the  Experience,  in  which  he  showed  the 
agreement  of  the  documentary  evidence  from  England  with  that  supplied 
by  Denmark,  Sweden,  and  Germany,  and  adduced  by  Dezeimeris. 

Notwithstanding  the  diversity  of  opinion  now  noticed,  revaccinations  on 
a  great  scale  were  performed  in  the  northern  countries  of  Europe,  particu- 
larly in  Germany.  Since  1823,  every  soldier,  on  admission  into  the  Prus- 
sian army,  has  been  immediately  revaccinated.  The  practice,  thus  adopted 
in  foreign  countries,  was  in  the  first  instance  condemned  in  France,  not- 
withstanding the  vigorous  manner  in  which  some  defended  it,  and  although 
followed  by  numerous  physicians  of  the  highest  repute,  including  Favart, 
Rayer,  Robert,  and  many  others :  it  was  afterwards  mildly  recommended, 
and  has  at  last  been  accepted  as  a  proper  proceeding.  Revaccination 
is  now  the  rule  in  public  practice,  and  it  has  been  made  obligatory  in 
the  French  army.  Epidemics  of  small-pox  have  only  made  it  too  clear, 
that  when  small-pox  prevailed  in  a  population,  persons  who  had  been  long 
previously  vaccinated  were  struck,  and  that  the  disease  was  most  severe  in 
those  in  whom  the  date  of  vaccination  was  most  remote. 

The  history  of  epidemics  ought  to  tell  us  what  is  the  influence  of  revac- 
cination upon  the  progress  of  small-pox,  and  I  cannot  give  you  a  better 
example  of  the  information  which  they  afford  than  by  laying  before  you 
the  abstract  of  the  excellent  work  on  this  subject  by  Dr.  Gintrac,  pub- 
lished in  the  Gazette  des  Hopitaux  of  11th  July,  1857  : 

"  In  a  parish  containing  a  population  of  about  2600  souls,  a  young 
woman  who  had  been  vaccinated  was  attacked,  towards  the  end  of  Oc- 
tober, 1853,  with  small-pox  contracted  during  a  long  residence  with  a 
relation  suffering  from  that  disease.  During  the  whole  of  her  illness  this 
young  woman  was  attended  by  her  mother,  who  also  took  the  disease, 
although  she  was  fifty-seven  years  of  age,  and  had  been  vaccinated.  Both 
recovered:  but,  early  in  January,  at  the  beginning  of  the  mother's  con- 
valescence, the  disease  was  becoming  epidemic.  It  invaded  families, 
attacking  each  member  in  succession  or  simultaneously.  In  January,  the 
number  of  persons  seized  exceeded   180,  and  by  the  loth  of  February  it 

had  readied  nearly  260.  From  day  to  day,  the  number  rapidly  increased. 
Men  and  women,  vaccinated  and  unvaccinated  persons,  those  who  had  bad 
and  those  who  had  not  had  small-pox,  yielded  in  almost  equal  proportions 
to  the  epidemic  influence." 

No  opportunity  could  have  been  more  favorable  for  studying  the  influ- 
ence of  vaccination  upon  the  course  and  severity  of  small-pox.  Dr.  Gin- 
trac, recapitulating  the  (acts  which  he  saw,  has  drawn  the  following  con- 
clusions : 

"  There  were  uo  cases  of  small-pox  in  vaccinated  subjects  under  twelve 
vears  of  age.  The  greater  the  age  of  those  attacked,  or  in  other  word-, 
the  longer  the  interval  since  vaccination,  the  greater  was  the  severity  of 
the  disease.  Some  families  Btrikingly  exemplified  the  remarkable  relation 
which  existed  between  the  more  or  less  advanced  age  of  the  patient,  and 
the  greater  or  less  Beverity  of  the  attack.     In  a  family  of  eight,  father, 

mother  and  six  children,  the  parents  had  confluent    small -pox  :   three  BOOB, 

aged  twenty-six,  twenty-three,  and  twenty-two  respectively,  had  the  disease 


cow-pox.  125 

less  severely;  two  sons,  aged  eighteen  and  fifteen,  had  modified  small-pox  ; 
and  the  other  son,  aged  twelve,  though  constantly  exposed  to  the  contagion 
in  the  same  room  with  the  others,  had  no  eruption  at  all.  In  another 
family  consisting  of  seven  persons  occupying  the  same  lodging,  five  were 
struck  down  by  the  epidemic,  of  whom  three  had  been  vaccinated  between 
twenty  and  thirty-five  years,  and  two  from  fourteen  to  fifteen  years  pre- 
viously. In  all  of  them,  there  was  a  great  similarity  in  the  prodromic 
symptoms  and  eruption,  but  when  the  disease  attained  the  suppurative 
stage,  those  who  had  been  most  recently  vaccinated  recovered  in  a  few 
days,  and  the  others  suffered  severely  and  had  prolonged  suppuration." 

"It  was  ascertained  that  in  general,  the  disease  was  decidedly  modified, 
and  essentially  milder,  in  those  who  had  been  vaccinated  :  in  them  the 
duration  of  the  attack  was  less  than  half  of  the  usual  duration.  There 
were  only  prodromic  and  initiatory  symptoms  ;  when  the  period  of  suppura- 
tion was  reached,  desiccation  took  place,  and  the  disease  seemed  from  loss 
of  power  to  be  unable  to  proceed  any  farther.  There  were  no  fatal  cases 
among  the  patients  who  had  been  vaccinated.  Ten  deaths  occurred  among 
the  unvaccinated.  The  ages  of  those  who  died  were  one,  two,  twenty-one, 
twenty-three,  twenty-seven,  twenty-nine,  thirty-one,  fifty-two,  fifty-five,  and 
fifty-seven.  In  all  of  these  cases,  death  took  place  during  the  suppurative 
period." 

"  In  February,  1854,  when  the  epidemic  was  daily  striking  down  many 
individuals,  the  question  of  vaccination  and  revaccination  was  keenly  dis- 
cussed. It  having  been  at  last  decided  that  both  should  be  practiced,  they 
were  immediately  resorted  to.  In  less  than  ten  days,  180  vaccinations 
and  712  revaccinations  were  performed.  The  result  surpassed  the  most 
sanguine  hopes." 

"In  180  persons  vaccinated  for  the  first  time,  171  had  true  prophy- 
lactic pocks,  which  furnished  lymph  for  vaccination ;  and  in  the  nine 
remaining  persons,  there  was  no  result." 

"  The  possibility  of  vaccination  taking  effect  twice  in  the  same  person  is 
no  longer  doubted :  it  is  nevertheless  necessary  to  inquire  what  modifica- 
tion the  vaccinal  fermentation  undergoes  in  persons  previously  vaccinated, 
and  what  is  the  course  of  the  pocks  in  a  second  vaccination.  Here  are  the 
results  of  712  revaccinations.  In  302  individuals,  the  success  was  com- 
plete ;  the  pocks  were  developed  about  the  fourth  day  and  were  full  on  the 
seventh  :  on  the  eighth  day,  they  in  due  course  became  surrounded  by  an 
erysipelatous  areola,  then  desiccated,  and  formed  crusts  which  fell  off  on 
the  twentieth  day.  The  pocks  were  umbilicated,  and  presented  indisputa- 
bly all  the  characters  of  the  legitimate  vaccinal  eniption.  In  eighty-five 
of  the  revaccinated,  the  pocks  were  modified  :  they  appeared  on  the  third 
day  after  the  punctures,  became  filled  between  the  fifth  and  seventh  days 
with  a  plastic  lymph,  became  surrounded  by  a  reddish  areola,  and  some- 
times even  caused  enlargement  of  the  axillary  glands.  The  non-umbili- 
cated  pocks  presented  neither  the  swelling  nor  hardness  which  belong  to 
cow-pox,  and  when  the  crusts  fell  no  perceptible  cicatrix  was  left.  In  119 
cases,  the  introduction  of  the  vaccine  virus  produced,  within  twenty-four 
hours,  an  acuminated  pimple  which  rapidly  disappeared.  In  206  cases, 
no  visible  effect  was  produced  on  the  skin.  The  persons  who  had  been 
vaccinated  and  revaccinated,  successfully  or  unsuccessfully,  almost  all 
escaped  small-pox.  There  were  five  exceptions,  but  in  these  cases,  vaccina- 
tion only  preceded  the  eruption  of  small-pox  by  a  few  days." 

"  The  following  are  some  of  the  conclusions  drawn  from  the  observations 
made  during  the  epidemic." 

"  Small-pox  did  not  attack  indiscriminately  and  by  chance ;  it  generally 


126  cow-pox. 

seized  the  old  and  respected  the  young.  If  this  epidemic  has  shown  that 
cow-pox  is  not  absolutely  preservative,  a  fact  established  by  the  daily  occur- 
rence of  sporadic  cases,  it  has  at  least  established  that  cow-pox  exerts  a 
salutary  influence  upon  the  issue  of  an  attack  of  small-pox  by  shortening 
its  duration  and  lessening  its  danger." 

"  Revaceination  applied  generally  to  a  population  during  the  full  tide 
of  an  epidemic,  has  at  once  arrested  its  ravages  and  destroyed  its  power  of 
development :  it  has  proved  itself  to  be  undeniably  prophylactic,  and  it 
even  seems  to  have  imparted  a  certain  degree  of  immunity  to  persons  in 
whom  the  disease  was  already  incubating.  Finally,  revaccinations  per- 
formed in  the  midst  of  an  epidemic  have  been  found  to  be  free  from  all 
bad  consecpiences,  notwithstanding  the  fears  of  evil  which  were  entertained 
by  some  physicians." 

The  results  of  Dr.  Gintrac's  experiments  agree  in  a  remarkable  manner 
with  those  obtained  on  a  large  scale  in  Germany,  Denmark,  and  Sweden, 
of  which  you  will  find  an  account  in  the  essay  of  Dezeirneris,  in  volume 
second  for  1838,  of  the  Experience. 

The  statistical  summaries  of  the  German  authors,  applicable  to  the  four 
years,  from  1834  to  1837  inclusive,  prove  that  the  occurrence  of  cases  of 
small-pox  became  more  and  more  unusual,  just  in  proportion  as  re-revac- 
cination  became  more  and  more  practiced.  I  cannot  place  before  you  all 
the  tables  which  have  been  drawn  up  in  illustration  of  this  subject,  and 
must  confine  myself  to  the  following  brief  abstract,  which  will  give  you  a 
fair  idea  of  the  facts.  In  1834  there  were  619  cases  of  small-pox;  in  1835, 
there  were  259  cases ;  in  1836,  there  were  only  30 ;  and  although  in  1837 
the  number  was  94,  that  was  very  much  under  619. 

Other  statistical  summaries  also  corroborate  that  which  was  demonstrated 
by  Dr.  Gintrac's  observations,  to  the  effect,  that  the  immunity  derived  from 
vaccination  had  become  weak  and  temporary,  and  also  that  more  than 
tweuty-five  years  ago,  the  utility  of  re-revaccinatioD  was  great.  From  the 
summaries  referred  to,  it  appears  that  of  44,000  persons  who  were  revac- 
cinated,  20,000  had  the  legitimate  cow-pock,  a  result  which  superabundantly 
showed  that  nearly  half  of  those  operated  on  had  lost  their  vaccinal  im- 
munity. Nine  thousand  had  had  abortive  cow-pox.  It  was  only  in  fifteen 
thousand  that  vaccination  produced  no  other  effect  than  a  slight  redness, 
lasting  from  twenty-four  to  thirty-six  hours,  round  the  place  where  the  punc- 
tures had  been  made. 

Similar  conclusions  were  arrived  at  by  Dr.  Marc  d'Espine,  of  Geneva. 
Vou  will  find  his  papers  in  th&Arehives  G&n&rales  dt  Medecirn  for  June  and 
July,  1859. 

Another  question  has  now  to  be  solved  :  What  is  the  duration  of  vaccinal 
immunity?  Or  otherwise  expressed:  At  what  age,  and  how  often,  ought 
individuals  to  !»•  revaccinated  ? 

So  long  ago  as  1804,  Dr.  Godson  raised  doubts  as  to  the  preservative 
power  of  vaccination,  ami  alleged  that  it  did  not  confer  immunity  tor  more 
than  three  years ;  but  on  the  other  side  of  the  question,  Jenner  then  showed 
that  the  duration  of  the  preservative  power  was  much  longer,  by  adducing 
cases  in  which  he  had  ineffectually  attempted  to  inoculate  with  small-pox 
persons  who  had  bad  cow-pox,  in  one  case,  twenty-three,  in  another  twenty- 
seven,  and  in  a  third  fifty  years  previously.  However,in  the  earl)  days  of 
Vaccination,  the  immunity  which  it  gave  seemed  so  protracted  as  to  lead 
to  the  belief  that  it  might  continue  during  the  whole  of  lite,  but  afterwards, 
when  it  became  admitted  thai  the  immunity  was  nut  perpetual,  endeavors 
win;  made  to  ascertain  it-  limit.-.  I  have  already  said  that,  in  France, 
Dra.  Caillot,  Boulu,  Berland,  and  Genouil  had  each  fixed  those  Limits,  the 


cow-pox.  127 

tii-t  at  ten  or  twelve  years,  the  second  at  fourteen  or  fifteen,  the  third  at 
seventeen  or  eighteen,  and  the  last-mentioned  physician  at  from  twenty  to 
twenty-five  years.  But  it  i<  impossible  to  name  any  absolutely  precise 
period.  For  example,  I  re  vaccina  ted  three  of  my  daughter's  children  :  in 
the  eldest,  aged  seven  years,  and  in  the  second,  aged  five  and  a  half,  I  saw 
normal  cow-pox  reproduced  three  years  after  their  first  vaccination,  while 
in  the  third,  who  was  under  lour  years,  there  was  no  result  when  I  vaccin- 
ated her  the  second  time. 

Dr.  Marc  d'Espine,  holding  very  much  the  same  opiuion  as  Dr.  Caillot, 
says  that  the  first  revaccination  ought  to  be  performed  between  the  ages  of 
ten  and  fifteen.  He  says,  that  inasmuch  as  the  generalization  of  vaccina- 
tion has  advanced  the  age  of  the  maximum  frequency  of  small-pox  from 
infancy  to  adolescence  and  maturity,  so  will  the  generalization  of  revac- 
cination carry  it  on  twelve  or  fifteen  years  farther,  bringing  the  maximum 
to  a  period  of  life  beyond  the  age  of  thirty.  Arguing  in  this  way,  he 
suggests  the  necessity  of  a  second  revaccination  at  thirty,  and  even  a  third 
re  vaccination  about  the  age  of  forty. 

Resting  my  convictions  upon  the  facts  which  I  have  now  cited,  I  gen- 
erally recommend  vaccination  to  be  repeated  as  nearly  as  possible  once 
every  five  years.  If  this  practice  is  unnecessary,  it  is  at  all  events  free  from 
•objection.  We  ought  certainly  to  endeavor  to  multiply  the  chances  of  im- 
munity from  small-pox — and  even  from  modified  small-pox,  which,  though 
generally  a  mild  disease,  is  in  exceptional  cases  attended  with  danger,  a 
fact  I  was  careful  to  point  out  when  giving  you  its  history. 

The  principles  which  apply  to  the  revaccination  of  persons  under  thirty- 
five,  are  equally  applicable  to  those  who  have  passed  that  age.  Dr. 
Vleminckx,  who  recommended  revaccination  after  thirty-five,  was  met 
with  the  objection,  that  when  that  period  of  life  was  attained  the  aptitude 
to  contract  small-pox  had  become  less,  it  being  alleged  that  the  successful 
revaccination  of  persons  of  fifty  and  sixty  did  not  in  the  least  degree  tend 
to  show  the  existence  of  such  an  aptitude. 

Maintaining  the  great  principle  hitherto  generally  admitted,  that  suc- 
cessful revaccination  is  proof  of  the  return  of  aptitude  to  take  small-pox, 
Dr.  Vleminckx  threw  out  the  idea,  that  if  the  individuals  referred  to  have 
either  become  insusceptible  or  less  susceptible  to  variolous  contagion  in  the 
ordinary  way,  they  might  perhaps  contract  the  disease,  if  inoculated  with 
the  matter  of  small-pox:  he  then,  defending  his  practice  of  revaccination, 
replied  to  objectors  by  reminding  them  that  cases  of  small-pox  were  still 
too  common  in  this  very  class  of  persons. 

The  practical  conclusion  to  be  drawn  from  all  the  facts  is,  that  we  ought 
to  prescribe  revaccination  and  a  repetition  of  revaccination  according  to 
circumstances,  but  particularly  if  an  epidemic  of  small-pox  is  prevailing; 
and  that  we  ought  to  promote  the  general  adoption  of  revaccination  with 
as  much  zeal  as  wTe  bestow  on  propagating  the  practice  of  vaccination, 
because  revaccination  undoubtedly  augments  the  chance  of  resisting  vari- 
olous contagion,  and  renders  the  disease  milder  in  those  wdio  are  not  proof 
against  it. 

Gentlemen,  the  opposition,  the  unjust  and  vehement  attacks  which  the 
immortal  discovery  of  Jenner  encountered  when  first  announced  to  the 
world,  have  been  renewed  in  our  day.  Within  the  last  few  years,  some 
physicians,  a  very  small  number  it  is  true,  following  the  path  opened  up  to 
them  by  a  mathematician,  a  stranger  to  our  art,  have  desired  to  put  vac- 
cination once  more  on  its  trial.  These  vacdnophobists — for  that  is  the 
absurd  name  which  they  have  taken — returning  to  the  ideas  of  Rhazes, 
who  regarded  small-pox  as  a  natural  and  useful  depuration  of  the  blood, 


128  cow-pox. 

exhuming  the  theories  and  ideas  of  the  celebrated  Hoffmann,  of  Willis,  of 
Violante,  and  of  Hahn  (which  perhaps,  nevertheless,  they  did  not  under- 
stand), have  asserted  that  small-pox  was  a  necessary  disease.  They  say 
that  it  is  as  old  as  the  human  race;  that  it  exists  as  a  germ  in  the  economy  ; 
that  every  one  has  within  his  body  a  special  proclivity,  in  virtue  of  which 
he  must  sooner  or  later  be  affected  ;  and,  finally,  that  the  prevention  of  the 
manifestation  of  the  variolous  germ  is  a  proceeding  similar  to  the  practice 
of  those  who  would  wish  to  prevent  the  manifestation  of  the  herpetic  or 
gouty  principle.  They  go  much  farther,  for  they  add  that  cow-pox,  by 
setting  itself  up  in  opposition  to  the  external  manifestations  of  small-pox, 
has  originated  new  diseases  more  terrible  than  that  which  it  was  wished  to 
destroy^  and  that  in  point  of  fact  vaccination  has  raised  the  death-rate  in 
Europe. 

Such,  gentlemen,  are  the  conclusions  at  which  statisticians  have  arrived 
after  long  and  toilsome  exertions!  But  are  they  unaware  that  the  statistical 
weapon  has  two  edges  ?  Do  they  not  know  that  from  the  same  elements, 
from  the  same  facts,  one  may  lead,  or  be  led,  to  opposite  conclusions?  Do 
thev  not  know  that  a  statistician  can  make  statistics  say  whatever  he  wishes 
thern  to  say  ?  If  asked  to  prove  this  statement,  I  shall  bring  forward  as  a 
case  in  point  this  very  attempt  to  make  out  a  charge  against  vaccination. 
On  the  one  side,  the  vaccinophobists  have  used  statistics  to  maintain  their 
accusation,  and  the  defence  has  equally  derived  its  arguments  from  the 
same  source.  This  is  explained  by  the  former  having  been  dominated  by 
a  deplorable  preconceived  idea,  and  by  the  others  having  examined  the 
figures  in  a  spirit  of  enlightened  and  judicious  criticism. 

If  it  be  a  fact  that  there  has  been  an  increase  in  the  rate  of  mortality  in 
Europe,  it  would  certainly  be  interesting  to  study  the  causes  of  the  increase, 
but  such  inquiries  would*  here  be  out  of  place,  for,  as  I  hope  to  prove,  vac- 
cination is  in  any  case  blameless.  Be  the  conjecture  true  or  false,  it  belongs 
to  that  vast  question,  the  displacement  of  mortality,  which  involve-  as  an 
accredited  hypothesis  the  general  principle  which  leads  to  the  conclusion, 
that  humanity  pays  the  debt  of  death  in  accordance  with  an  inevitable  and 
inexorable  law. 

If  small-pox  played  the  essential  part  which  some  wish  to  assign  to  it, 
if  it  were  a  natural*  depuration  of  the  blood,  if  it  were  almost  an  indispen- 
sable condition  in  the  economy  of  the  human  body,  it  must  have  existed 
from  all  time.  Although  Hahn  has  laboriously  disinterred  notices  of  this 
disease  from  among  the  historical  remain-  of  Grecian  Medicine,  one  must 
hold  by  the  opinion  held  by  Werlhof,  and  reproduced  by  Van  Swieten. 
Small-pox  was  unknown  in  the  times  ,,f  Hippocrates,  Galen,  and  JDtius: 
these  illustrious  observers  make  no  mention  of  it.  If  it  existed  in  their 
times  they  must  have  described  it.  for  they  could  not  have  disregarded  a 
disease  presenting  such  precise  characters. 

If  we  admit  that  small-pox  is  as  old  as  the  world,  we  must  also  admit 
that  the  germ  remained  quiescenl  for  many  centuries^  till  an  opportunity 
occurred  for  manifesting  it-elf.     It  would  he  necessary  to  assume,  in  respect 

of  the  whole  human  race  from  the  creation,  that  which  Rhazes  ami  the  par- 
tisans of  his  theory  assume  regarding  each  individual,  viz.,  thai  the  morbific 
germ  of  small-pox  remain-  concealed  in  the  body,  for  a  longer  or  Bhorter 

period,  in  a   home  of  its  own,  which   Hoffmann  localized    in  certain  part-  of 
the   spinal    marrow,  which   Willis,  and    after   him   Violante,  placed    in    the 
suprarenal  capsules — eapndis  atrabilariis,  nve  renibus  succenturiatis  dictis 
whence  sooner  or  later,  he  said,  il  made  its  irruption.     Need  I  say  that  this 
doctrine  is  neither  in  accord  with  fact  nor  reason? 

Small-pox.  then,  iiia-much    as    il    has   always  existed,  is    not    a    ii.cc-arv 


cow-pox.  129 

malady.  Nor  is  it  a  constitutional  malady,  for  in  constitutional  diseases 
there  must  be  a  diathesis.  Now,  what  do  we  moan  by  diathesis  t  Diathesis 
is  a  special  state,  a  particular  proclivity  in  the  economy  which  is  either 
hereditary  or  acquired,  but  which  is  essentially  and  invariably  chronic:  it 
is  transmittible  from  father  to  son,  and,  in  virtue  of  this  hereditary  power, 
is  reproduced  with  identically  the  same  fundamental  character:  in  form  it 
is  liable  to  modifications  and  varieties,  but  its  morbid  manifestations  are  in 
general  strongly  marked  with  a  good  deal  of  distinctiveness. 

Gout  and  rheumatism,  for  example,  are  diathetic  maladies.  When  gout 
is  quiescent  during  the  interval  between  its  attacks,  the  individual  seems  to 
enjoy  perfect  health  ;  but  when  an  attack  comes  on  the  diathesis  manifests 
itself,  sometimes  by  inflammation  of  joints,  by  peculiar  secretions  in  par- 
ticular parts,  such  as  the  joints,  the  skin  (especially  that  of  the  hands),  the 
soles  of  the  feet — at  other  times  by  neuralgic  affections,  asthma,  gravel,  or 
dyspeptic  symptoms.  In  whatever  way  these  manifestations  appear  we  can 
generally  recognize  in  them  an  expression  of  the  gouty  diathesis.  It  is  the 
same  with  rheumatism  :  the  diathesis  which  constitutes  that  disease  will 
make  itself  known  in  a  great  variety  of  forms,  and  by  very  different  special 
lesions  of  the  heart,  fibrous  tissues,  nervous  system,  &c.  These  numerous 
forms  of  disease  are  all  parts  of  one  disease,  which,  by  attention,  we  can 
diagnose.  The  same  may  also  be  said  of  scrofula.  But  the  essential  parts 
of  these  diatheses  are  on  the  one  hand  chronicity,  and  on  the  other  a  ten- 
dency to  returns  and  repetitions,  not  only  in  the  same  individual,  but  also 
in  his  direct  and  collateral  descendants.  Thus,  a  manifestation  of  the  stru- 
mous or  tubercular  diathesis  in  any  one  organ  leads  us  to  fear  strumous 
manifestations  in  other  organs.  An  attack  of  gout  or  rheumatism  in  an 
individual  makes  us  expect  a  succeeding  attack  ;*  and  a  succession  of  such 
attacks  leads  us  to  apprehend  that  the  disease  will  reappear  in  his  children, 
for  experience  has  taught  us  that  gout,  rheumatism,  tubercle,  and  scrofula, 
descend  from  generation  to  generation. 

Is  it  so  with  small-pox  ?  Is  it  so  with  other  contagious  diseases  ?  Small- 
pox is  an  essentially  acute  disease,  which  runs  its  course  in  a  determinate 
space  of  time,  leaving  no  trace  of  its  passage  except  cicatrices  on  the  skin. 
Will  any  one  venture  to  say  that  it  is  hereditary?  The  cases  of  intra-uterine 
small-pox  which  occur  are  accounted  for  by  contagion.  But  are  the  children 
of  parents  who  have  had  small-pox  at  some  former  period  necessarily  vario- 
lous, as  children  of  tuberculous  and  gouty  parents  are  born  predisposed  to 
tubercle  and  gout? 

There  are,  however,  some  points  of  resemblance  between  contagious  and 
diathetic  diseases,  and  indeed  some  have  called  the  former  the  acute  dia- 
theses. Like  diathetic  diseases  they  involve  a  special  disposition  of  the 
economy,  but  they  differ  from  them  essentially  in  being  acute,  and  in  not 
being  transmittible  by  descent :  they  are  caused  only  by  the  operation  of  a 
special  morbific  principle  ;  and  thus  in  a  certain  way  they  are  transmittible 
from  a  sick  person  to  another  individual :  but  they  differ  from  diathetic 
diseases  in  being  propagated  by  the  transmission  of  a  contagium. 

From  the  very  fact  that  small-pox  has  not  always  existed,  it  is  evident 
that  it  must  have  become  spontaneously  developed  in  its  first  subject :  it 
has  originated,  therefore,  under  the  influence  of  causes  which  have  escaped 
observation.  If,  moreover,  it  should  one  day  disappear  from  pathology,  as 
has  disappeared  leprosy,  a  disease  so  common  in  former  times,  or  if  it  should 
cease  to  present  the  characters  by  which  it  is  now  recognized,  it  is  reasonable 
to  suppose  that  it  can  again  originate  without  contagion,  under  the  influence 
of  causes  similar  to  those  whence  it  first  sprung.  This  mode  of  development 
vol.  i. — 9 


130  cow-pox. 

has  hitherto,  however,  eluded  observation,  and  no  one  can  adduce  a  single 
well-established  case  of  spontaneous  small-pox.  It  was  originally  brought 
into  Europe  by  contagion,  and  to  this  day  is  propagated  by  contagion.  It 
is  difficult  to  demonstrate  the  influence  of  contagion  in  great  centres  of 
population,  where  people  are  so  commingled  and  so  confusedly  brought  into 
contact  with  each  other,  but  in  small  places  it  is  more  appreciable.  If  an 
epidemic  of  small-pox  break  out  in  a  village  where  no  case  of  the  disease 
has  been  seen  for  twenty,  twenty-five,  or  thirty  years,  it  can  generally  be 
ascertained  that  it  has  been  imported  by  some  one  who  has  come  from  a 
place  where  it  was  prevailing.  Among  other  examples  of  this,  read  the 
cases  published  by  Dr.  Gintrac,  whom  I  mentioned  in  connection  with  the 
subject  of  revacciuation  :  read  also  the  work  of  Dr.  Marc  d'Espine,  wherein 
you  will  see  how  some  epidemics  can  be  followed  up  to  their  source. 

It  is  not  necessary  that  the  person  who  conveys  the  contagion  should  have 
had  the  disease.  All  writers  on  the  subject  testify  that  the  variolous  con- 
tagium  possesses  an  inconceivable  power  of  reproduction.  The  minutest 
drop  of  variolous  matter,  or  the  effluvia  from  a  living  or  dead  patient,  are 
sufficient  to  transmit  the  disease.  Moreover,  the  morbific  germ,  like  certain 
volatile  substances  which,  for  a  longer  or  shorter  period,  cling  to  the  vases 
in  which  they  have  been  shut  up,  or  to  the  rooms  in  which  they  have  been 
placed,  has  an  action  vast  beyond  all  appreciable  limitation,  a  divisibility 
which  is  infinite :  the  most  imperceptible  atom  is  sometimes  sufficient  to 
engender  the  disease,  just  as  the  minutest  spark  of  fire  suffices  to  kindle  a 
conflagration  when  it  falls  amid  combustible  materials.  Small-pox  is  propa- 
gated by  contagion,  whether  the  contagium  be  communicated  by  inoculation 
or  by  absorption  from  air  carrying  variolous  effluvia.  It  is  then  neither  a 
diathetic,  nor  an  essentially  constitutional  disease,  and  still  less  is  it  a  dis- 
ease  necessary  to  the  human  economy,  inasmuch  as  it  has  not  always  existed. 

And,  gentlemen,  it  is  not  the  only  new  disease.  Was  not  Asiatic  cholera 
a  new  disease  in  France  when  it  broke  out  among  us  in  1832?  I  admit 
that  it  had  been  known  in  India  long  before  that,  but  even  in  India  where 
it  seems  to  have  had  its  origin,  the  date  of  its  appearance  is  not  very  remote, 
as  the  first  well-authenticated  epidemic  observed  occurred  in  that  country 
about  the  middle  of  last  century.  It  is  hardly  eight  years  ago  since  yellow 
fever  was  unknown  to  more  than  four-fifths  of  the  globe,  and  to  two-thirds 
of  the  transatlantic  hemisphere.  Till  then,  it  had  so  completely  spared 
South  America,  notwithstanding  the  numerous  lines  of  communication  estab- 
lished between  north  and  south,  that  no  case  had  been  seen  in  the  Brazils, 
Bahia,  Fernambouc,  Buenos  Ayres,  and  Montevideo.  Bui  after  thai  time, 
haying  passed  the  line,  it  cruelly  ravaged  these  countries,  and  began  to 
reach  the  shores  of  the  Pacific  Ocean :  it  is  only  two  years  since  it  appeared 
at  Lima, where  it  has  been  neither  very  fatal  nor  very  severe:  and  till  now 
it  has  not  been  seen  in  California.  Unfortunately,  there  is  every  reason  to 
believe  that  it  will  continue  its  progress,  and  that,  proceeding  beyond  its 
presenl   limit-,  it  will  invade  countries  hitherto  preserved  from  it-  ravages. 

Besides   the   new   discuses — small-pOX,  cholera,  and    yellow    fever — there 

are  others  which  have  been  err sously  supposed  to  he  new,  some  from  the 

former  mean-  of  diagnosis  having  been  defective,  ami  others  from  neglect 
of  the  histories  hit  by  our  predecessors.  The  del  ractorsof  vaccination  point 
to  these  diseases,  miscalled  new,  when  they  argue  thai  vaccination,  by  pre- 
venting the  external  manifestations  of  small-pox,  has  caused  the  develop- 
meiii  of  diseases  more  terrible  than  -mall-pox  itself.     It  ha-  been  said  ami 

written,  that  through  the  ah.-ence  of  small-pox.  the  blood  is  no  longer  depu- 
rated, and  the  economy  no  longer  put  into  a  condition  to  resisl  morbid 
actions;  hence,  it  has  been  said,  proceed  the  Uterine  affections,  the  diphtheria. 


cow-pox.  131 

and  particularly  the  typhoid  fever  so  common  in  our  day,  and  by  the  two 
latter  of  which  communities  are  decimated. 

But  there  were  g 1  reasons  for  uterine  affections  having  been  imper- 
fectly known.  The  speculum,  which  has  rendered  so  great  services  to 
uterine  diagnosis,  was  not  in  common  use  till  Recamier  generalized  its 
employment  in  the  beginning  of  the  present  century,  though  it  hud  been 
invented  in  the  days  of  Paulus  JDgineta,  and  Rhazes,  and  modified  subse- 
quently by  Ambrose  Pare,  Scultet,  and  Garengeot.  Fifty  years  ago,  the 
vaginal  examination  of  the  uterus  by  the  finger  was  unheard  of,  except  in 
eases  of  pregnancy  :  up  to  that  time  woman  would  have  revolted  at  the 
very  idea  of  such  examinations,  and  no  physician  would  have  dared  to 
propose  them.  Now,  it  is  no  longer  so,  and  even  our  English  neighbors 
have  freely  accepted  the  speculum  and  the  toucher.  Nowadays,  we  are 
likewise  better  acquainted  than  formerly  with  uterine  pathology.  Neverthe- 
less, though  then  but  imperfectly  understood,  uterine  diseases  existed  in  the 
days  of  our  predecessors,  as  their  writings  testify.  The  pathological  anat- 
omy of  these  affections  had  engaged  the  attention  of  physicians,  as  you  can 
see  by  reading  the  cases  recorded  by  Morgagni,  who  quotes  a  certain  num- 
ber from  the  works  of  preceding  authors.*  Although  the  acquaintance 
with  uterine  affections  was  imperfect  in  early  times,  it  was  considerably 
diffused  even  among  the  general  public,  as  is  evident  from  the  very  signifi- 
cant manner  in  which  they  are  alluded  to  in  the  epigrams  of  the  ancient 
poets. 

Diphtheria  has  also  been  proclaimed  as  a  new  conquest  of  human  infirm- 
ity. In  verity,  a  doleful  conquest !  It  has  been  said  that  this  terrible 
disease  was  unknown  in  former  ages,  and  did  not  begin  to  show  itself  till 
after  the  practice  of  vaccination  had  become  common.  Need  I  discuss 
such  a  proposition  as  this?  Any  one  possessed  of  even  a  very  slight 
acquaintance  with  the  history  of  medicine  is  aware  that  sore  throat  with 
plastic  exudation  [angine  couenneuse],  the  most  common  form  of  diphtheria, 
was  long  ago  observed  and  described,  and  that  authors  of  the  most  remote 
antiquity  mention  it.  Iretseus  called  it  the  Syrian  and  the  Egyptian  dis- 
ease, which  shows  that  when,  he  wrote,  it  was  common  in  Syria  and  Egypt. 
Without  going  so  far  back  into  antiquity,  but  at  the  same  time  going  back 
to  the  sixteenth  century,  an  epoch  remote  from  our  own,  it  may  be  stated 
that  Spanish  physicians  of  that  period  described  frightful  epidemics  of 
angina  and  croup  wdiich  ravaged  the  Iberian  peninsula  and  Italy.  The 
name  which  they  gave  to  this  affection  of  the  trachea  was  morbus  drangu- 
latorius,  and  they  have  also  preserved  the  names  by  which  it  is  commonly 
known — garotillo  and  male  in  canna.  Finally,  to  come  nearer  our  own 
times,  was  not  gangrenous  sore  throat  described  a  hundred  years  ago,  in 
France,  Sweden,  Germany,  and  America,  under  the  names  of  diphtheritic 
angina  and  croup  ?  Vaccination,  therefore,  cannot  have  the  discredit  of 
originating  a  disease  which  had  an  existence  prior  to  vaccination.  Indeed, 
if  we  were  to  reason  after  the  manner  of  the  vaccinophobists  we  might  rather 
say  that  vaccination  arrested  the  development  of  diphtheria,  because  by  a 
singular  chance  never  were  diphtheritic  angina  and  croup  less  prevalent 
than  at  the  beginning  of  the  present  century,  the  very  time  at  which  cow- 
pox  began  to  be  propagated  by  vaccination. 

The  argument  upon  which  the  depredators  of  vaccination  chiefly  rest 
is  drawn  from  their  allegation  that  typhoid  fever  is  a  more  common  disease 
now  than  prior  to  the  Jenuerian  discovery.  In  reply,  it  is  only  necessary 
to  refer  to  some  pages  of  the  aphorisms  of  Stoll ;  for  in  the  short  chapter 

*  Morgagni  :  De  Sedibus  et  Causis  Morborum  :  45,  46  et  47. 


132  cow-pox. 

which  he  devotes  to  putrid  fever  [febris  pvirida],  it  is  impossible  not  to 
recognize  our  own  typhoid  fever,  portrayed  in  its  most  striking  characters 
and  with  all  its  symptoms.  Is  there  any  difference  between  it  and  the 
ataxo-adynamic  fever  of  Pinel  ?  Do  not  the  words  of  Prost,  published  in 
1802,  show  us  this  fever,  attacking  subjects  of  twenty  and  thirty  years  of 
age,  who,  be  it  remembered,  had  never  been  vaccinated,  and  iu  whose 
bodies  were  found  on  examination  after  death  the  very  intestinal  lesions 
now  regarded  as  essentially  characteristic  of  dothienteritis  ?  Similar  ana- 
tomical proofs  are  also  supplied  by  the  treatise  of  Petit  and  Serres.  These 
physicians  observed  the  affection,  which  they  described  in  1814,  in  indi- 
viduals above  fifteen  years  of  age,  and  who  consequently  could  not  have 
been  vaccinated.  Typhoid  fever,  then,  so  inappropriately  appealed  to,  has 
no  connection  whatever  with  cow-pox  :  it  existed  long  before  Jenner,  though 
under  different  names,  such  for  example,  as  synochus putris,  febris putiida, 
lafievre  adynamique,  la  fievre  nerveuse,  lafievre  maligne,  &c. 

The  physicians  wThose  opinions  I  am  now  calling  in  question — because 
they  have  made  some  noise  lately — see  in  typhoid  fever  a  repressed  small- 
pox, the  eruption  being,  as  they  say,  on  the  mucous  surface  of  the  intestine, 
in  place  of  on  the  skin  :  they  repeat  the  statement  of  Lecat,  comprised  in 
the  name  of  gangrenous  mesenteric  small-pox,  which  he  gave  to  an  epidemic 
disease  prevalent  at  Rouen  in  1763.  I  am  quite  willing  to  admit  that 
typhoid  fever  bears  a  resemblance  to  small-pox,  to  this  extent,  that  its 
symptoms  are  those  of  an  eruptive  fever,  and  that  it  has  a  pimply  eruption 
for  its  specific  anatomical  characteristic :  but  that  is  not  the  sense  in  which 
I  understand  that  the  attempt  is  made  to  establish  the  relationship  of 
typhoid  fever  and  small-pox.  The  physicians  who  call  typhoid  fever  a 
kind  of  small-pox  do  not  say  that  typhoid  fever  and  small-pox  are  analo- 
gous, but  they  are  identical.  They  lose  sight  of  the  fact  that  the  intestinal 
lesions  of  typhoid  fever  bear  no  resemblance  to  the  pustules  of  small-pox. 
If  it  be  said  that  the  dissimilarity  of  the  lesions  is  explained  by  the  differ- 
ence of  their  seats,  I  reply,  that  upon  comparing  in  the  most  unprejudiced 
manner  possible  dothienteritic  eruption  with  variolous  eruption  on  the 
mucous  membrane  of  the  mouth  and  pharynx,  I  could  not  discover  any 
similarity  between  them.  Finally,  if  typhoid  fever  and  small-pox  are  the 
same  disease,  persons  who  have  had  one  could  not  take  the  other :  and  this 
is  a  point  in  respect  of  which  facts  utterly  contradict  the  theory  of  the 
vaccinophobists.  You  have  very  recently  seen  in  our  wards  convalescent 
small-pox  patients  seized  with  typhoid  fever,  and  others  during  convales- 
cence from  severe  attacks  of  typhoid  fever  take  small-pox. 

To  those  who  object  to  vaccination,  on  the  ground  that  since  its  intro- 
duction there  has  been  an  increase  in  the  mortality  from  typhoid  fever,  I 
would  remark,  that  as  the  infantile  population  (thanks  to  vaccination)  is 
no  longer  decimated  by  epidemics  of  small-pox,  the  representatives  of  the 
children  who  used  to  die  in  childhood,  grow  up,  to  run  the  risk  of  all  the 
diseases  incident  to  adolescence  and  manhood,  a  circumstance  which  would 
explain  why  typhoid  fever  may  perhaps  be  more  frequenl  now  than  for- 
merly. 

Should  the  day  ever  come  when  we  shall  have  the  good  fortune  to  dis- 
cover such  prophylactics  for  measles  and  scarlatina  as  cow-pox  is  for  small- 
pox, there  will  perhaps    lie    people  who   in    their   turn  will  try  to  show  that 

measles  and  scarlatina  are  accessary  maladies,  the  prevention  of  which 

occasions  the  development  of  new  diseases.  Such  individuals  would  not  he 
more  mistaken  than  those  whose  theories  regarding  COW-poX  we  have  dow 
been  refuting. 

If  those  gentlemen  were  logical  in  their   reasoning,  they  would  hold  that 


CHICKEN-POX.  133 

the  more  severe  small-pox  is,  and  the  more  copious  the  eruption,  so  much 
the  more  complete  will  be  the  depuration  of  the  organism,  and  so  much 
the  better  protected  will  the  economy  be  from  the  diseases  from  which 
small-pox  exempts  ;  consequently,  that  the  confluent  is  the  most  desirable 
form  of  the  disease  ! 

It  appears  then,  that  no  charge  can  be  substantiated  against  cow-pox, 
that  the  verdict  must  be  in  favor  of  it  as  a  prophylactic  against  small-pox, 
and  that  the  discovery  of  Jenner  must  remain  unchallenged  as  one  of  the 
greatest  benefits  conferred  by  medicine  on  humanity.  The  only  reproach 
which  can  be  adduced  is  that  the  prophylactic  power  of  vaccination  has  in 
our  day  too  often  become  unreliable,  and  is  gradually  diminishing.  On 
that  account,  adopting  in  principle  the  opinion  of  Gregory,  I  would  prefer 
variolation  to  vaccination ;  but  nevertheless,  it  is  to  the  latter  we  must 
have  recourse,  for  reasons  which  I  laid  before  you  when  discussing  the 
inoculation  of  small-pox. 


LECTURE    IV. 

CHICKEN-POX. 

Chicken-pox,  or   Varicella,  essentially  different  from  Modified  Small-pox. — 
Unlike  Small-pox  it  does  not  protect  from  Variolous  Contagion. — Small- 
pox does  not  pjrotect  from  Chicken-pox. —  Course  and  Characteristics  of 
the  Eruption. 

Gentlemen  :  If  I  concur  with  the  general  opinion  of  physicians  in 
believing  that  small-pox  and  modified  small-pox  are  identical,  I  am  not 
at  one  with  them  as  to  the  nature  of  chicken-pox,  or  flying  small-pox 
\_petite  verole  volante~]  as  it  is  still  very  commonly  designated.  You  will 
read  in  books,  you  will  hear  it  said  and  repeated,  that  varicella  is  only  a 
modification  of  variola ;  that  chicken-pox  and  modified  small-pox  are 
identically  the  same  disease ;  and  that  both  are  merely  different  forms  of 
small-pox.  You  already  know  my  opinion  on  this  subject :  with  many 
others  I  hold  that  chicken-pox  and  modified  small-pox  are  as  much  stran- 
gers to  one  another  as  small-pox  is  a  stranger  to  measles;  that  they  resem- 
ble one  another  as  little  as  measles  resembles  scarlatina;  and  that  they  are 
as  different  as  possible  from  each  other  in  their  symptoms,  forms,  and 
essential  nature.  And  I  will  venture  to  affirm,  that  physicians  who  main- 
tain an  opposite  opinion  have  never  taken  the  trouble  to  examine  chicken- 
pox;  for  if  they  had,  they  must  have  become  convinced  of  their  error. 

Chicken-pox  looked  at  from  a  general  point  of  view,  as  an  abstraction 
deduced  only  from  its  anatomical  characters,  presents  such  sharply-marked 
differences  from  modified  small-pox  that  it  is  difficult  to  understand  how 
the  two  diseases  should  have  been  confounded.  Then,  on  the  other  hand, 
we  learn  from  the  history  of  epidemics  that  chicken-pox  can  exist  in  an 
epidemic  form  by  itself,  whereas  modified  small-pox  never  prevails  without 
being  accompanied  by  normal  small-pox.  Again,  the  two  diseases  differ 
in  respect  of  the  age  of  the  person  for  whom  they  have  a  predilection. 
Small-pox  before  the  discovery  of  vaccination,  and  prior  to  the  practice  of 
variolous  inoculation,  while  it  chiefly  attacked  children,  likewise  attacked 


134  CHICKEN-POX. 

adults,  whereas  chicken-pox  was  then  as  now  almost  limited  to  young  sub- 
jects, not  attacking  adults,  who  had  escaped  it  in  their  youth.  As  inocula- 
tion in  England,  Germany,  and  France,  dates  from  last  century,  as  vacci- 
nation was  not  in  common  use  till  the  beginning  of  the  present.  cas<  -  of 
modified  small-pox  were  very  rare  in  those  days :  but  at  that  time  chicken- 
pox  was  perfectly  known  and  described.  Except  in  exceedingly  rare  ex- 
ceptional cases,  small-pox  does  not  attack  a  child  vaccinated  two  or  three 
years  previously.  You  may  with  impunity  inoculate  such  a  child.  But  if 
you  bring  him  into  contact  with  another  child  who  has  chicken-pox,  he 
easily  takes  it.  From  this  fact  alone,  it  is  evident  that  chicken-pox  is  not 
small-pox.  Again,  if  a  person  who  has  just  had  chicken-pox  is  brought 
into  contact  with  a  centre  of  variolous  contagion,  he  ought  not  to  contract 
small-pox  if  the  chicken-pox  of  which  the  marks  are  still  visible  were  the 
remains  of  modified  small-pox ;  but  nevertheless  we  have  learned  from 
experience  that  such  an  individual  may  quite  well  contract  small-pox. 

The  two  exanthematous  diseases  may  even  go  on  simultaneously.  Dr. 
Delpeeh,  in  a  paper  published  in  1845,  narrates  the  case  of  a  child,  who 
had  had  at  the  same  time  small-pox  and  chicken-pox. 

A  person  will  never  contract  small-pox  from  being  exposed  to  the  con- 
tagion of  chicken-pox.  Will  there  be  a  similar  immunity  if  you  inoculate 
an  individual  with  virus  takeu  from  the  mildest  possible  case  of  modified 
small-pox?  Again,  small-pox  presents  itself  under  very  variable  forms, 
but  chicken-pox  is  always  the  same  in  form  and  symptoms:  in  no  case 
does  an  antecedent  attack  of  small-pox  exercise  the  slightest  influence 
upon  it.  Moreover,  while  second  attacks  of  small-pox  occur  only  as  excep- 
tional cases,  second  attacks  of  chicken-pox  are  far  from  being  so  uncom- 
mon. Do  not  all  these  considerations  clearly  prove  that  verolette — for  this 
also  is  a  name  of  chicken-pox — differs  essentially  from  small-pox? 

The  differences  between  the  two  diseases  come  out  still  more  strongly 
when  we  examine  them  more  minutely,  comparing  chicken-pox  with  mod- 
ified and  with  natural  small-pox.  In  distinct  small-pox,  as  I  have  reiter- 
ated on  several  occasions,  the  fever  of  invasion  lasts  for  three  days,  and  the 
eruption  appears  on  the  third:  in  modified  small-pox,  distinct  or  confluent, 
the  period  of  invasion  has  the  same  duration  as  in  the  natural  form  of  the 
disease.  The  course  of  chicken-pox  is  quite  different.  To-day,  a  child  is 
seized  with  headache,  feelings  of  general  discomfort,  and  all  the  symptoms 
which  accompany  the  onset  of  any  fever;  but  on  the  very  same  day,  before 
twenty-four  hours  have  passed,  there  are  visible  on  some  pari  of  the  body 
— it  may  be  on  the  face,  back,  abdomen,  or  legs — small  slightly  acuminated 
rosy  spots,  resembling  the  rosy  lenticular  spots  of  putrid  fever.  During 
the  first  twenty-four  hours,  from  ten  to  fifteen  such  spots  may  be  seen.     The 

fever,  nevertheless,  continues.     On  the  following  day,  froi le  hundred  to 

one  hundred  ami  fifty  spots  may  be  counted:  those  of  the  previous  evening 
have  by  this  time  elevated  the  epidermis,  the  elevations  being  generally  in 
the  form  of  blebs,  which  are  sometimes  rounded  in  the  mosl  perfect 
manner,  and  contain  a  serosity  transparent  like  rock-water,  and  without 
any  surrounding  inflammatory  areola.  This  description  is  quite  inappli- 
cable to  the  natural  variolous  eruption:  it  is  also  inapplicable  to  the 
manner  in  which  the  eruption  of  modified  small-pox  appears  in  respect  of 
situation,  development,  ;ui<i  form.  The  eruption  of  modified  small-pox — 
unlike  that  of  chicken-pox  bears  no  resemblance  to  a  phlyctsena,  a  bleb 
of  pemphigus,  or  to  certain  forms  of  herpes.  These  palpable  anatomical 
characters  are  in  themselves  Bufficienl  to  establish  categorically  the  differ- 
ences which  so  clearly  distinguish  the  two  affections  from  each  other. 

Next   morning,  there  is  almost  no  fever,  and  it  is  observed  that  ;i  new 


CHICKEN-POX.  135 

crop  of  from  one  hundred  to  one  hundred  and  fifty  spots  have  appeared 
during  the  night.  In  the  evening  of  this  day,  fever  again  sets  in,  and  con- 
tinues till  next  day,  when  the  spots  of  the  previous  evening  have  become 
blebs,  and  new  spots  appear  (without  indicating  a  preference  for  any  par- 
ticular locality),  in  the  situations  where  the  eruption  had  already  conic 
out.  Successive  crops  of  eruption,  and  new  onsets  of  fever,  sometimes  vio- 
lent, occurring  during  the  night  and  ceasing  during  the  day,  are  repeated 
for  four  or  five  nycthemera.  The  fever,  therefore,  has  no  resemblance  to 
the  variolous  fever,  which  is  continuous,  and  usually  during  a  single  par- 
oxysm brings  out  the  eruption  however  generally  distributed  it  may  be 
over  the  body. 

After  four  or  five  attacks  of  fever,  the  eruption  of  chicken-pox  is  complete, 
and  there  is  no  more  fever.  The  rosy  elevations,  which  after  from  seven  to 
ten  hours  were  transformed  into  blebs,  perfectly  round,  shining,  and  dis- 
tended, with  lactescent  serosity,  in  from  twenty-four  to  thirty-six  hours  more 
increase  in  size,  and  become  irregular  in  shape,  like  some  of  the  pustules  of 
ecthyma  ;  their  serosity  acquires  an  opaline  appearance  ;  and  an  inflamma- 
tory areola  surrounds  them.  They  remain  in  this  state  for  about  three 
days.  Towards  the  third  day,  the  serosity  is  replaced  by  pus :  the  pustule 
bursts  :  it  is  large,  irregular,  and  painful.  Thus,  whilst  from  eight  to  nine 
days  are  required  for  the  evolution  of  the  variolous  pustule,  three  nycthem- 
era are  enough  for  the  bleb  of  the  chicken-pox.  Farther,  the  variolous 
pustules  are  largest  on  the  hands,  but  it  is  on  the  back  and  trunk  that  the 
varicellous  pustules  attain  the  greatest  size. 

On  the  seventh  day,  the  pustules  of  chicken-pox  are  dry,  and  in  their 
place  are  to  be  seen  blackish  crusts  like  those  which  succeed  the  pustules  of 
ecthyma,  or  red  spots  such  as  are  presented  by  imperfectly  healed  blisters, 
according  as  they  have  proceeded  more  or  less  freely  to  suppuration,  or 
have  broken  the  skin  like  a  blistering  plaster  of  cantharides  or  ammonia. 

In  chicken-pox,  the  eruption  is  in  the  form  of  blebs  :  in  small-pox  it  is 
in  the  form  of  pustules.  This  important  difference,  irrespective  of  other 
distinctive  characteristics  drawn  from  the  general  symptoms,  is  quite  suffi- 
cient to  establish  the  non-identity  of  the  two  diseases. 

The  following  case,  for  which  I  am  indebted  to  M.  Dumontpallier,  fur- 
nishes me  with  additional  evidence  of  the  essential  nature  of  the  difference 
between  small-pox  and  chicken-pox : 

"  On  Tuesday,  4th  March,  1862,"  writes  M.  Dumontpallier,  "  I  was  called 

in  to  the  family  De  R .     The  eldest  of  the  daughters,  between  thirteen 

and  fourteen  years  of  age,  had  been  only  slightly  unwell  from  the  previous 
evening,  but  nevertheless,  at  my  first  visit  on  the  4th  March,  I  observed  a 
vesicular  eruption  on  the  face,  arms,  legs,  and  trunk.  There  existed  slight 
lassitude,  with  some  feeling  of  debility  and  pains  in  the  limbs,  a  very  little 
aching  in  the  loins,  no  nausea,  and  hardly  any  fever.  This  young  girl  had 
beautiful  vaccinal  cicatrices.  I  diagnosed  the  case  to  be  one  of  modified 
small-pox.  The  patient  was  soon  restored  to  health ;  but  she  will  retain 
one  or  two  pock-marks  on  the  face. 

"  On  Saturday,  8th  March,  I  vaccinated  Miss  De  R 's  two  sisters, 

aged  respectively  ten  and  twelve,  and  also  Mrs.  De  R and  her  hrother, 

a  young  man  of  twenty-three.     A  vaccinal  pock  was  developed  on  the  arm 

of  Mrs.  De  R ,  but  in  the  two  girls  and  the  young  man,  the  vaccination 

did  not  take  effect.  Matters  remained  in  this  state  till  Monday,  17th 
March,  that  is  till  thirteen  days  after  the  onset  of  the  fever  in  the  eldest  of 
the  three  sisters,  and  nine  days  after  the  vaccination  of  the  family,  when  I 
was  sent  for  to  see  the  two  youngest  sisters.  I  was  told  that  both  had  had 
some  feelings  of  discomfort  on  the  previous  day :   during  the  day  they  had 


136  SCARLATINA. 

taken  a  walk,  but  in  the  evening  had  begged  to  be  allowed  to  go  early  to 
bed.  Next  day,  the  17th,  a  very  beautiful  eruption  of  papules,  which  soon 
became  slightly  vesicular,  appeared  on  the  face,  limbs,  and  back.  On  the 
following  day,  the  blebs  were  filled  with  lactescent  serosity,  and  soon  dried 
up  into  the  form  of  crusts.  There  was  no  severity  in  any  of  the  general 
symptoms,  and  by  the  third  day  the  appetite  had  returned. 

"  I  called  in  Professor  Trousseau  in  consultation,  who  had  no  hesitation  in 
saying  that  it  was  a  case  of  chicken-pox.  He  came  to  this  conclusion  from 
the  short  duration  of  the  period  of  invasion,  the  vesicular  form  of  the  erup- 
tion, the  rapidity  of  the  desiccation,  and  the  small  amount  of  constitutional 
disturbance.     It  is  evident,  from  the  facts  just  stated,  in  the  first  place,  that 

the  Misses  De  R were  proof  against  the  contagion  of  small-pox,  for  they 

were  still  under  the  protecting  influence  of  a  first  vaccination  ;  and  in  the 
second  place,  that  small-pox  and  chicken-pox  are  diseases  distinct  from 

each  other  in  their  nature  and  in  their  germ,  as  the  Misses  De  R took 

chicken-pox,  though  proof  against  small-pox." 

Chicken-pox  sometimes  presents  phenomena  which  are  never  met  with 
in  small-pox.  Thus,  in  an  epidemic  of  chicken-pox  which  prevailed  in  the 
Necker  Hospital,  the  fever  ceased  when  the  malady  began  ;  and  during 
from  fifteen  to  forty  days  pemphigoid  blebs  appeared  on  different  parts  of 
the  body,  leaving,  on  the  surfaces  which  they  had  occupied,  ulcerations 
exactly  like  those  of  pemphigus,  which  ulcerations  continued  for  six  weeks 
or  two  months.     No  such  occurrences  are  ever  observed  in  small-pox. 

To  sum  up :  Epidemic  conditions,  general  symptoms,  the  manner  in 
which  the  eruption  appears,  and  its  form,  all  combine  to  establish  the  essen- 
tially different  nature  of  chicken-pox  and  small-pox.  Again,  chickeu-pox 
is  never  a  fatal  disease.  No  physician  has  ever  seen  a  patient  die  of  chicken- 
pox,  though  of  course  there  may  be  a  fatal  issue  from  some  complication 
independent  of  the  exanthematous  fever.  This  cannot  be  said  of  small-pox, 
nor  of  modified  small-pox.  Finally,  the  incubation  of  small-pox  extends 
over  nine,  ten,  or  eleven  days,  as  has  been  demonstrated  in  the  practice  of 
inoculation,  whereas  the  incubation  of  chicken-pox  is  a  period  of  from  fifteen 
to  twenty-seven  days.  Chicken-pox  is  not  inoculable,  or  at  all  events  my 
attempts  to  inoculate  it  have  been  failures:  but  when  u  child  suffering  from 
it  returns  to  its  family,  we  may  prognosticate,  from  the  teaching  of  expe- 
rience, that  within  from  fifteen  to  twenty-seven  days  other  children  in  the 
house  will  have  taken  the  disease. 


LECTUKE  V. 

SCARLATINA. 

Variety  in  the  ( 'li>ir<ici>  rs  of  Epidemics. —  Contagion. —  Incubation. —  Compli- 
cations at  the  Beginning  of  an  Attack.— Characters  of  the  Eruption. 
Desquamation. 

Gentlemen:  It  is  now  nearly  sis  months  since  wo  have  been  fre- 
quently receiving  cases  of  Bcarlatina  into  our  wards.  In  town,  it  seems  I" 
bo  prevalent  as  a  somewhat  severe  epidemic.  You  have  here  at  present,  an 
opportunity  of  judging  I'm-  yourselves  of  the  strange  forms  which  this  (lis- 


SCARLATINA.  137 

ease  is  apt  to  assume.  I  am  unwilling  to  allow  the  Opportunity  to  pass 
without  bringing  it  under  your  notice,  as  it  is  a  malady  rather  imperfectly 
known  by  hospital  students. 

Scarlatina  is  more  variable  in  its  forms  and  symptoms  than  any  other 
of*  the  contagious  exanthematous  fevers;  and  its  dangers  are  also  more  diffi- 
cult to  foresee.  Small-pox,  whether  distinct  or  confluent,  mild  or  malig- 
nant, is  always  small-pox:  its  leading  characters  can  always  be  recognized — 
always,  except  with  a  very  few  exceptions,  chiefly  observed  by  our  prede- 
cessors— its  external  anatomical  lesions  being  peculiar  to  itself,  whether  it 
be  in  its  natural  form,  or  modified,  as  it  so  often  is,  by  vaccination  or  a  pre- 
vious attack  of  small-pox.  Scarlatina,  on  the  contrary,  may  exist  without 
showing  itself  on  the  skin  ;  and  when  this  is  the  case,  the  disease  is  not  the 
less  serious  on  that  account.  Measles  always  preserves  pretty  exactly  its 
characteristic  features:  its  diagnosis  is  usually,  almost  always,  easy:  its 
complications  are  generally  foreseen,  and  occur  at  a  certain  stage,  even  on 
a  particular  day  which  the  physician  can  predict.  Scarlatina,  as  we  shall 
see,  preseuts  complications  which  for  the  most  part  cannot  be  foreseen,  and 
of  which  the  most  experienced  practitioner  can  know  nothing  beforehand, 
even  when  they  are  imminent. 

Scarlatina  is  sometimes  so  very  mild,  that  Sydenham,  one  of  the  greatest 
medical  observers  of  past  times,  said  of  it :  "  Hoc  morbi  nomen  (vix  enim 
altius  assurgit)."  Sydenham  gives  us  in  his  writings  only  the  results  of  his 
personal  experience,  and  as  he  had  never  seen  severe  scarlatina,  he  spoke 
of  the  disease  with  a  sort  of  contempt  which  he  was  far  from  having  for 
measles  or  small-pox.  In  our  own  day,  some  of  the  authors  to  whom  we 
ought  always  to  refer  state,  that  for  a-  long  series  of  years  the  epidemics  of 
scarlatina  which  came  under  their  observation  were  so  far  from  being- 
serious  that  they  were  without  fatal  cases.  Graves  mentions  that  from 
1800  to  1804  scarlatina  ravaged  Ireland,  and  was  very  fatal;  while  from 
1804  to  1831,  the  physicians  who  had  found  it  so  terrible  in  1800,  1801, 
1802,  1803,  and  1804,  saw  scarcely  any  fatal  cases,  so  wonderfully  mild 
had  been  the  disease.  But  in  1831,  an  epidemic  of  malignant  scarlatina 
broke  out  in  Dublin  and  its  vicinity  :  in  1834,  it  covered  Ireland  with 
mourning  more  extensive  than  that  which  was  caused  some  years  later  by 
typhus,  or  than  that  which  had  been  produced  two  years  previously  by  the 
outbreak  of  Asiatic  cholera.* 

At  the  commencement  of  my  medical  studies,  when  attending  the  clinic 
of  Bretonneau,  my  illustrious  master  taught  his  class  that  scarlatina,  which 
he  had  formerly  heard  spoken  of  as  a  very  dangerous  malady,  was  then  a 
mild  affection.  He  told  us  that  from  1799  to  1822  he  did  not  recollect 
having  seen  a  single  fatal  case;  and  yet  he  had  long  practiced  in  the  coun- 
try before  he  became  first  physician  to  the  hospital  at  Tours.  The  numerous 
cases  which  he  met  with  both  in  his  hospital  and  private  practice  seemed  at 
that  time  to  have  satisfied  him  that  scarlatina  was  the  mildest  of  all  the  exan- 
themata. But  in  1824,  an  epidemic  broke  out  in  Tours  and  its  environs :  in 
less  than  two  months  Bretonneau  learned  that  several  patients  had  died 
with  such  frightful  rapidity  that — being  opposed  to  the  doctrines  of  Brous- 
sais  then  in  repute — he  blamed  the  treatment  adopted  by  his  colleagues, 
who  bled  most  resolutely  with  a  view  to  subdue  the  sore  throat  and  the  so- 
called  inflammatory  fever  which  attends  the  beginning  of  the  attack.  By 
and  by,  coming  personally  to  close  quarters  with  the  disease,  he  found  that 
he  could  not  always  successfully  contend  against  it,  and  he  saw  it  carry  off 

*  Graves:  Lecons  de  Clinique  Medicate.  Traduit  par  Jaccoud,  2me  edition,  T.  i. 
Paris,  1863. 


138  SCARLATINA. 

many  of  his  own  patients.  The  result  was  that  Bretonneau,  who  had  for- 
merly looked  upon  scarlet  fever  as  a  slight  malady,  now  learned  to  regard 
it  as  equally  mortal  with  plague,  typhus,  and  cholera. 

Thus  you  see  that  during  a  quarter  of  a  century,  scarlatina  appeared  as 
an  epidemic  without  showing  any  severity :  then  all  at  once  it  became 
changed  in  its  manifestations,  and  cruelly  smote  all  whom  it  touched.  It 
is  not  usual  for  measles  or  small-pox  to  manifest  themselves  in  this  way. 
Very  severe  epidemics  of  measles  and  small-pox  do,  no  doubt,  sometimes 
occur,  but  as  epidemics  they  never  show  such  extremes  of  mildness  and 
severity  as  scarlatina.  Scarlatina  is  a  disease  which  is  more  influenced 
than  measles  or  small-pox  by  a  dominating  epidemic  constitution,  and 
hence  it  arises  that  an  epidemic  of  scarlatina  is  sometimes  very  mild,  and 
at  other  times  very  severe. 

You  may  have  observed,  gentlemen,  with  what  care  I  have  interrogated 
our  patients  with  a  view  to  ascertain  the  circumstances  under  which  they 
contracted  scarlatina.  Causes  which  generally  favor  the  appearance  of 
other  diseases  have  very  little  to  do  with  the  evolution  of  the  exanthema- 
tous  pyrexia,  and  in  respect  of  their  causation,  contagion  ought  to  be  the 
point  most  particularly  inquired  into.  We  shall  afterwards  have  to  return 
to  the  consideration  of  the  evolution  of  contagion-germs.  I  should  fear 
that  I  was  doing  injustice  to  this  great  question  were  I  only  to  skim  its 
surface:  I  should,  through  my  own  fault,  be  unable  to  make  myself  under- 
stood by  you.  You  have  seen  how  much  importance  I  attach  to  ascertain- 
ing the  day  of  first  contact,  direct  or  indirect,  with  a  contaminated  person 
or  place.  You  have  seen  that  proof  of  this  contact  was  sometimes  clear, 
and  that  at  other  times  it  was  quite  unattainable,  and  also  that  there  were 
cases  in  which  communication  between  the  patients  and  persons  with  scar- 
latinous infection  had  been  such  as  to  make  it  impossible  to  determine  the 
duration  of  the  period  of  incubation. 

Nothing  is  more  difficult  than  to  state  the  exact  time  at  which  contagion 
has  been  contracted  in  an  exanthematous  fever,  when  the  virus  has  not 
been  directly  introduced  by  inoculation ;  and,  consequently,  nothing  has 
been  more  variable  than  the  manner  in  which  this  question  has  been  solved. 
According  to  some,  the  incubation  of  scarlatina  varies  in  duration  from 
three  to  five  days,  according  to  others  it  lasts  for  eighl  days,  and  some 
believe  that  it  may  be  prolonged  to  fifteen,  twenty,  or  even  thirty  days.  In 
fact  the  figures  given  have  been  hypothetical.  There  exists  an  unwilling- 
ness to  admit  the  fact  that  it  is  impossible  to  determine  the  duration  of  the 
period  of  incubation,  just  because  it  is  impossible  to  fix  the  date  of  its 
commencement.  Small-pox  is  the  only  fever  in  respect  of  which  this  date 
is  determinable  with  precision,  being  the  only  one  directly  inoculable.  In 
consequence  of  variolous  inoculation  having  during  half  a  century  been 
practiced  on  a  large  scale  throughout  Europe,  the  time  which  elapses  be- 
tween the  moment  at  which  the  virus  is  placed  under  the  skin,  and  that  at 
which  the  malady  declares  itself,  has  been  determined  with  precision.  The 
rigorous  determination  of  the  length  of  the  period  of  incubation  in  -mall- 
pox  is  dependent,  therefore,  upon  its  inoculabUity,  a  property  which  doc-  net 
belong  to  any  other  exanthematous  fever.  From  the  uon-inocu  lability  of 
the  other  exanthemata,  it  has  been  necessary  to  assume  as  the  beginning  of 

the  period  of  incubation,  the  moment  at  which  the  patient  was  firel  in  con- 
tact  with   an    infected    person.      Bui    inoculation    and    contact    are    not    the 

Mime  thing.     Here  is  a  case  in  point  !     Five  hundred  sheep  are  collected 

together  in  the  Mime  park,  or  in  the  same  fold  ;   one  of  them  takes  the  tag- 

sore,  an  eruptive  disease  of  sheep,  analogous  to  Bmall-pos  in  the  human 
specie-.    Fifteen  or  twenty  days  later,  seven  or  eighl  other  sheep  are  seized, 


SCARLATINA.  139 

and  on  each  succeeding  day  several  inure  fall  sick.  It  is  sometimes  four 
months  before  the  entire  five  hundred  have  taken  the  disease.  Now,  these 
animals  contracted  the  contagion  at  very  different  periods,  although  they 
were  all  shut  up  in  the  same  place,  breathed  the  same  impure  air,  were 
together  in  crowded  contact,  and  soiled  by  the  discharge  from  the  sores  of 
the  affected.  Is  there  any  reason  to  suppose  that  the  period  of  incubation 
was  longer  in  some  of  these  sheep  than  in  others?  None:  because  if  all 
the  sheep  had  been  inoculated  simultaneously,  the  manifestation  of  the 
disease  would  have  occurred  in  all  without  exception  on  exactly  the  same 
day.  Inoculation  and  contact,  then,  are  two  very  different  things :  by 
inoculation,  the  virus  is  introduced  almost  of  necessity  into  the  system  ; 
but  by  mediate  or  intermediate  contact,  the  absorption  of  the  virus,  its 
conception,  if  I  may  be  allowed  to  use  that  expression,  is  not  always 
secured — that  only  takes  place  when  the  economy  is  in  a  certain  state  of 
aptitude : — the  way  must  be  open,  so  to  speak.  When  absorption  has  once 
taken  place,  whether  after  inoculation  or  contact,  it  is  probable  that  the 
evolution  of  the  disease  occurs  within  a  determinate  time,  which,  within  a 
few  days  or  hours,  is  the  same  in  all  cases. 

Very  well !  Till  we  can  inoculate  scarlatina  by  the  scarlatinous  virus, 
we  shall  be  as  unable  to  determine  the  duration  of  its  period  of  incubation 
as  we  are  to  determine  the  duration  of  the  incubation  of  the  tag-sore  con- 
tagion in  the  different  sheep  constituting  the  flock  of  five  hundred.  In  a 
family  consisting  of  ten  individuals,  five  weeks  will  sometimes  elapse  before 
scarlatina  has  attacked  all  the  members,  the  case  being  quite  similar  to  that 
of  the  flock  of  sheep.  This  neither  arises  from  certain  individuals  having 
been  free  from  contact  for  a  certain  time,  nor  from  the  period  of  incubation 
having  lasted  longer  in  some  than  in  others,  but  from  the  difference  in  the 
respective  aptitudes  of  the  different  subjects  to  receive  the  contagium.  This 
is  what  we  see  take  place  with  syphilis.  When  the  syphilitic  virus  is 
scientifically  inoculated,  it  determines,  after  the  lapse  of  a  certain  number 
of  days,  the  evolution  of  a  specific  vesicle,  and  the  number  of  days  is  almost 
exactly  the  same  in-  every  case;  but  when  several  men  have  connection  with 
the  same  infected  woman,  some  will  take  the  pox  immediately,  while  others, 
after  having  been  exposed  on  several  successive  days  to  the  contagion,  will 
not  contract  the  disease  till  the  last  day,  or  perhaps  not  at  all.  This  is 
explained  by  the  fact,  that  those  who  at  once  contracted  the  disease  from 
the  first  contact  were  in  a  physiological  and  pathological  state  suitable  for 
the  absorption  of  the  virus,  while  the  others  were  not  in  that  condition  of 
aptitude. 

To  sum  up  :  The  duration  of  the  period  of  incubation  in  scarlatina,  that 
is  to  say,  the  time  which  elapses  between  the  exact  moment  at  which  the 
morbid  poison  is  absorbed,  and  the  exact  moment  at  which  appear  the  first 
manifestations  of  the  disease,  cannot  be  rigorously  determined  in  the  present 
state  of  our  knowledge.  The  same  statement  holds  good  in  respect  of 
measles. 

Under  very  exceptional  circumstances,  however,  it  is  possible  to  attain 
considerable  exactitude  as  to  the  duration  of  the  period  of  incubation  in 
scarlatina.  In  the  beginning  of  the  year  1859,  I  saw  a  very  curious  case 
which  occurred  in  the  practice  of  my  friend  Dr.  McCarthy,  who  did  me 
the  honor  of  calling  me  in  in  consultation.  A  London  merchant  had 
taken  one  of  his  daughters  to  the  Eaux  Bonnes  in  the  Pyrenees,  and  had 
passed  the  winter  with  her  at  Pau.  On  his  way  back  to  England  he  stopped 
at  Paris,  where  he  wished  to  remain  some  days.  His  eldest  daughter  was 
keeping  house  for  him  in  London.  Impatient  to  embrace  her  father  and 
sister,  she  started  for  Paris.     When  crossing  the  Channel,  she  was  seized 


140  SCARLATINA. 

with  fever  and  sore  throat,  and  seven  or  eight  days  later  arrived  at  Paris, 
in  the  middle  of  a  very  serious  attack  of  scarlatina.  She  alighted  at  the. 
hotel,  almost  at  the  very  moment  when  her  father  and  sister  arrived  from 
Pau.  The  two  sisters  remained  together  in  the  same  room,  and  in  twenty- 
four  hours  the  sister  who  had  come  from  Pa*u  showed  the  first  symptoms  of 
a  mild  attack  of  scarlatina.  In  London,  the  disease  was  then  epidemic; 
but  there  were  no  cases  at  Pau.  This  curious  history  proves  that  in  scarlet 
fever  the  duration  of  the  period  of  incubation  is  sometimes  not  more  than 
twenty-four  hours.  I  am,  however,  very  far  from  believing  that  that  is 
its  ordinary  duration.  Although  the  period  of  incubation  is  limited  with 
precision  in  small-pox,  there  is  probably  no  similar  exactitude  of  limitation 
in  the  other  exanthematous  fevers. 

The  period  of-  invasion  in  scarlet  fever  is  quite  as  much  without  exact 
limits  as  the  period  of  incubation.  Recall  to  your  recollection  what  takes 
place  in  small-pox.  In  normal  small-pox,  when  the  eruption  appears  within 
forty-eight  hours  of  the  first  manifestation  of  symptoms,  it  may  be  affirmed 
that  the  case  will  be  confluent,  for,  as  a  general  rule,  it  is  towards  the  end 
of  the  second  day,  or  at  the  commencement  of  the  third,  that  the  pustules 
begin  to  come  out  in  that  form  of  the  disease ;  and  when  the  eruption  does 
not  appear  till  the  fourth  day,  the  diagnosis  is — distinct  small-pox.  In 
cases  of  confluent  small-pox,  it  is  very  unusual  for  the  eruption  to  be  re- 
tarded till  the  fourth  day,  and  it  is  as  unusual  in  distinct  small-pox  for  it 
to  appear  on  the  second.  Observe,  that  I  am  at  present  only  speaking  to 
you  of  normal  small-pox.  I  was  on  a  former  occasion  careful  to  point  out 
that  in  the  modified  disease  the  symptoms  are  different. 

In  scarlatina,  events  do  not  proceed  as  in  small-pox.  In  some  cases,  the 
eruption  comes  out  during  the  first  four  or  five  hours  of  the  fever,  while  in 
other  cases  there  is  no  fever  at  the  beginning  of  the  disease,  a  fact  men- 
tioned by  Heister  and  other  old  authors,  and  which  in  later  times  has  been 
repeated  by  various  writers.  Barthez  and  Rilliet  state  that  in  eighty-seven 
cases  observed,  the  eruption  was  the  first  symptom  of  the  malady  in  four 
cases:  in  the  majority  of  the  eighty-four  cases,  the  fever  of  invasion  lasted 
twenty-four  hours,  and  rarely  continued  longer.  It  is  still  more  unusual, 
except  in  complicated  cases,  for  the  eruption  to  be  delayed  beyond  the 
second  day,  and  very  much  more  unusual  for  it  to  be  retarded  till  alter  the 
third  day.  Some  physicians  believe  that  they  have  seen  cases  in  which  the 
eruption  did  not  appear  till  during  the  third  day.  I  do  not  absolutely 
deny  the  possibility  of  such  an  occurrence,  but  I  say  emphatically  that  the 
occurrence  is  one  of  extreme  rarity.  My  opinion  is,  that  in  the  class  of 
cases  referred  to,  the  eruption  is  often  not  recorded,  because,  though  present, 
it  has  escaped  observation,  owing  to  its  not  having  been  looked  for  in  the 
proper  place.  As  a  general  rule,  we  firsl  seek  on  the  face  for  the  eruption 
in  exanthematous  fevers,  because,  in  point  of  fact,  it  first  shows  itself  there 
in  measles  and  sniall-pox;  but  in  scarlatina  the  eruption  docs  not  conic  out 
firsl  on  the  face.  It  generally  appears  first  on  the  trunk,  forearms,  lower 
part  of  abdomen,  and  bend  of  the  thighs,  ami  may  exist  in  these  localities 
from  twenty-four  to  thirty-six  hours  before  it  is  visible  on  the  face  or  neck. 

Under  Buch  circumstances,  one  might  suppose  that  the  eruption  was  only 

beginning  to  appear,  when  in  reality  it  had  been  out  for  some  time;   but  it 

is  easy  to  avoid  this  mistake,  it  we  are  aware  of  the  tint  I  have  now  men- 
tioned. 

There   are,  however,  complicated    Cases  of  scarlatina,  a-  of  small-pox,  in 

which  the  period  of  invasion  is  prolonged  greatly  beyond  its  ordinary  term. 
It  sometimes  happens  in  seriously  complicated  cases  of  scarlatina  that 
the  exanthem  does  nol  show  it-elf  till  as  late  even  as  the  eighth  day  ;  as  I 


SCARLATINA.  141 

know  from  the  following  case.  Six  years  ago,  I  was  .summoned  by  my 
honorable  colleague  Dr.  Sarrazin  to  see  a  child  of  six  or  seven  years  of  age 
supposed  to  have  cerebral  fever.  He  was  complaining  of  headache,  and 
had  vomiting.  We  observed  squinting,  slowness  of  pulse,  stupor,  and  som- 
nolence. From  these  symptoms  we  believed  that  the  patient  was  suffering 
from  inflammation  of  the  brain  and  its  membranes.  I  saw  the  child  again 
on  the  fifth,  sixth,  and  seventh  days  without  changing  my  diagnosis,  and 
continued  to  give  a  very  unfavorable  prognosis.  On  the  eighth  day,  there 
appeared  a  well-marked  scarlatinous  eruption,  accompanied  by  the  usual 
sore  throat :  from  that  time,  the  cerebral  symptoms  entirely  ceased.  I  have 
not  seen  another  case  like  this  in  the  whole  course  of  my  medical  experi- 
ence, but  I  know  that  similar  cases  have  been  observed  by  others.  They 
are  exceptional  and  very  rare.  As  a  general  rule,  I  repeat,  the  period  of 
invasion  is  very  short  in  scarlatina. 

The  symptom  which  generally  characterizes  it  is  fever  with  or  without 
previous  rigors :  in  the  last  patients  you  have  seen  in  the  wards,  these 
rigors  were  absent.  The  pulse  is  quicker  than  in  the  other  exanthematous 
fevers.  This  is  an  important  fact  ;  for  in  studying  the  disease  in  its  com- 
ponent parts,  in  speaking  of  scarlatina  without  eruption,  we  find  that  we 
often  form  our  diagnosis  solely  from  this  extreme  frequency  of  pulse,  which 
is  very  rarely  met  with  in  other  affections  liable  to  be  confounded  with 
scarlatina.  Diarrhoea  and  vomiting  often  accompany  the  fever  of  invasion. 
The  sore  throat  almost  always  shows  itself  simultaneously  with  the  fever  : 
this  is  the  symptom  to  which  the  patient  first  calls  the  attention  of  the 
physician,  and  it  therefore  takes  a  very  important  place  in  the  diagnosis. 
The  tongue  has  no  characteristic  appearance  on  the  first  day  :  it  is  febrile, 
that  is  to  say  coated  with  a  somewhat  slimy  fur,  and  scarcely  red  at  the 
point  and  edges.  On  the  veil  of  the  palate,  however,  there  is  already  per- 
ceptible a  rather  bright  redness,  and  sometimes  a  dotted  appearance.  This 
redness  is  very  distinct  upon  the  tonsils,  which  are  slightly  swollen. 

When  the  type  of  the  disease  is  malignant,  the  symptoms  assume  a 
totally  different  form.  There  is  a  frequency  of  pulse  still  greater  than  in 
simple  cases ;  and  sometimes  iu  adults  from  the  first  day  of  the  fever,  even 
before  there  is  any  appearance  of  eruption,  the  pulse  is  130,  140,  150,  or 
even  160.  Disturbance  of  the  nervous  system  at  the  same  time  super- 
venes, in  the  form  of  great  restlessness,  convulsions,  invincible  insomnia, 
and  delirium,  or  at  least  a  muttering  delirium  when  the  patient  is  left 
alone.  Such  symptoms  are  very  unusual  in  simple  sore  throat  or  pyrexiae 
other  than  scarlatina.  From  its  first  day,  nay  even  from  its  first  hours, 
malignant  scarlatina  makes  itself  known  in  all  its  malignity,  and  this 
malignity  may  be  so  intense  as  to  carry  off  the  patients  within  the  first 
twenty-four  hours. 

I  was  summoned  by  my  friend  Dr.  Bigelow,  to  see  a  young  American 
lady  at  a  boarding-school  near  Paris.  From  morning,  she  had  been  in  a 
state  of  frightful  delirium  :  she  had  incessant  vomiting,  intense  fever,  a 
pulse  too  frequent  to  be  counted,  and  an  extreme  dryness  of  skin.  On 
seeing  the  patient,  I  was  led  by  these  symptoms  to  pronounce  the  illness  to 
be  scarlatina  ;  and  although  there  was  nothing  else  to  demonstrate  its  exist- 
ence, my  diagnosis  was  confirmed  by  the  presence  of  the  characteristic 
scarlatinous  eruption  in  another  young  girl  in  the  same  boarding-school 
where  the  disease  was  at  that  time  epidemic.  Our  patient  died  before  the 
close  of  the  day. 

In  1824,  at  the  commencement  of  that  disastrous  epidemic  which  deso- 
lated Tours — and  of  which  I  have  already  spoken — I  saw,  along  with  Bre- 
tonneau,  a  young  woman  die  in  eleven  hours  with  symptoms  of  the  most 


142  SCARLATINA. 

terrible  description — delirium,  excessive  agitation,  and  an  extraordinary 
acceleration  of  pulse.  There  was  nothing  else  to  indicate  the  nature  of  the 
disease,  except  that  we  were  then  in  the  middle  of  an  epidemic  of  scarla- 
tina, and  that  several  members  of  this  young  lady's  family  had  taken  the 
disease. 

Under  similar  circumstances,  during  an  epidemic  of  scarlatina,  particu- 
larly when  the  disease  has  already  attacked  persons  in  immediate  commu- 
nication with  your  patient,  be  very  guarded  in  your  diagnosis,  if  the  case 
present  cerebral  symptoms.  Be  specially  guarded,  if  such  symptoms  declare 
themselves  at  the  beginning  of  the  illness,  as  they  then  almost  always 
announce  that  the  malady  is  malignant  scarlatina,  which  with  very  few 
exceptions  proves  rapidly  fatal.  I  must  insist  upon  this  point,  as  inatten- 
tion to  it  will  cause  most  serious  errors  of  diagnosis,  and  give  rise  to  mistakes 
in  prognosis  exceedingly  injurious  to  the  reputation  of  the  physician.  People 
forgive  us  more  easily  for  allowing  our  patients  to  die,  than  for  having  made 
a  mistake  as  to  the  issue  of  an  illness.  The  very  great  importance  of  these 
precepts  has  been  emphatically  proclaimed  by  Hippocrates  in  his  first 
chapter  on  prognosis.*     He  says : 

"  To  my  mind  he  is  the  best  physician  who  knows  beforehand  what  is 
going  to  happen.  By  penetrating  into,  clearly  describing  the  present  and 
the  future  of  the  maladies  of  his  patients,  and  explaining  svmptoms  which 
they  omit  to  state,  he  will  gain  their  confidence.  Convinced  of  his  superior 
intelligence,  they  will  unhesitatingly  place  themselves  under  his  direction. 
It  is  impossible  to  restore  every  patient  to  health,  but  the  prediction  of  the 
succession  of  symptoms  will  be  even  more  highly  appreciated.  It  is  of 
importance  to  recognize  the  nature  of  similar  affections,  to  know  the  extent 
to  which  they  exceed  the  constitutional  power,  and  likewise  to  discern 
where  there  is  any  supernatural  element  in  the  disease ;  for  that  is  a  point 
which  affects  the  prognosis.  It  is  in  this  way  that  the  physician  will  obtain 
the  merited  meed  of  admiration,  and  practice  his  profession  with  ability. 
Knowing  the  cases  which  are  curable,  he  will  be  the  better  aide  to  guard 
his  patients  from  danger,  by  indicating  the  precautions  to  be  taken  against 
each  untoward  contingency :' and  by  foreseeing  and  predicting  fatal  and 
favorable  issues,  he  will  escape  blame." 

Such  are  the  considerations  which  ought  always  to  be  present  to  your 
minds,  and  the  full  import  of  which  you  already  understand. 

But  to  return  to  our  subject:  when,  during  an  epidemic  of  scarlatina,  you 
meet  with  the  formidable  symptoms  of  which  I  have  now  spoken,  give  your 
opinions  with  reservations,  for  the  cases  may  perhaps  terminate  rapidly  in 
death.  .Similar  fatal  symptoms  almosl  never  show  themselves  thus  unex- 
pectedly in  measles  or  small-pox. 

The  temperature  rises  to  a  higher  point  in  scarlatina  than  in  any  other 
eruptive  fever.  The  skin  of  the  patienl  communicates  to  the  hand  a  sensa- 
tion of  the  sharpest  and  most   pungent   heat.     The  thermometer  placed  in 

the  axilla   sometimes  rises  to  forty-tvt '  forty-two  and  a   half  degrees, 

which  is  the  highest  temperature  ever  observed  in  disease.  The  fever  con- 
tinues moderate,  and  the  heal  inconsiderable  during  the  prodron a  stage, 

but  about  twenty-four  hours  prior  to  the  eruption,  the  temperature  rises 
Buddenly  to  a  high  point,  at  which  ii  remains  during  the  development  of 
tie  exanthem.  lie'  maximum  of  the  eruptive  process  corresponds  exactly 
with  the  maximum  of  temperature :  this  is  the  reverse  of  what  occurs  in 
small-pox,  in  which  there  is  a  diminution  of  temperature  proportionate  to 
the  evolution  of  the  exanthem.     In   scarlatina,  the  abatement  of  beat,  in 

*  IIii'i-ocKATK  :   <Kuvres  Completes.     Trad.  Littre.     Paris,  1840,  T.  ii.  p.  111. 


SCARLATINA.  143 

place  of  being  rapid  as  in  small-pox,  is  gradual,  steady,  without  exacerba- 
tions, and  is  not  completed  till  from  four  to  eight  days  have  elapsed. 

I  have  endeavored  to  point  out  to  you  at  the  bed  of  the  patient,  the  char- 
acters of  the  eruption,  but  I  tear  that  I  have  not  succeeded,  notwithstand- 
ing the  careful  manner  in  which  I  have  proceeded.  Upon  consulting 
certain  books,  one  might  suppose  that  it  was  impossible  for  a  physician  to 
have  anyscope  for  hesitation  in  the  differential  diagnosis  of  eruptive  fevers. 
Measles  is  an  eruption  of  small,  isolated,  irregular  spots,  with  blank  inter- 
vals between  them.  Small-pox  is  recognized  by  its  small  acuminated 
papules,  which  on  the  second  day  become  vesicular;  on  the  third,  pustular; 
and  about  the  eighth,  umbilicated  and  surrounded  by  an  inflammatory 
areola.  These  features  are  so  well  marked,  that  they  cannot  be  mistaken. 
As  to  scarlatina,  we  are  told  that  its  characteristics  are  still  more  precise : 
it  is  a  diffused  scarlet  redness  of  the  skin  occurring  in  patches.  This  is  all 
very  simple,  but  the  description  is  far  from  an  accurate  account  of  what  is 
seen  in  all  cases.  Indeed,  I  have  shown  you  cases  of  measles  in  which  the 
eruption  was  diffuse  and  uniform,  without  intervals  of  unaffected  skin.  Such 
cases  are  certainly  exceptional ;  but  still  there  are  such  cases.  On  the  other 
hand,  we  meet  with  cases  of  scarlatina,  both  distinct  and  confluent,  with 
the  eruption  in  some  places  in  patches,  or  in  numerous  small,  red,  rounded 
points,  perfectly  isolated  from  each  other,  and  devoid  of  that  winy  rasp- 
berry hue  generally  attributed  to  it :  though  differing  in  appearance  from 
measles,  it  may  be  mistaken  for  that  eruption.  The  eruptions  most  com- 
monly mistaken  for  scarlatina  are  those  to  which  I  have  already  called 
your  attention,  as  pretty  frequently  occurring  at  the  beginning  of  attacks 
of  small-pox,  particularly  of  modified  small-pox,  and  to  which  the  epithets 
scarlatiniform  and  morbilliform  have  been  applied. 

Scarlatina  is  distinguished,  at  the  first  appearance  of  the  eruption,  from 
other  eruptive  fevers,  by  the  redness  of  the  skin  being  often  accompanied 
by  the  millet-seed  rash,  which  is  almost  invariably  met  with  when  the  scar- 
latinous rash  is  confluent  in  ever  so  small  a  degree.  The  miliary  erivption 
shows  itself  on  the  sides  of  the  neck,  on  the  chest,  and  on  the  lower  part  of 
the  abdomen :  it  can  be  detected  without  being  seen,  by  passing  the  hand 
over  these  parts,  from  the  little  inequalities  communicating  the  sensation  of 
what  is  called  goose-skin.  When  the  inequalities  are  examined  by  the  eye, 
a  multitude  of  small  vesicles  are  seen,  which,  at  the  end  of  thirty-six  or 
forty-eight  hours,  are  filled  with  a  lactescent  fluid. 

The  scarlatinous  eruption  itself  is  not  really  constituted  by  one  uniform 
blush  as  in  erysipelas,  but  by  an  infinite  series  of  small  red  elevations  of  the 
skin  resembling  the  vesicles  of  a  very  closely  placed  eczema.  The  elevations 
can  be  recognized  by  the  touch,  and  the  correctness  of  their  description  now 
given  can  be  verified  by  using  the  magnifying  glass.  It  will  also  be  seen 
that  the  small  elevations  rest  upon  a  rosy  basement.  The  intensity  of  the 
redness  of  the  skin  is  greatest  on  the  neck,  chest,  abdomen,  and  internal 
aspect  of  the  arms  and  thighs.  When  strong  pressure  with  the  finger  is 
made  on  the  parts  occupied  by  the  eruption,  or  when  a  pencil  is  drawn  over 
the  skin,  as  if  to  mark  a  line,  the  redness  gives  place  momentarily  to  a  white 
line  across  the  red ;  on  the  removal  of  the  pressure  the  redness  rapidly  reap- 
pears. This  fact  did  not  escape  the  notice  of  our  predecessors,  and  you  will 
find  it  clearly  stated  by  Borsieri.  The  eruption  comes  out  everywhere  pretty 
nearly  at  the  same  time,  but  is  generally  visible  on  the  neck  and  chest  before 
it  show's  itself  on  the  face.  The  character  which  it  presents  on  the  face  and 
trunk  is  similar;  it  is  streaky,  with  a  bright  red  in  some  places  along- 
side of  white  streaks:  on  the  face,  which  is  swollen,  the  skin  seems  as  if  it 
bore  the  marks  of  a  smart  slap  with  the  fingers  of  the  open  hand :  there  is 


144  SCARLATINA. 

swelling  of  the  hands  and  feet,  as  well  as  of  the  face.  The  swelling,  which 
shows  itself  with  the  eruption,  also  increases  along  with  it,  and  is  therefore 
most  conspicuous  about  the  second  or  third  day.  The  tumefied  condition 
of  the  hands  is  very  obvious  to  the  sight,  impedes  the  movement  of  the 
fingers,  and  prevents  the  patient  from  closing  the  hand.  The  swelling  keeps 
pace  with  the  eruption,  and  generally  disappears  at  the  same  time  from  the 
face  an?Nextremities.  The  swelling  I  am  now  speaking  of  must  be  very 
carefullv  distinguished  from  scarlatinous  rheumatism,  which  I  shall  have 
forthwith  to  bring  under  your  notice. 

When  we  look  at  the  patient's  throat  we  find  that  it  is  of  a  bright  red 
color,  and  that  the  veil  of  the  palate  and  tonsils  are  swollen ;  the  latter  very 
ofteD  present  small  whitish  concretions,  the  earliest  manifestation  of  the 
membranous  sore  throat  of  scarlatina. 

The  aspect  of  the  tongue,  already  described,  is  so  essentially  specific,  that 
it  is  in  itself  sufficient  to  enable  one  to  recognize  the  existence  of  scarlatina. 
Xothing  like  it  is  ever  met  with  in  measles  or  small-pox.  It  is  as  specific 
in  scarlatina  as  are  pustules  on  the  mucous  membrane  of  the  mouth  in  small- 
pox. On  the  first  day  there  is  only  a  slimy  fur,  more  or  less  thick,  more 
or  less  white,  and  which,  if  the  patient  has  vomited,  has  a  yellow  or  green 
color:  at  the  point  and  edges  there  is  only  a  slight  redness.  On  the  second 
day  the  redness  increases  in  intensity  and  in  extent :  and  this  chauge  con- 
tinues to  proceed  on  the  third  day.  About  the  fourth  or  fifth  day  the 
saburral  coating  has  almost  or  altogether  disappeared :  the  whole  tongue  is 
then  scarlet  and  swollen,  and  the  papilla?  rise  above  the  level  of  its  surface 
in  such  a  way  as  to  give  it  a  strawberry-like  aspect.  This  appearance  is 
produced  by  the  tongue  being  denuded  of  its  epithelium :  we  can  sometimes 
see  this  desquamation  in  progress,  and  can  even  accelerate  it  by  gentle  rub- 
bing with  a  bit  of  linen  cloth.  This  is  a  constant  phenomenon  in  scarlatina, 
except  when  there  is  an  absence  of  fever;  and  nothing  like  it  is  met  with 
in  measles  or  small-pox,  even  when  in  the  latter  there  is  stomatitis.  About 
the  seventh  or  eighth  day  the  tongue,  whilst  it  retains  its  red  color,  becomes 
smoother:  about  the  eighth  or  ninth  day  the  restoration  of  the  epithelium 
commences  very  perceptibly,  being  at  first  exceedingly  thin,  then  of  the 
thickness  of  on  ion-peel ;  and  about  the  twelfth  day  it  has  nearly  regained 
its  normal  thickness,  but  the  mucous  membrane  still  remains  redder  than 
natural. 

In  studying  the  relation  which  the  severity  of  the  disease  bears  to  the 
intensity  of  the  erupt  ion,  it  becomes  obvious  that  some  authors  have  in  respect 
of  this  subject  fallen  into  a  capital  error  liable  to  lead  astray  those  prac- 
titioners who  are  not  familiar  with  scarlatina.  These  authors  say  that  when 
the  eruption  is  full-blown,  bright,  and  well  come  out  (to  use  the  common 
phrasei,  the  patient  is  in  less  danger  of  serious  complications.  The  opposite 
of  this  position  is  the  truth.  In  scarlatina,  as  in  small-pox,  the  more  intense 
the  eruption,  in  the  same  ratio,  the  more  severe  is  the  disease.  In  uon-eon- 
fiuent  scarlatina  the  danger  is  usually  less  than  in  continent,  just  a-  the 
danger  is  Less  in  distinct  than  in  confluenl  small-pox.  In  both  of  these 
(.•xanthomatous  fevers,  in  proportion  to  the  intensity  of  the  eruption  is  the 
severity  of  the  symptoms  ami  the  peril  to  the  patient:  this  proposition  is 
established  by  what  has  been  seen  in  the  course  of  epidemics,  and  you  have 
an  opportunity  of  verifying  it  for  yourselves  by  the  observation  of  patients 
in  the  wards.  The  proposition,  however,  is  not  absolute.  In  scarlatina,  as 
in  small-pox,  if  the  eruption  is  checked  by  some  serious  antagonistic  deter- 
mination, by  profuse  hemorrhage,  by  greal  disturbance  of  the  nervous  sys- 
tem, it  comes  out  badly  and  incompletely. 

Scarlatina, as  I  said  in  beginning  my  lecture, is  not  always  like  itself;  it 


SCARLATINA.  145 

is  identical  in  its  essence,  but  very  dissimilar  in  the  forms  which  ii  assumes. 
In  some  cases,  after  ten  or  twelve  hours  of  lever,  an  insignificanl  eruption 

appears  on  the  neck  and  trunk,  and  in  two  or  three  days  the  slight  febrile 
excitement  by  which  it  was  accompanied  disappears,  the  patient  having 
scarcely  experienced  any  discomfort.  Desquamation  proceeds  by  small 
Stripes  or  patches,  and  sometimes  in  a  manner  hardly  perceptible:  in  five 
or  six  days  more  the  patient  is  restored  to  perfect  health.  If  he  avoid  ex- 
posure to  cold,  and  other  acts  of  imprudence,  the  whole  affair  is  at  an  end. 
The  malady  has  been  of  so  simple  a  character  that  it  might  have  run  its 
course  unnoticed. 

Between  the  very  mild  and  the  very  severe,  the  two  forms  which  I  have 
had  principally  in  my  eye  when  sketching  the  leading  features  of  the  dis- 
ease, all  intermediate  forms  are  met  with ;  and  there  is  besides  that  terrible 
scourge,  malignant  scarlatina,  than  which  no  pestilential  disease  is  more 
formidable. 

Desquamation  in  scarlatina  is  not  very  well  understood  by  the  majority 
of  physicians.  This  morning  I  showed  you  two  women,  in  one  of  whom, 
though  at  the  seventy-second  day,  it  is  still  going  on:  in  the  other,  at  the 
thirty-fifth,  it  is  in  full  activity.  The  red  color  of  the  skin  generally  dis- 
appears with  greater  or  less  rapidity  before  desquamation  commences,  but 
it  begins  sometimes  in  various  parts  of  the  body  while  the  eruption  is  still 
visible.  It  begins  on  the  neck  and  chest  between  the  sixth  and  ninth  days: 
it  then  proceeds  on  the  limbs,  then  on  the  hands  (first  on  the  back  and  then 
on  the  palms),  and  last  of  all  on  the  soles  of  the  feet.  On  the  whole  body 
desquamation  presents  special  characters,  but  they  are  more  distinctly 
marked  on  the  hands  and  feet  than  elsewhere.  On  the  trunk  the  scales  are 
tolerably  large,  often,  it  is  true,  not  being  more  than  two  or  three  millime- 
tres in  breadth,  but  at  other  times  measuring  from  one  to  two  centimetres. 
On  the  arms  and  legs,  where  the  epidermis  is  a  little  thicker,  the  desquama- 
tive plates  have  sometimes  a  size  of  four  or  five  centimetres,  and  they  can 
be  stripped  off  in  broad  bands,  as  is  the  case  after  erysipelas  and  inflamma- 
tion of  the  areolar  tissue.  Scarlatinous  desquamation  never  assumes  the 
furfuraceous  form,  as  in  the  desquamation  which  follows  measles.  In  measles 
the  bran-like  scales  are  so  small  that  unless  you  look  at  them  very  closely 
you  cannot  see  them,  and  it  even  often  happens  that  this  white,  dry  epider- 
mic dust,  resembling  flour  in  appearance,  is  only  observable  upon  brushing 
the  skin  of  the  patient  with  the  sleeve  of  the  coat.  In  scarlatina  the  des- 
quamation of  the  hands  and  feet  has  too  significant  an  appearance  to  be 
mistaken.  The  epidermis  peels  off  in  irregular  flakes,  variable  in  size,  and 
sometimes  very  large,  like  pieces  of  a  glove.  From  the  feet,  where  the  pro- 
cess goes  on  most  slowly,  the  detached  flakes  are  still  thicker  than  those 
which  come  off  the  hands,  and  in  some  cases  the  nails,  which  as  you  know 
are  prolongations  of  the  epidermis,  fall  from  the  toes.  This  is  a  rare  occur- 
rence, but  it  has  been  observed,  and  one  example  of  it  is  recorded  by  Graves. 

In  concluding  my  remarks  on  the  subject  of  desquamation,  let  me  add 
that  Wunderlich  has  observed  a  considerable  elevation  of  temperature  dur- 
ing the  process.  Thisis  not  what  we  should  expect,  and  is  the  reverse  of 
what  we  meet  with  in  small-pox.  To  me  it  seems  to  prove  that  the  fever 
is  far  from  being  ended  when  the  more  palpable  symptoms  of  the  disease 
have  ceased ;  and  as  the  morbific  action  is  not  completely  exhausted,  one 
can  to  a  certain  extent  understand  the  development  of  those  formidable 
complications  which  insidiously  supervene  during  this  period,  and  of  which 
I  shall  have  much  to  say  by  and  by. 

vol.  i. — 10 


146  SCARLATINA. 


Cerebral  and  Nervous   Complications. — Sore   Throat,   Complicated  with 
Diphtheria. — Buboes. — Rheumatism. 

The  most  striking  as  well  as  the  most  alarming  phenomena  in  scarlatina 
are  the  nervous  symptoms  which  are  liable  to  occur.  Their  intensity  is  a 
peculiar  feature  in  this  disease,  and  in  most  cases  they  suffice  to  establish 
the  diagnosis  between  it  and  the  other  exanthematous  fevers.  We  hardly 
ever  meet  with  serious  cerebral  disturbance  in  the  beginning  of  an  attack 
of  measles  or  small-pox,  with  the  exception  of  epileptoid  convulsions,  which 
are  not  very  unusual  at  the  onset  of  both  of  these  diseases,  particularly  in 
children;  but  as  ultimately,  when  the  eruption  appears,  there  is  not  even  a 
possibility  of  any  confusion  except  between  measles  and  scarlatina,  the  in- 
tensity of  the  nervous  symptoms  in  the  latter  constitutes  the  capital  circum- 
stance which  determines  the  differential  diagnosis. 

In  scarlatina,  nervous  symptoms  set  in  from  the  very  first:  during  the 
first  day  there  is  delirium.  I  am  now  speaking  of  what  takes  place  in  the 
severe  forms  of  scarlatina,  for  in  the  mild  forms,  we  only  meet  with  dis- 
turbance of  the  nervous  system  in  exceptional  cases.  In  very  severe  scar- 
latina, delirium  seldom  fails  to  occur,  and  in  the  worst  cases,  it  is  as 
formidable  as  in  typhoid  fever  of  the  most  aggravated  type:  it  declares 
itself  simultaneously  with  the  appearance  of  the  exanthem,  and  often  con- 
tinues up  to  the  period  of  desquamation,  or,  to  speak  more  correctly,  till 
the  subsidence  of  the  fever. 

There  are  other  forms  of  nervous  disturbance  met  with  in  scarlatina, 
besides  those  which  are  indicated  by  the  terms  carphologia,  jactitation,  coma, 
and  coma  vigil.  In  a  word,  we  meet  with  every  form  of  typhic  nervous 
disturbance.  And  in  children,  we  also  meet  with  epileptoid  convulsions 
during  the  first  two  or  three  days  of  the  disease,  but  less  frequently  than  at 
the  beginning  of  attacks  of  measles  and  small-pox,  when,  as  I  have  al- 
ready remarked,  they  are  not  uncommon.  But  convulsions  in  scarlatina 
have  a  much  more  serious  import;  for  whilst  they  are  considered  by  some 
authors  (among  whom  is  Sydenham,  from  whom  in  this  I  dissent  i,  when 
occurring  in  small-pox  as  a  favorable  omen,  and  are  generally  looked  on  as 
having  only  a  moderately  unfavorable  influence  on  the  prognosis  in  the 
onset  of  measles,  they  always  indicate  considerable  danger  when  they  occur 
during  the  first  or  second  day  of  scarlatina.  They  indicate  still  greater 
danger  when  they  occur  in  the  third  stage  of  the  disease,  in  connection 
with  general  oedema.  I  shall  afterwards  have  to  explain  what  they  then 
imply,  and  to  point  out  that  they  are  almost  invariably  followed  by  a  fetal 
issue.  Even  in  adults  there  are  examples  of  epileptiform  phenomena. 
They  occur  about  the  second  or  third  day  of  the  disease,  and  principally  in 
individuals  subjeel    to  true  epileptic  seizures.     These  convulsions  recur, 

they  are  followed  by  coma,  and  death  may  close  the  scene  within  twenty- 
four  hours  from  their  first  manifestation. 

Dyspnoea    is   another   nervous   complication   which  is  important,   ami    of 

Binister  presage.  The  difficulty  of  breathing  of  which  I  speak  is  quite  un- 
connected with  any  appreciable  lesion  of  the  Lungs,  and  in  this  respect,  as 
well  as  in  the  sadness  of  its  meaning,  resembles  the  same  symptom  so  often 

met  with  in  many  Beptic  diseases,  LB  puerperal  typhus,  in  camp  typhus,  and  in 

cholera.  You  saw  a  tcnihle  example  of  this  Kind  of  dyspnoea  in  a  recently 
delivered  woman  who  was  carried  off  by  scarlatina  with  fearful  rapidity, 
and  the  history  of  whose  case  I  shall  recall  to  your  recollection,  when  we 
coiiio  to  consider  the  subjeel  of  treatment. 

Besides  the  nervous  symptoms  dependent  upon  disturbance  of  the  cere- 


SCARLATINA.  147 

braj  mid  spinal  systems,  there  are  others  originating  in  the  ganglionic  >vs- 
tem  which  I  must  now  mention  :  and  among  which  probably  is  the  alarm- 
ing dyspnoea  I  have  just  been  speaking  of.  Every  one  is  acquainted  with 
Claude  Bernard's  remarkable  inquiries  into  the  functions  of  the  great  sym- 
pathetic nerve:  all  know  that  when  this  nerveis  divided,  the  parts. to  which 
its  branches  are  distributed  are  not  paralyzed,  but  on  the  contrary  manifest 
increased  functional  action  in  augmented  calorification  and  secretion.  The 
scientific  professor  of  the  College  of  France  has  shown  that  on  cutting  on 
one  side  the  branches  of  the  sympathetic  which  are  distributed  to  the  ear 
and  face  of  the  rabbit,  the  temperature  of  these  parts  rises  to  four  or  five 
degrees  Centigrade  above  the  normal  temperature,  and  above  that  of  the 
corresponding  parts  of  the  opposite  side  where  no  section  has  been  made. 
He  has  shown  that  by  destroying  the  thoracic  ganglia  and  the  ganglia  of 
the  solar  plexus,  effects  of  increased  vascularity  are  produced  similar  to 
those  seen  in  the  experiments  just  mentioned,  and  causing  violent  inflam- 
mation :  he  has  also  shown  that  the  secretions  are  greatly  influenced  by  the 
ganglionic  system.  Applying  to  pathology  the  results  of  the  physiological 
experiments,  we  come  to  the  conclusion  that  when  there  is  abnormal  in- 
crease of  temperature  in  an  animal,  there  is  more  disturbance  of  the  sym- 
pathetic than  of  the  cerebro-spinal  system.  Xow,  there  certainly  is  no  dis- 
ease attended  by  so  great  a  general  elevation  of  temperature  as  scarlatina. 
When  the  Centigrade  thermometer  is  placed  in  the  axilla,  or  is  introduced 
into  the  rectum  of  scarlatinous  patients,  it  marks  forty  or  forty-one  degrees. 
Dr.  Currie  has  even  noted  112°  Fahrenheit,  which  is  equivalent  to  forty- 
four  and  a  half  degrees  Centigrade.  This  increase  of  temperature  can  only 
be  explained  by  a  great  disturbance  and  a  very  impaired  power  in  the  gan- 
glionic system,  a  condition  at  the  same  time  indicated  by  disorder  in  func- 
tions under  the  influence  of  the  great  sympathetic,  as  manifested  in  inces- 
sant bilious  vomiting  in  the  beginning  of  the  disease,  lasting  sometimes  for 
four,  five  or  six  days,  and  in  intractable  profuse*  diarrhoea  which  I  have 
often  seen. 

It  is  essential  to  bear  in  mind  that  these  morbid  symptoms  are  not 
of  an  inflammatory  character.  If,  under  the  influence  of  the  notion  that 
the  dry  burning  skin  is  a  proof  of  the  presence  of  inflammation,  we  treat 
the  vomiting  and  diarrhoea  by  antiphlogistic^,  we  pursue  the  most  pitiable 
and  perilous  course  we  could  adopt.  Of  all  the  eruptive  fevers,  scarlatina 
is  that  which  least  demands  the  employment  of  antiphlogistics,  a  mode  of 
treatment,  which  is  also  rarely  beneficial  in  small-pox  or  measles. 

There  remains  another  complication  to  be  noticed,  viz.,  hemorrhage  from 
the  mucous  surfaces,  and  into  the  subcutaneous  cellular  tissue.  When 
there  is  from  the  beginning  of  the  attack  a  hemorrhagic  tendency,  death 
is  invariably  the  issue ;  while  hematuria  when  observed,  as  it  frequently  is, 
in  the  course  of  the  disease,  and  in  conjunction  with  anasarca,  is  a  much 
less  evil  omen.  You  have  seen  several  patients  restored  to  perfect  health 
after  having  passed  bloody  urine  for  more  than  a  fortnight.  We  shall  after- 
wards return  to  this  subject. 

The  sore  throat  of  scarlatina  is  the  next  topic  which  presents  itself. 
It  is  very  difficult  to  understand  well  and  describe  well  this  affection.  It 
seems,  in  general,  sufficiently  easy  to  point  out  its  simple  and  its  serious 
forms;  but  in  respect  of  the  latter  there  is  one  form,  which  in  its  turn  we 
shall  have  to  study,  in  which  this  facility  does  not  exist — a  form  in  which 
diphtheria  probably  intervenes  as  a  complication,  to  contradict  the  antici- 
pations of  physicians,  and  to  impart  to  the  sore  throat  a  character  of  the 
most  alarming  severity.  I  have  already  established  that  the  sore  throat 
is  an  essential  part  of  scarlatina.     It  is  very  rarely  absent,  even  in  the 


148  SCARLATINA. 

mildest  cases,  just  as  it  is  very  unusual  for  measles,  however  mild,  to  be 
unattended  by  pain  in  the  larynx.  Sore  throat  is  also  met  with  in  small- 
pox, for  three  or  four  pustules  on  the  pharynx  are  quite  enough  to  produce 
it ;  but  there  is  a  very  marked  difference  between  variolous  and  scarlatin- 
ous sore  throat. 

In  scarlatina,  from  the  first  day  of  the  attack,  as  I  have  already  said, 
the  veil  of  the  palate  has  a  red  hue,  analogous  to,  but  deeper  than,  that  of 
the  skin :  the  tonsils  are  swollen,  and  of  a  purple  color.  The  fever  con- 
tinues its  course,  and  after  from  two  to  four  days,  there  often  appear  on 
one  and  sometimes  on  both  tonsils  small  whitish  concretions,  generally  of 
a  milky  whiteness,  unless  the  patient  has  vomited,  when  they  may  be 
stained  by  the  ejecta  from  the  stomach.  In  minutely  examining  them, 
and  raising  them  up  with  the  handle  of  a  spoon,  we  find  that  they  differ 
from  diphtheritic  false  membranes.  The  latter  are  generally  yellowish- 
white,  adherent  to  the  tonsils,  and  when  seized  with  the  forceps  generally 
peel  off  in  strips:  the  concretions  are  pultaceous,  less  adherent  to  the  tonsil 
which  they  cover,  devoid  of  the  character  of  false  membrane,  and  much 
more  resemble  the  secretions  which  form  on  the  surface  of  ill-conditioned 
ulcers.  In  point  of  fact,  they  are  nothing  more  than  a  compound  of  epi- 
dermis and  sebaceous  matter  produced  by  the  tonsil,  and  not  at  all  a 
pseudo-membranous  secretion.  Dr.  Peter,  indeed,  has  shown  that  the 
characteristic  feature  of  pultaceous  sore  throat  is  an  exaggerated  produc- 
tion of  epithelium,  which  by  desquamating  rapidly  gives  rise  to  the  fibrin- 
ous-looking  deposits.  It  is  an  affection,  therefore,  which  has  no  relation 
to  diphtheria.* 

As  the  progress  of  the  affection  advances,  its  intensity  may  become  so 
formidable  as  to  embarrass  both  respiration  and  deglutition,  but  especially 
the  latter.  The  drinks  which  the  patient  takes  are  returned  by  the  nose, 
and  the  voice  becomes  nasal.  The  cervical  glands,  particularly  those  at 
the  angle  of  the  jaw,  are  swollen.  Without  any  medical  intervention,  or 
under  very  slight  treatment,  this  kind  of  sore  throat  begins  to  abate  in 
severity  as  the  disappearance  of  the  cutaneous  scarlet  eruption  commences. 
The  tonsils  throw  off  the  coucretions,  which  leave  behind  them  a  red  and 
sometimes  excoriated  surface;  and  the  affection  is  cured.  The  throat  and 
tongue,  however,  remain  susceptible,  and  this  increased  sensibility  is  more 
persistent  in  the  former  than  in  the  latter.  This  condition  ultimately 
ceases  after  a  sort  of  desquamation  analogous  to  that  which  wo  sec  take 
place  on  the  tongue.  Such  is  the  common,  and  simplest,  form  of  the  sore 
throat  of  scarlatina. 

I  have  already  told  you  that  there  are  other  more  serious  forms;  and  one 
of  them,  to  which  I  have  already  referred,  is  according  to  my  experience 
almost  invariably  fatal.  To  that  form  of  sore  throat  I  must  in  a  very 
special  manner  direct  your  attention.  Some  individuals  have  scarlatina 
in  a  medium  degree  of  severity :  there  is  a  little  delirium  ai  night,  and 
scarcely  any  other  nervous  symptoms:  (lie  pulse  is  rapid;  the  pain  in  the 
throat  is  moderate.  On  the  eighth  or  ninth  day  of  the  attack,  recovery 
seems  a  certainty :  the  fever  lias  subsided,  the  eruption  lias  disappeared, 
and  the  family  has  ceased  to  he  anxious.  In  this  propitious  slate  of  the 
case,  swelling  suddenly  appears  at  the  angles  of  the  jaws,  which  no1  only 
takes  possession  of  thai  situation,  hut  extends  to  the  neck  and  sometimes 
fcq  part  of  the  face  :  a  sanious  fetid  fluid  Hows  profusely  from  the  nasal 
fossae:  the  tonsils  become  very  large:  the  breath  exhales  an  intolerable 


*  Petes  (Michel) :   Article  "  Anoin  es"  in  the  Dictionnaire  Encyclopfidiquc  dea 
Sciences  M6dicales,  T.  Lv,  p.  707. 


SCARLATINA.  149 

smell:  the  pulse  becomes  small  and  suddenly  regains  its  rapidity:  the 
delirium  reappears,  and  other  nervous  symptoms  occur.  Then,  the  delirium 
continuing,  coma  supervenes:  at  the  same  time,  the  skin  becomes  cold,  the 
pulse  acquires  a  more  and  more  miserable  character,  and  after  three  orfour 

days  of  this  state,  the  patient  dies,  sometimes  sinking  slowly,  and  at  other 
times  being  carried  off  suddenly  as  if  in  a  faint. 

How  are  we  to  explain  what  has  taken  place?  Has  diphtheria  super- 
vened to  complicate  the  scarlatina,  aud  divert  it  from  its  proper  course? 
The  symptoms  bear  so  strong  a  resemblance  to  the  terrible  forms  of  that 
frightful  disease  which  carry  off  both  adults  and  children  before  the  affec- 
tion has  extended  to  the  larynx,  the  false  membranes  still  remaining  local- 
ized in  the  nasal  fossae,  ears,  and  throat — the  symptoms  so  much  resemble 
the  rapidly  fatal  forms  of  diphtheria,  that  one  is  induced  to  believe  that 
the  case  is  no  longer  one  of  scarlatina,  but  that  the  other  dreadful  scourge 
has  come  to  destroy  the  patient.  I  am  the  more  disposed  to  adopt  this 
view,  as  under  certain  circumstances  the  laryux  is  invaded.  Graves  cites 
cases  of  persons  dying  of  croup  at  the  end  of  an  attack  of  scarlatina,  and 
also  of  persons  recovering  from  the  exanthematous  fever  after  having  dis- 
charged false  membranes  of  tubular  shape,  moulded  in  the  trachea.  In 
mentioning  theses  cases,  Graves  calls  me  to  account  for  having  mistaken 
this  form  of  scarlatinous  sore  throat;  and  in  proof  of  my  having  committed 
a  mistake,  he  quotes  my  expression — "Scarlatina  does  not  like  the  larynx." 
During  my  period  of  service  at  the  Children's  Hospital,  I  so  often  found 
such  an  extraordinary  identity  between  the  sore  thoat  of  malignant  scarla- 
tina and  the  sore  throat  of  malignant  diphtheria,  that  I  became  shaken  in 
my  opinion.  At  present,  I  cannot  prevent  myself  from  believing,  though 
I  dare  not  affirm  it  as  a  fact,  that  the  symptoms  now  under  consideration 
depend  upon  a  complication  with  a  formidable  form  of  diphtheria  occur- 
ring at  the  close  of  the  attack  of  scarlatina.  The  patients  certainly 
sink  with  all  the  symptoms  of  diphtheritic  poisoning,  such  as  a  lowering 
of  the  general  temperature,  a  small  pulse,  a  fetor  of  the  breath  exhaling 
from  mouth  and  nose,  and  a  general  paleness  of  the  skin,  a  combina- 
tion of  symptoms  not  met  with  in  any  other  serious  disease.  We  can  sup- 
pose, then,  that  in  persons  placed  under  certain  conditions,  as  for  example 
in  a  centre  of  epidemic  diphtheritic  influence,  such  as  is,  one  may  say, 
always  dominant  in  hospitals  for  children,  the  scarlatinous  sore  throat  may 
become  the  starting-point  of  a  diphtheritic  attack,  exactly  in  the  same  way 
that  a  small  excoi'iation  behind  the  ear,  an  ulceration  of  the  vulva,  or  any 
other  solution  of  continuity  existing  in  persons  in  the  midst  of  erysipela- 
tous epidemic  influences,  may  become  the  starting-point  of  erysipelatous 
manifestations.  A  circumstance  which  tends  to  support  me  in  looking  at 
the  facts  from  this  point  of  view  is  this — that  I  can  only  recollect  one  case 
of  recovery  from  sore  throat  supervening  suddenly  at  the  ninth  or  tenth 
day  of  an  attack  of  scarlet  fever.  The  patient  who  made  this  recovery 
was  the  daughter  of  my  honorable  friend  Dr.  Caffe.  Now,  in  true  scar- 
latinous sore  throat,  even  of  a  serious  character,  beginning  with  the  exan- 
thematous fever,  and  reaching  its  maximum  intensity  on  or  between  the 
fifth  and  eighth  days  of  the  disease,  recovery  is  the  rule,  and  generally 
takes  place  without  the  assistance  of  art. 

When  we  come  to  consider  the  treatment  of  scarlatina,  I  will  speak  of 
the  treatment  of  scarlatinous  sore  throat :  in  the  meantime,  I  will  only 
remark  that  membranous  scarlatinous  sore  throat  runs  a  very  different 
course  from  diphtheritic  sore  throat.  Observe,  I  am  not  now  alluding  to 
the  malignant  scarlatinous  sore  thi'oat,  to  which  I  directed  your  attention, 
but  to  the  simple  form  of  the  affection,  which,  as  I  have  already  said,  is 


150  SCARLATINA. 

almost  always  accompanied  by  pultaceous  concretions.  The  diphtheritic 
affection  has  a  tendency  to  spread  to  the  nose  and  larynx,  but  the  scarlati- 
nous sore  throat  generally  remains  confined  to  the  pharynx,  and  notwith- 
standing Dr.  Graves's  condemnation  of  the  proposition,  I  still  maintain, 
that  scarlatina  has  no  liking  for  the  larynx.  True  scarlatinous  sore  throat, 
then,  is  pharyngeal,  differing  in  this  respect  from  the  sore  throat  of  mea- 
sles, which  is  laryngeal,  and  from  that  of  small-pox,  which  is  both  pharyn- 
geal and  laryngeal.  The  voice  of  scarlatinous  patients,  when  affected,  is 
snuffling,  but  its  tone  is  sonorous  :  the  voice  does  not  undergo  the  modifi- 
cations to  which  it  is  subjected  in  the  other  form  of  sore  throat,  when  trav- 
ersing the  throat,  nose,  and  mouth.  In  measles,  it  often  happens,  that  the 
tone  of  the  voice,  very  much  altered  during  its  formation  in  the  larynx, 
undergoes  no  farther  change  in  traversing  the  back  part  of  the  throat. 

In  describing  the  eruption,  I  noted  that  the  swelling  by  which  it  is  ac- 
companied impedes  the  movements  of  the  fingers  and  toes;  but  a  congested 
state  of  the  integuments  is  not  the  sole  cause  of  the  complaints  which  the 
patients  make  of  this  description  of  embarrassment :  it  may  also  be  depend- 
ent upon  rheumatism,  another  complication  of  the  acute  stage  of  scarlet  fever. 
Scarlatinous  rheumatism  is,  at  least  in  adults,  a  very  common  epiphenom- 
enon,  and  we  have  at  present  two  patients  suffering  from  it.  The  nature 
of  the  affection  is  often  mistaken  from  the. absence  of  the  general  symptoms 
of  ordinary  rheumatism,  and  from  the  rheumatic  manifestation  being  con- 
fined, in  the  majority  of  cases,  to  three  or  four  joints,  particularly  to  those 
of  the  hand  and  wrist.  The  patients  complain  of  very  little  else,  and  unless 
attention  is  directed  to  this  particular  condition,  its  existence  may  remain 
unnoticed.  By  minute  interrogation,  by  carefully  examining  and  applying 
a  certain  degree  of  pressure  to  the  joints,  articular  pains  are  found  t<>  be 
present  in  perhaps  a  third  of  the  cases.  It  is  important  to  know  this ;  for 
acute  affections  of  the  joints,  general  arthritis,  pericarditis,  and  endocarditis 
frequently  occur  during  the  course  of  the  disease.  Graves  has  called  atten- 
tion to  these  complications.  I  have  observed  them.  They  seem  to  be  of 
the  nature  of  rheumatism.  St.  Vitus's  dance  is  sometimes,  in  children,  a 
consequence  of  scarlatinous  rheumatism.      I  shall  return  to  that  subject. 

Engorgements  of  the  glands,  true  scarlatinous  buboes,  occur  sometimes 
towards  the  close  of  an  attack  of  scarlatina,  about  the  decline  of  the  erup- 
tion. They  are  met  with  in  different  situations,  but  chiefly  in  the  neck. 
All  pestilential  diseases  are  accompanied  by  buboes.  For  example,  dothi- 
enteritia  lias  its  mesenteric  buboes:  for  as  you  are  aware,  about  the  ninth 
or  tenth  day  of  that  disease,  the  mesenteric  glands  may  become  SO  enor- 
mously large  as  to  equal  in  size  the  egg  of  a  pigeon.  Scarlatina,  which  is 
likewise  a  pestilential  disease,  has  also  its  buboes.  The  cervical  region  is 
their  principal  seat,  and  their  evolution  is  contingent  upon  the  lesions  of 
the  throat.  From  the  very  beginning  of  the  disease,  swelling  of  the  glands 
is  observable  in  both  sides  of  the  neck  and  al  the  angles  of  the  jaw.  Some- 
times the  cervical  glands  suddenly  become  the  seat  of  inflammation,  about 
the  tenth  or  twelfth  day,  independent  of  the  effects  of  the  severe  form  of 
sore  throal  of  which  I  have  spoken.  The  skin  becomes  red  and  tense,  and 
in  four,  five,  or  six  days,  there  is  formed  an  abscess  of  greater  or  less  size, 
from  which,  if  opened,  pus  issues.  The  cellular  tissue  surrounding  the 
glands  is  in  some  cases  sphacelated.  I  recollect  a  1ml  of  fourteen  years  of 
age,  in  whom  the  gangrenous  condition  was  so  extensive  that  the  muscles 
of  the  neck  were  dissected,  a-  occurs  in  diffuse  phlegmonous  inflammations, 
showing  the  carotids  pulsating  at  the  bottom  of  a  horrible  wound.  The 
patient    recovered,  hut  a    hideous  deformity   remained  as  a  consequence 


SCARLATINA.  151 

of  the  gangrenous  destruction  of  tissue.  A  similar  case  is  described  by 
( waves. 

Analogous  lesions  may  occur  in  parts  of  the  body  where  there  an-  no 
glands  or  at  least  where  they  do  not  seem  to  have  been  the  starting-point 
of  the  mischief.  In  the  lad  whose  case  I  have  just  detailed,  besides  the 
great  abscess  in  the  neck,  a  diffuse  phlegmon  appeared  in  the  leg,  on  the 
tenth  day  of  the  attack  of  scarlatina  :  it  caused  considerable  shortening  of 
the  tendon,  and  left  such  an  amount  of  permanent  lameness  as  was  sufficient 
to  exempt  him  from  military  service,  when  he  was  drawn  iu  the  conscrip- 
tion six  or  seven  years  afterwards. 

Scarlatina  may  cause,  not  only  glandular  engorgements,  acute  buboes, 
and  diffuse  phlegmonous  inflammation  of  the  cellular  tissue  during  the 
active  period  of  the  disease,  but  likewise  chronic  engorgement  of  the  gland.-. 
In  children  untainted  with  scrofula,  we  meet  with  chronic  glandular  en- 
gorgements dating  from  the  beginning  of  the  attack  of  scarlatina,  and  con- 
tinuing two,  three,  or  four  months  after  recovery.  In  persons  of  strumous 
diathesis  these  engorgements  become  king's  evil  \ecrouelles~],  and  in  them 
the  inflammation  of  the  glands  often  terminates  in  scrofulous  ulceration. 


Complications  occurring  during  the  Decline  of  the  Disease. — Anasarca. — 
Hcematuria. — A Ibum  in  u ria. —  Con  vulsions. —  (Edema  of  the  Glottis. — 
Pleurisy. — Pericarditis. —  Endocarditis. — Rheumatism. — Scarlatina  with- 
out Eruption. — Anasarca  without  Eruption. — Treatment. 

AVe  have  still  to  study,  on  the  one  hand,  the  complications  which  super- 
vene during  the  period  of  the  decline  of  scarlet  fever ;  and  on  the  other,  to 
consider  the  disease  in  its  rudimentary  forms,  by  which  term  I  am  far  from 
meaning  its  simple  forms,  but  the  forms  which  it  assumes  when  its  usual 
characteristics  are  absent,  when  it  is,  as  in  many  cases,  so  disfigured  that  we 
cannot  recognize  it  except  by  the  exercise  of  an  exceedingly  minute  atten- 
tion. This  is  undoubtedly  the  most  important  part  of  the  history  of  scar- 
latina— less  important,  however,  from  a  nosological  than  from  a  practical 
point  of  view. 

The  complications  of  the  period  of  decline  may  be  divided  into  two 
groups;  first,  the  immediate ;  and  second,  the  mediate,  or  those  which  occur 
much  later  than  the  immediate. 

In  the  decline  of  the  disease,  we  may  still  meet  with  nervous  complica- 
tions. An  individual  recovers  from  scarlatina:  he  is  convalescent,  and  you 
have  ceased  to  be  anxious  about  him,  when  fits  of  vomiting  suddenly  occur, 
like  those  which  ushered  in  the  original  seizure :  the  vomiting  is  accompa- 
nied by  delirium,  alarming  restlessness,  and  great  frecpiency  of  pulse,  the 
patient  ere  long  dying  comatose  or  in  convulsions.  Nevertheless,  there  is 
an  absence  of  anasarca,  albuminuria,  hematuria,  and  of  everything  which 
could  lead  one  to  anticipate  the  symptoms  just  enumerated.  Complications 
of  this  kind  are  met  with  in  adults  as  well  as  in  children.  Occurring 
during  the  wane  of  the  disease,  they  have  a  much  more  unfavorable  mean- 
ing than  when  they  appear  in  the  first  stage,  though  they  are  then  of  very 
serious  import.  I  cannot,  therefore,  too  often  repeat,  that  we  ought  not  to 
look  upon  patients  as  recovered  from  scarlatina  till  long  after  the  cessation 
of  the  last  of  the  morbid  phenomena.  There  is  no  other  disease  which  so 
greatly  foils  the  physician,  and  so  completely  throws  him  out  in  his  calcu- 
lations. The  fever  is  at  an  end,  and  there  is  nothing  wrong  to  be  seen  ex- 
cept some  symptoms  which  in  appearance  are  very  slight.  You  state  that 
recovery  has  taken  place ;  but  nevertheless  the  malady  may  remain  uncon- 


152  SCARLATINA. 

quered,  and  may  carry  off  the  patient  with  great  rapidity  at  a  time  when 
there  no  longer  seemed  anything  to  fear. 

Anasarca  is  one  of  the  immediate  phenomena  of  the  wane  of  the  di- 
which  ought  most  particularly  to  engage  our  attention.  It  is  met  with  in 
cases  of  medium  severity,  rather  than  in  those  of  the  most  serious  forms  of 
scarlatina.  It  not  only  occurs  in  convalescent  patients  who  have  been  ex- 
posed to  cold,  who  have  committed  some  imprudence,  such  as  an  error  in 
diet,  but  even  in  those  who  have  been  constantly  surrounded  with  even- 
possible  care,  and  watched  with  unremitting  solicitude.  MM.  Barthez  and 
Rilliet  have  noted  that  this  symptom  was  present  in  one-fifth  of  their  cases. 
It  never  appears  till  fifteen  or  twenty  days  after  the  eruption,  and  I  have 
seen  it  supervene  a  month  after  the  eruption  was  entirely  gone.  Anasarca 
generally  sets  in  suddenly.  It  invades  the  face,  and  every  part  of  the 
body.  It  sometimes  happens  that  a  child  whom,  at  our  evening  visit,  we 
left  lean  and  wretched-looking,  appears  quite  plump  on  the  morrow,  in  con- 
sequence of  turgescence  caused  by  infiltration  of  the  subcutaneous  cellular 
tissue.  This  turgescence  sometimes  attains  its  maximum  in  twenty-four 
hours:  it  is  generally  universal,  and  much  greater  in  degree  than  when  the 
anasarca  is  dependent  on  organic  affections  of  the  heart,  or  on  Bright's  dis- 
ease. But  there  are  cases  in  which  it  shows  very  little,  and  is  limited  to 
the  face  and  extremities.  The  anasarca  is  associated  with  a  remarkable 
paleness  of  the  skin,  and  is  almost  always  preceded  or  accompanied  by 
hsematuria. 

Hematuria  is  in  point  of  fact  a  rather  common  occurrence  in  scarlatina, 
although  it  frecpuently  escapes  observation.  If  the  blood  pas.-ed  is  pure,  or 
only  slightly  altered  by  admixture  with  the  acids  of  the  urine,  which  lias 
then  a  black  color,  the  sanguineous  character  of  the  urine  is  recognized  and 
pointed  out  by  the  persons  in  attendance  on  the  patient ;  but  it  i?  not  ob- 
served when,  from  the  quantity  of  blood  being  less,  the  urine  is  rose-colored. 
The  tint  of  bloody  urine  may  be  as  greenish  as  whey,  which  has  a  tint  essen- 
tially different  from  urine  in  Bright's  disease,  as  well  as  from  every  other 
description  of  urine.  During  the  first  few  days,  the  hsematuria  may  be  so 
great  as  to  enable  one  to  see  blood  at  the  bottom  of  the  urinal,  and  on  pour- 
ing the  urine  into  a  test-tube,  there  will  be  perceived  a  precipitate  of  blood- 
globules  occupying  one  or  two  centimetres.  The  liquid  resembles  a  strong 
solution  of  rhatany.  As  the  affection  progresses,  the  urine  assumes  the 
color  indicated  by  this  comparison,  but  the  presence  of  blood  can  .-till  be 

ascertained  by  finding  altered  hi l-globules  adhering  to  the  sides  of  the 

test-tube,  as  well  a>  by  an  enormous  quantity  of  albumen  being  contained 
in  the  urine.  When  the  urine  is  heated,  and  treated  with  nitric  acid,  we 
do  not  obtain  a  white  albumen  as  in  Bright's  disease,  but  an  albumen  which 
i-  either  of  a  brownish  hue,  or  slightly  stained  in  color  like  that  which  we 
meet  with  in  acute  albuminuria. 

Albuminuria — this  acute  albuminuria,  generally  transient,  and  in  the 
majority  of  cases  disappearing  at  the  end  of  a  fortnighl  or  three  v 
sometimes  even  more  rapidly,  may  pass  into  a  chronic  state,  and  become 
real  Bright's  disease.  The  acute  symptoms  have  disappeared,  ami  the  econ- 
omy seems  to  have  returned  to  it-  normal  state:  but  notwithstanding,  on 
examining  the  urine  from  time  to  time,  we  find  that  it  always  contain-  albu- 
men. When  it  i.-  persistent  in  the  mine  for  a  month  or  -i\  weeks,  the 
symptom  i-  very  unfavorable.  It  -how-  that  the  kidney  has  begun  to  be 
infiltrated  with  fibro-plastic  deposit,  and  that,  sooner  or  later,  the  patient 
will  -ink  under  the  progress  of  the  new  complication. 

Anasarca,  like  the  transient  albuminuria  which  it  accompanies,  and  to 
which  it  i-  related,  is  generally,  but  particularly  by  children,  quick!; 


SCARLATINA.  153 

rid  of  with  the  aid  of  simple  hygienical  measures.  But  it  sometimes  hap- 
pens that  in  spite  of  every  care,  this  complication,  particularly  when  it  has 
come  on  very  rapidly,  carries  off  patients  by  producing  effects  variable  in 
their  nature,  and  which  it  behooves  us  to  understand. 

When  anasarcous  scarlatinous  patients  complain  of  sudden  and  violent 
headache,  accompanied  by  disordered  vision,  convulsions  are  to  be  dreaded. 
It  is  necessary  that  you  hear  in  mind  this  fact,  both  that  you  may  inform 
the  families  of  your  patients  of  what  may  happen,  and  that  you  may  use 
means  to  prevent  the  convulsions,  which  is  sometimes  possible.  The  meas- 
ures occasionally  employed  with  success  consist  in  keeping  the  head  in  an 
elevated  position,  placing  the  patient  so  that  his  legs  hang  over  the  bed, 
and  purging  him  somewhat  briskly.  But  in  the  majority  of  cases,  do  what 
you  will,  the  convulsions  supervene,  and  often  prove  at  once  fatal.  In 
other  cases,  they  recur  at  intervals  of  an  hour  and  a  half,  of  an  hour,  of 
half  an  hour,  and  then  they  become  almost  continuous,  one  fit  beginning 
before  the  previous  one  is  quite  terminated,  till  at  last  the  patient  dies  in  a 
state  of  coma. 

It  sometimes  happens  that  the  anasarca  gets  possession  of  deepseated 
parts.  I  have  seen  it  seize  the  veil  of  the  palate,  the  uvula,  the  epiglottis, 
and  the  aryteno-epiglotticlean  ligaments.  In  the  child  in  whom  we  wit- 
nessed these  lesions,  symptoms  of  oedema  of  the  glottis  immediately  set  in  ; 
and  it  was  only  by  an  energetic  cauterization  of  the  upper  part  of  the  larynx 
that  life  was  saved.  My  colleague,  Professor  Richet,  mentioned  to  me  his 
having  been  called  to  a  child  affected  with  this  description  of  consecutive 
cedema  of  the  glottis,  in  whom  he  was  obliged  to  have  recourse  to  tracheot- 
omy to  prevent  impending  death.  For  persons  to  be  carried  off  in  scarlati- 
nous anasarca  by  this  affection  of  the  respiratory  passage  is  not  uncommon: 
suffocation  takes  place  all  the  more  readily,  that  the  throat  having  been 
previously  in  an  inflamed  condition,  an  extension  takes  place  of  the  inflam- 
mation to  the  aryteno-epiglottidean  ligaments,  where  it  becomes  the  head- 
quarters of  an  oedematous  turgescence ;  and  also  the  more  readily,  that 
tumefaction  of  the  pharynx  complicates  the  swelling  of  the  upper  orifice  of 
the  larynx. 

I  have  now  to  speak  of  some  other  affections  which  occur  in  the  wane  of 
scarlatina,  which,  though  they  begin  to  be  better  known  than  formerly,  are 
still  much  less  familiar  to  practitioners  than  the  complications  I  have 
already  described.  I  allude  to  malignant  pleurisy,  pericarditis,  and  rheuma- 
tism. The  latter  I  have  already  referred  to.  In  treating  of  eruptive  fevers, 
it  is  usual  to  say  that  there  is  a  peculiar  tendency  to  thoracic  affections  in 
measles:  the  statement  is  correct,  for  measles  attack  the  bronchial  tubes  first, 
and  in  preference  to  all  other  parts:  it  there  declares  its  presence  before  any- 
thing can  be  seen  on  the  skin,  just  as  scarlatina  makes  its  existence  known 
by  the  sore  throat  prior  to  the  appearance  of  the  cutaneous  eruption.  The 
first  symptom  of  niorbillous  fever  is  pulmonary  catarrh,  and  hence  it 
is  easy  to  understand  how  this  affection,  when  more  than  ordinarily  severe, 
should  pretty  frequently  give  rise  to  inflammation  of  the  lungs.  Thus  it 
happens  that  when  the  fever  continues  on  the  seventh  or  eighth  day  of  an 
attack  of  measles,  it  is  almost  a  certainty  that  the  patient  has  either  acute 
catarrh,  pneumonia,  or  perhaps  pleurisy.  But  authors  are  unanimous  in 
stating  that  scarlatina  has  no  tendency  to  attack  the  thoracic  organs.  In 
truth,  these  organs  are  not  assailed  during  the  acute  period  of  the  disease ; 
but  they  enjoy  no  such  immunity  when  it  is  on  the  wane.  It  is  not  un- 
common after  scarlatina,  both  in  those  who  are,  and  in  those  who  are  not 
affected  with  anasarca,  to  meet  with  the  sudden  occurrence  of  chest  symp- 


154  SCARLATINA. 

toms;  but  it  is  not,  as  in  measles,  the  lungs  which  suffer,  hut  the  serous 
membranes — the  pleune  and  the  pericardium. 

Pleurisy  occurring  as  a  complication  of  scarlatina  is  generally  of  a  bad 
kind,  not  only  in  respect  of  the  rapidity  with  which  effusion  takes  place, 
but  also  in  respect  of  the  quality  of  the  effused  fluid.  About  the  eighth  or 
tenth  day  of  the  pleurisy,  the  effusion  is  often  of  a  purulent  character,  as  in 
puerperal  pleurisy.  This  production  of  pus  depends  upon  the  fact,  which 
we  cannot  explain,  that  there  exists  a  condition  of  general  contamination, 
in  virtue  of  which  scarlatinous  inflammations  have  an  extreme  tendency  to 
suppuration.  At  the  Children's  Hospital,  I  had  occasion  to  perform  para- 
centesis of  the  chest  in  a  scarlatinous  child  who,  so  early  as  the  twelfth  day, 
had  pus  in  the  pleura.  In  another  little  patient,  I  performed  the  same 
operation  at  the  twelfth  day  of  the  pleurisy,  and  withdrew  seven  hundred 
and  fifty  grammes  of  perfectly  formed  pus.*  This  child  had  become  ana- 
sarcous  without  having  had  the  eruption,  but  there  could  be  no  doubt  as  to 
the  nature  of  the  disease,  as  scarlatina  was  prevailing  in  the  household.  I 
shall  have  to  say  more  regarding  this  case  immediately. 

In  scarlatinous  pericarditis,  the  tendency  to  suppuration  is  not  so  strong 
as  in  scarlatinous  pleurisy.  Scarlatinous  pericarditis  is  also  less  frequent, 
and  comes  on  more  gradually.  The  relation  which  exists  between  inflamma- 
tion of  the  pericardium  and  scarlatina  was  pointed  out  by  Graves,  and  has 
been  established  in  a  very  remarkable  manner,  especially  by  Dr.  Thore,  jun. 
He  has  shown  that  in  a  certain  number  of  patients  convalescent  from  scarla- 
tina, some  died  from  acute  hydro- pericarditis,  and  others  recovered  after 
having  had  the  same  affection.'" 

Articular  rheumatism,  as  I  have  already  said,  is  an  exceedingly  common 
complication  of  scarlatina.  "We  have  seen  it  in  the  acute  stage  of  the  dis- 
ease, and  have  met  with  it  in  adults  in  a  proportion  of  cases  greater  than 
that  in  which  it  is  generally  believed  to  occur.  We  have  also  encountered 
it  during  the  wane  of  the  disease.  The  same  occurrence  was  pointed  out 
by  Grave-.;::  "In  a  great  number  of  cases,"  he  writes,  "I  have  met  with 
articular  rheumatism  as  a  sequel  of  scarlatina."  Similar  statements  have 
been  made  by  other  reliable  observers,  among  whom  may  be  mentioned 
Drs.  Pidoux,  Murray,  and  Yalleix.  The  coincidence  of  rheumatism  with 
scarlatina  was  nevertheless  a  generally  forgotten  fact,  and  consequently  f<»r 
several  years  past  I  have  been  constantly  insisting  upon  it  in  my  lectures. 
It  is  a  singular  eccentricity  of  scarlatinous  rheumatism  that  it  rarely 
assumes  a  formidable  character:  it  is  more  localized,  but  less  liable  to 
return  than  ordinary  rheumatism;  when  it  has  once  left  a  joint,  it  seldom 
comes  back  to  it :  generally,  it  goes  away  quickly  and  spontaneously,  with- 
out requiring  any  treatment.  The  manifestation  of  the  rheumatic  diathesis 
in  scarlatina  gives,  however,  up  to  a  certain  point,  an  explanation  of  the 
development  of  pleurisy  and  pericarditis:  it  assists  us  in  understanding  why 
these  affections  are  a~  frequent  as  they  are.  and  why  it  happens  that  endo- 
carditis occurs  as  you  yourselves  have  seen  and  as  authors  have  stated. 
Generally  speaking,  in  the  first  instance,  scarlatinous  rheumatism  attacks 
the  joints,  and  then  the  serous  membranes  of  the  heart  and  the  pleurae,  but 
times,  like  pure  rheumatism,  it  seizes  the  thoracic  organs  al  the  first 


*  p(  formed   pus   weighing  750   French    grammes,   may    1 timated  n- 

rather  less  than  1}  British  imperial  pints.— Further  particulars  of  this 
case  will  be  found  al  p.  157  — Tb  \n-i  ltob 
f  Thork,  flls:   De  I'Hydropericardite  Ai^ue*  Consecutive  b  la  Scarlatina 
fraitement.    .!/•  G  v.  1866, 6me  serie,  T.  xii,  p.  174. 

Gbavks:    Lecpns  do  Clinique  Bledicale. 


SCARLATINA.  155 

brunt,  without  touching  the  articulations.  Sometimes  also,  it  takes  the 
terrible  and  pitilessly  fatal  suppurative  form.  In  point  of  fact,  it  is  as  a 
sequel  of  scarlatina  and  puerperal  fever  that  we  see  suppurative  rheumatism. 

For  the  first  few  days,  the  affection  appears  to  be  mild,  then  the  articula- 
tions become  painful,  intense  fever  sets  in,  delirium  supervenes,  ataxo-adv- 
namic  phenomena  appear,  and  death  closes  the  scene.  On  dissection,  pus  is 
found  in  the  articular  cavities  and  in  the  sheaths  of  the  tendons. 

Such  are  the  complications  of  the  wane  of  scarlatina  which  belong  to  the 
group  we  named  immediate;  the  mediate  complications  come  on  at  a  much 
later  period,  and  are  linked  with — are  sequela?  of — those  of  the  first  group. 

St.  Vitvs's  dance  is  the  most  important  of  the  mediate  sequela?  of  scarla- 
tina. In  children  you  will  see  this  affection  following  very  close  upon  the 
exanthematous  fever,  showing  itself  in  three  months,  two  months,  or  even 
in  six  weeks.  The  remarkable  researches  of  Dr.  Germain  See  have  thrown 
light  upon  the  relations  which  exist  between  rheumatism  and  chorea.*  His 
researches  and  later  observations,  including  my  own,  justify  us  in  stating 
that  it  is  unusual  for  children  to  escape  St.  Yitus's  dance  who  have  had 
attacks  of  acute  articular  rheumatism ;  and  to  this  statement  may  be  added, 
as  a  sort  of  corollary  to  it,  though  requiring  to  be  received  less  absolutely, 
that  a  child  who  has  had  St.  Vitus's  dance  generally  has  rheumatism  sooner 
or  later.  In  chorea,  consecutive  to  scarlatina,  the  bellows-sound  indicates 
the  existence  of  cardiac  lesions,  the  result  of  pre-existing  endocarditis.  And 
sometimes  the  rubbing  pericardiac  sound,  the  last  characteristic  manifesta- 
tion of  scarlatinous  rheumatism,  points  out  to  us  that  it  is  by  the  rheuma- 
tism that  the  convulsive  neurosis  is  linked  with  the  attack  of  scarlatina, 
and  constitutes  one  of  its  mediate  sequelse. 

You  have  often  seen  suppuration  supervene  in  different  parts  of  the  body 
after  exanthematous  diseases:  you  have  especially  seen  the  boils, the  super- 
ficial and  deep  abscesses  which  indefinitely  prolong  the  convalescence  of 
confluent  small-pox,  and  endanger  the  life  of  the  patient.  You  recollect  a 
case  which  we  recently  lost,  in  St.  Agnes's  Ward,  from  exhaustion  caused  by 
these  colliquative  suppurations. 

After  scarlatina  some  of  the  mucous  membranes,  particularly  those  of  the 
nose  and  ear,  remain  for  months  or  even  for  years  affected  with  chronic 
eczema.  Some  of  you  may  very  recently,  and  not  without  surprise,  have 
seen  me  make  a  retrospective  diagnosis  of  scarlatina  from  having  before  me 
eczematous  corvza.  The  patient  to  whom  I  refer  was  a  woman  who  came 
into  hospital  for  a  condition  of  general  discomfort,  characterized  by  exces- 
sive debility  and  absence  of  fever.  She  was  affected  with  eczematous  nasal 
catarrh.  I  observed  that  she  also  had  on  the  elbows  excoriations  covered 
with  crusts  of  comparatively  recent  date.  I  attributed  the  excoriations  to 
violent  rubbing,  the  rubbing  to  delirium,  and  the  delirium  to  a  fever.  I 
further  concluded  that  the  fever  was  probably  scarlatina,  as  that  fever 
frequently  produces  delirium,  and  brings  corvza  in  its  train.  In  reply  to 
my  interrogations,  the  woman  said  that  a  month  previously  she  had  had 
scarlatina,  which  had  been  accompanied  by  delirium,  and  followed  by  gen- 
eral debility.  My  diagnosis  was  not  the  result  of  inspiration,  but  was  a 
logical  deduction  from  an  association  of  ideas,  and  a  bringing  together  of 
phenomena.  The  lesion  of  the  mucous  membrane  sometimes  extends  to  the 
deeper  parts,  caries  and  necrosis  of  the  bone  taking  place.  Other  conse- 
quences may  also  result,  such  as  lachrymal  fistula,  perforation  of  the  tym- 
panum, and  loss  of  the  small  bones  of  the  ear;  caries  of  the  petrous  portion 
of  the  temporal  bone,  leading  to  incurable  deafness;  facial  paralysis,  and, 


*  Germain  See  :  Memoires  de  l'Academie  de  Medecine.     Parts,  1850,  t.  xv,  p.  373 


lfo 


SCARLATINA. 


unfortunately  in  not  a  few  cases,  to  inflammation  of  the  meninges,  and 
abscesses  of  the  brain  at  points  contiguous  to  the  affected  bone.  These  ter- 
rible occurrences  sometimes  follow  measles,  but  not  so  frequently  as  they 
succeed  scarlatiua. 

We  have  now  come  to  that  part  of  our  subject  which  is  the  most  difficult, 
aud  which  is  likewise,  from  a  practical  point  of  view,  the  most  important. 
I  refer  to  disguised  scarlatina,  to  which  I  have  given  the  name  of  defaced 
scarlatina  [scarlatine  frusle\.  You  know  what  an  antiquary  means  by  a 
defaced  inscription;  it  is  an  inscription  the  greater  part  of  which  is  obliter- 
ated, and  of  which  there  may  remain  only  a  line,  a  letter,  or  a  point.  Dis- 
eases, too,  are  defaced ;  or,  in  other  words,  they  present  nothing  for  the 
physician  to  read  but  a  single  word  of  the  symptomatological  phrase,  and 
with  this  one  word  he  has  to  reconstruct  the  entire  phrase,  just  as  the 
archaeologist  or  the  numismatist  has  to  restore  the  effaced  inscription  by 
filling  up  the  blanks  in  the  remaining  letters.  Deciphering  is  a  department 
with  which  the  physician  and  the  antiquary  have  to  become  acquainted  by 
the  use  of  very  similar  means:  the  antiquary  must  begin  by  learning  to 
read  what  is  written  on  well-preserved  medals  and  unmutilated  stones;  and 
at  the  beginning  of  his  studies  the  student  of  medicine  requires  to  recognize 
in  a  disease  the  aggregate  of  its  characteristic  symptoms;  but,  by  and  by, 
as  the  skilled  antiquary  deciphers  a  lost  inscription  by  a  remaining  word 
or  letter,  so  the  student  becomes  a  skilled  physician,  and  will  divine  the 
whole  nature  of  a  disease  from  a  single  sign.  Of  all  diseases,  gentlemen, 
scarlatina  is  that  which  is  most  frequently  defaced  [frmte]. 

A  case  in  point  will  be  more  useful  than  an  elaborate  description.  In 
1829  a  friend  wrote  to  inform  me  that  scarlatina  was  prevalent  in  a  little 
village  near  Mennecy,  in  the  department  of  Seine-et-Oise,  and  that  it  was 
most  severe  in  the  communes  of  Villeroy  Castle.  I  was  particularly  pleased 
to  go  to  study  this  epidemic,  as,  in  consequence  of  the  castle  being  perfectly 
isolated  from  the  village,  I  could  easily  follow  all  the  movements  of  the 
disease.  I  saw  members  of  the  same  family  who,  after  having  had  sore 
throat  without  eruption,  were  afterwards  proof  against  scarlatina,  though 
surrounded  by  cases  of  various  degrees  of  severity.  Their  sore  throat  had 
been  of  a  very  aggravated  form,  and  accompanied  by  ardent  fever:  the  red- 
ness of  the  pharynx  was  very  characteristic,  and  the  consecutive  stripping 
of  the  tongue  left  no  room  for  doubt  as  to  the  nature  of  the  affection.  I  saw 
other  patients  who  had  the  original  disease  apparently  very  slightly,  as  they 
had  only  drooped  a  little  for  eight  or  ten  days,  hut  who,  nevertheless,  after- 
wards became  swollen,  and  passed  blood  with  the  urine.  At  that  date  we 
were  not  acquainted  with  albuminuria.  I  was  struck  by  the  facts  I  have 
now  stated, aud  I  came  to  the  conclusion  that  the  persons  who  had  only  had 
eruption  and  ponsecutive  anasarca,  those  who  had  only  had  anasarca,  and 
those  who  had  only  had  sore  throat,  hail  all  had  scarlatina,  the  affections 
seen  in  all  of  them  being  manifestations  of  that  disease. 

At  Meaux,  in  1854,  along  with  my  accomplished  friend  Dr.  Blache,  I 
observed  similar  occurrences.  A  young  girl,  fourteen  years  of  age,  took 
violent  scarlatina,  characterized  by  atheromatous  SOre  throat,  intense  fever, 
and  the  specific  eruption.  Someday.-  later  her  sister,  living  in  the  same 
house,  was  seized  with  similar  symptom.-:   almost  at    the  same  time  a  lady's 

maid  sickened:  two  or  three  days  afterwards  a  valet,  who  had   remained 

the   whole  day   in    the   apartment    with    the    invalids,  became   affected  with 

violent  -me  throat,  accompanied  by  a  deposit  of  pulpy  matter  on  the  tonsils, 
a  vi'(\,  and  subsequently  peeled  tongue.  Burning  i'rxi'r,  bul  do  eruption.  It 
was  evident  tome  thai  the  family  physician,  Dr.  Saint-Amand,  was  right 
in  believing  thai  all  had  had  scarlatina:  thai  the  valet,  being  in  the  midst 


SCARLATINA.  157 

of  the  epidemic  influence,  had  taken  the  fever  like  the  other  members  of 
the  family,  lmt  in  a  different  form:  in  him  the  inscription  "scarlatina"  was 
defaced,  -whereas,  in  the  other  cases,  it  was  complete.  Another  member  of 
this  household,  a  hoy  of  six  years  of  age,  all  at  once,  and  without  having 
had  a  moment's  previous  illness,  hecame  swollen.  Dr.  Blache  and  I  were 
then  called  in  in  consultation.  We  considered  the  case  to  be  one  of  scar- 
latinous anasarca  coming  on  at  the  first  brunt  of  the  attack  of  scarlatina. 
The  anasarca  was  considerable,  and  accompanied  by  hematuria.  The  father 
and  mother,  persons  very  watchful  over  the  health  of  their  son,  assured  us 
that  on  the  morning  of  the  very  day  on  which  the  boy  became  ill,  he  had 
taken  his  breakfast  as  usual :  and  the  master  of  the  boarding-school  where  he 
attended  stated  that  he  had  played  in  his  customary  manner.  In  this  case, 
then,  there  was  neither  fever  nor  eruption,  and  scarlatina  was  detected  solely 
by  the  individual  symptom  for  which  Ave  were  called  in.  Eight  days  later 
the  boy  had  a  double  pleurisy:  death  was  supposed  to  be  impending,  when 
Dr.  Blache  and  I  were  again  called  in.  We  detected  effusion  in  both  pleurae : 
four  days  later  we  found  that  one  side  of  the  chest  was  restored  to  its  natural 
state,  and  that  the  other  was  enormously  distended.  We  proposed,  and 
forthwith  performed,  paracentesis,  withdrawing  750  grammes  of  pus.  For 
two  or  three  months  Dr.  Saint-Amand  injected  ioflinous  solutions  into  the 
pleurae.  Although  the  lung  was  perforated  during  the  treatment,  the  child 
recovered,  and  at  present  enjoys  most  excellent  health.  I  have  not  met 
with  another  similar  case.  But  as  regards  examples  of  defaced  scarlatina, 
you  will  find  them  scattered  in  the  works  of  authors.  Graves  has  in  par- 
ticular mentioned  several,  some  of  which  I  will  now  quote  from  his  clinical 
lectures. 

"  F was  taken  home  from  a  school  Avhere  scarlatina  was  prevailing :  he 

complained  of  pain  in  the  throat  on  swallowing,  slight  headache,  and  nausea. 
Next  day  the  tonsils  were  swollen,  and  there  was  increased  difficulty  in 
swallowing :  the  pulse  was  sharp,  and  the  skin  was  hot,  but  there  was  no 
trace  of  eruption.  These  symptoms,  without  increasing  in  severity,  con- 
tinued for  three  days,  and  then  disappeared.  Before  this  boy  had  com- 
pletely recovered,  his  father  and  two  sisters  took  scarlatina.  In  the  two 
sisters  the  eruption  appeared,  and  terminated  in  desquamation.  In  the 
father  there  were  only  a  few  small  red  points  on  the  skin,  and  no  subsequent 
desquamation  occurred. 

"O likewise  came  home  from  school  with  scarlatina.  During  his  attack 

his  two  sisters  and  brother  took  the  disease.  In  the  three  it  showed  itself 
in  the  form  of  an  eruption  of  small  spots  on  the  skin.  At  the  same  time, 
and  in  the  same  house,  a  valet  and  a  lady's  maid  were  seized  with  very 
violent  sore  throat  and  high  fever,  which  continued  for  some  days  :  in 
neither  case  was  there  any  eruption." 

These  cases  of  Dr.  Graves  are  identical  with  others  which  I  have  met 
with.  In  the  following  very  curious  narrative  relating  to  a  physician's 
family,  we  see  scarlatina  showing  itself  only  by  anasarca  at  the  onset  of  the 
illness,  just  as  occurred  ill  the  lad  whose  case  I  described  to  you  a  few 
minutes  ago.  The  facts  were  communicated  to  Dr.  Graves  by  an  eminent 
practitioner  of  Dublin. 

Some  years  ago,  scarlatina  broke  out  in  this  practitioner's  family.  It 
attacked  all  his  children  with  the  exception  of  one  young  lady,  who  had 
no  symptoms  whatever  of  the  disease,  although  she  waited  on  her  sisters 
during  their  illnesses.  All  was  going  on  well,  and  the  family  was  sent  to 
the  country  for  chauge  of  air:  the  sister  who  had  not  been  ill  went  with 
the  others.  In  the  country,  to  the  great  surprise  of  all,  this  young  lady 
was  suddenly  seized  with  that  special  form  of  anasarca  observed  in  those 


158  SCARLATINA. 

who  have  had  scarlatina.  Her  father,  who  attended  her  during  her  illness, 
was  exceedingly  struck  with  the  occurrence:  he  observed  the  case  with 
very  special  attention,  and  came  to  the  conclusion  that  it  was  one  of  latent 
scarlatina. 

Dr.  Graves,  in  speaking  of  these  cases,  remarks  that  they  are  very  inter- 
esting in  a  pathological  point  of  view,  as  tending  to  prove  that  diseases 
originating  in  contagion  very  often  do  not  exhibit  their  ordinary  series  of 
characteristic  symptoms. 

The  quotations  now  made  from  the  Irish  author  show  that  similar  phe- 
nomena occur  under  the  Dublin  and  under  the  Parisian  sky.  You  will 
assuredly  meet  with  these  cases  of  defaced  scarlatina  ;  and  you  will  do  well 
to  accustom  yourselves  to  recognize  them.  Graves  maintains  that  they  can 
only  be  cases  of  scarlatina,  because  the  disease  being  essentially  contagious, 
it  is  in^ossible  for  the  persons  who  have  only  had  sore  throat  or  anasarca 
to  be  in  the  midst  of  their  scarlatina-stricken  families,  and  yet  be  the  only 
ones  who  have  been  exempt  from  attack. 

In  December,  1860,  I  saw  with  my  friend  Dr.  Leon  Gros,  a  young  man 
of  fifteen  whose  case  furnishes  us  with  a  new  example  of  defaced  scarlatina 
— a  case  in  which  the  diagnosis  would  have  been  impossible  without  assist- 
ance from  accessory  circumstances.  This  youth  came  home  from  college 
with  a  little  fever  and  an  insignificant  sore  throat.  The  illness  was  so 
slight  that  Dr.  Gros  did  nothing;  and  after  two  days  of  trifling  indisposition 
the  patient  was  quite  well.  A  few  days  afterwards,  his  younger  sister  took 
scarlatina ;  and  during  her  convalescence,  the  brother  was  seized  with 
hematuria  which  continued  more  than  a  month.  I  never  entertained  the 
least  doubt  that  this  young  man  had  communicated  scarlatina  to  his  sister, 
and  that  his  hematuria  was  the  sequel  of  his  slight  febrile  attack.  Dr. 
Gros  did  not  feel  quite  sure  as  to  the  accuracy  of  this  view.  The  young 
man  did  not  contract  scarlatina  after  his  sister,  and  must  have  had  it  before 
her,  if  he  can  be  said  to  have  had  it  at  all.  In  this  case,  albuminuria 
continued  for  nearly  a  year;  and  it  required  the  most  assiduous  and  skil- 
ful treatment  on  the  part  of  Dr.  Gros  to  prevent  the  patient  becoming  a 
victim  to  an  exanthematous  fever  which  had  begun  so  mildly  as  to  make 
its  very  existence  a  matter  of  doubt. 

Eruptive  diseases . have  a  fatal  tendency  in  this  sense,  that  they  have 
determinate  characteristics  against  which  we  cannot  prevail.  This  remark 
is  equally  applicable  to  diseases  in  which  the  eruption  shows  itself  on  the 
skin,  and  to  th03e  in  which  it  conies  out  on  the  mucous  surface  of  the  intes- 
tine, as  in  dothienteritis  or  putrid  fever,  which  is  au  eruptive  affection  of 
the  alimentary  canal,  in  treating  these  diseases,  the  physician  must  not 
lose  sight  of  the  greal  practical  fact  that  it  is  imposible  to  stop  the  prog- 
ress of  a  putrid  fever,  and  equally  impossible  to  cut  short  an  attack  of 
small-pox  or  measles.  It  is  possible  by  injudicious  treatment,  at  great 
peril  to  the  patient,  to  retard,  and  in  sonic  degree  to  modify  the  appearance 

of  the  eruption,  but  the  evolution  of  an  exanthematous  fever  cannot  be 
prevented.  Treatment  ought  therefore  to  be  restricted  to  the  alleviation 
of  the  Bymptoms  and  complications  which  arise  during  its  course.  The 
physician  ought  in  this  class  of  disease  more  than  in  any  other,  to  be  the 
servant  and  interpreter  of  nature — ministt  r  naturae  et  ink  rprea  —for,  to  con- 
tinue the  quotation, — quidquid meditetur  etfaeiat,  si  naturanon  optemperat, 
naturanon  imperat:  be  oughl  to  remain  passive  when  things  take  their 
regular  course.     If  no  untoward  Bymptoms  occur,  there  is  nothing  for  him 

to  do  but  to  fold  his  arms,  for  at  the  end  of  a  few  days  the  malady  will 
have  safely  run  through  all  its  Stages.      Even  when   eruptive  fevers  a»ume 


SCARLATINA.  159 

some  threatening  symptoms,  our  interference,  it  must  be  confessed,  proves 
of  very  little  use.  The  auspicious  circumstances  in  which  the  interference 
of  art  proves  beneficial  occur  more  frequently  in  scarlatina,  than  in  mea- 
sles, small-pox,  or  putrid  fever. 

I  now  propose  to  point  out  to  you  the  good  which  the  physician  can 
do  in  scarlatina.  It  is  of  the  utmost  importance  that  he  have  always  pres- 
ent in  his  mind  the  fact,  that  this  disease  differs  much  from  itself  both  in 
symptoms  and  severity  :  he  must  always  remember  that  it  is  sometimes 
exceedingly  mild,  and  at  other  times  as  terribly  malignant  as  typhus  or 
plague:  in  a  word,  he  must  bear  in  mind  the  type  of  the  prevailing  epi- 
demic. It  behooves  him  not  to  set  down  to  the  account  of  successful  treat- 
ment results  entirely  attributable  to  the  mild  character  of  the  epidemic, 
and  equally  to  avoid  throwing 'the  blame  of  unfortunate  issues  upon  the 
treatment,  when  they  are  really  dependent  upon  the  inherent  malignity  of 
the  cases. 

Epidemics  of  scarlatina  may  be  of  a  formidable  type  iu  respect  of  an 
entire  population,  or  in  respect  of  a  single  family.  The  malignity  may;  so 
to  speak,  remain  confined  to  one  small  circumscribed  centre,  within  which 
nearly  all  who  are  attacked  will  have  the  disease  in  a  malignant  form. 
As  a  case  in  point,  I  may  refer  to  a  melancholy  statement  lately  made 
public  in  an  English  newspaper,  to  the  effect  that  a  clergyman  of  the  city 
of  York  lost,  by  scarlatina,  in  one  week,  his  six  or  seven  children. 

It  seems  as  if  the  scarlatinous  poison  with  which  such  unfortunates  are 
infected  has  a  special  energy,  and  that  the  constitutions  of  every  one  of 
them  is  specially  disposed  to  receive  it.  Whether  the  malignity  is  depend- 
ent upon  the  nature  of  the  disease  itself,  upon  the  constitution  of  the  epi- 
demic, as  Sydenham  and  others  allege,  or  whether  upon  the  idiosyncrasies 
of  individuals,  as  Stoll  believes,  there  is  no  uncertainty  as  to  the  great  fact, 
that  wdien  scarlatina  breaks  out  with  fury  in  a  family,  killing  the  first  per- 
son attacked,  there  is  cause  to  fear  that  it  will  carry  off  other  victims;  and 
that,  on  the  other  hand,  when  its  first  assault  upon  a  family  is  moderate, 
wdien  the  first  cases  are  mild,  there  is  reason  to  hope  that  all  the  subsequent 
cases  will  likewise  be  mild.  It  was  necessary  to  say  what  I  have  now  said 
before  entering  upon  the  subject  of  treatment,  so  that  you  might  be  put  on 
your  guard  against  yourselves.  I  cannot  too  often  repeat  that  the  best 
treatment  will  fail  when  the  type  of  the  disease  is  essentially  bad,  and  that 
when  it  is  mild,  recovery  will  be  the  rule,  even  when  inappropriate  or 
injurious  measures  have  been  employed. 

There  is  a  general  agreement  among  all  epidemiologists  that  injury  is 
done  by  pursuing  such  antiphlogistic  measures  as  local  or  general  bleeding, 
too  active  purging,  and  very  low  diet.  Most  authors  who  have  seen, 
studied,  and  recorded  several  successive  epidemics  point  out  the  danger  of 
this  kind  of  treatment  in  severe  cases  of  scarlatina,  even  when  acute  inflam- 
matory affections  have  supervened,  such  as  phlegmon  of  the  tonsils,  lymph- 
atic glands,  or  cellular  tissue.  Bleedings  and  the  application  of  leeches 
generally  produce  a  bad  effect,  probably  because  they  are  employed  to  com- 
bat the  symptoms  of  a  septic  disease,  a  malady  of  a  bad  character — mali 
moris — for  antiphlogistic  measures  almost  always  prove  disastrous  in  malig- 
nant diseases. 

Epidemiologists,  however,  while  they  condemn  antiphlogistic  treatment 
on  account  of  the  evil  which  they  have  seen  it  produce,  inculcate  that 
although  energetic  purgatives  ai*e  injurious,  mild  purgatives,  such  as  mer- 
curials and  the  neutral  salts,  are  of  real  service,  wdien  given  in  moderate 
doses.  My  own  experience  has  demonstrated  to  me  the  truth  of  that  doc- 
trine.    If  the  alimentary  canal  is  loaded,  and  signs  of  faulty  chylification 


160  SCARLATINA. 

exist,  it  is  advantageous  to  open  the  bowels  by  administering  a  purgative 
suited  to  the  age  and  strength  of  the  patient.  I  cannot  participate  in 
Sydenham's  dread  of  diarrhoea,  so  long  as  it  remains  moderate  and  is  depend- 
ent upon  a  loaded  condition  of  the  alimentary  passage. 

I  have  already  said  that  in  scarlatina,  particularly  in  the  acute  stage, 
patients  are  frequently  carried  off  by  nervous  affections.  These  affections 
mav  have  their  starting-point  in  the  centres  of  organic  life,  in  which  case 
they  are  characterized  by  an  exti'aordinary  elevation  in  the  temperature  of 
the  body,  by  vomiting  and  intractable  diarrhoea  ;  or  they  may  originate  in 
the  centres  of  animal  life,  when  the  phenomena  are  delirium,  coma  vigil, 
jerking  of  the  tendons,  and  convulsions.  I  have  already  insisted  on  the 
fact  that  vomiting  and  intractable  diarrhoea  at  the  onset  of  scarlatina  are 
very  unfavorable  symptoms,  and  that  it  is  difficult  to  control  them  by 
medicines.  It  is  in  vain  that  we  administer  opiates  and  poisonous  solinace- 
ous  drugs.  The  vomiting  and  diarrhoea  are  sometimes  moderated  by  the 
use  of  tepid  baths,  and  by  administering  ice,  effervescing  draughts,  and 
small  doses  of  calomel.     They  are  generally  aggravated  by  bloodletting. 

Cold  affusions  have  been  proved  by  experience  to  produce  beneficial 
effects  in  these  affections  dependent  on  disturbance  of  the  nervous  system, 
particularly  on  those  originating  in  the  centres  of  animal  life;  but  never- 
theless, it  is  with  trembling  that  the  practitioner  employs  them,  dime 
was  the  first  to  formulate  rules  for  their  use.  He  employed  cold  affusions 
with  a  certain  measure  of  success  in  a  large  number  of  very  bad  cases  of 
scarlatina.  Emboldened  by  fortunate  results,  he  became  still  more  urgent 
in  his  recommendation  of  this  method  of  treatment,  and  laid  it  down  as  a 
general  rule  of  practice  that  it  ought  to  be  adopted  in  scarlatina  when 
there  were  formidable  nervous  symptoms,  such  as  delirium,  convulsions, 
diarrhoea,  excessive  vomiting,  and  great  heat  of  skin. 

The  patient  being  placed,  naked,  in  an  empty  bath,  has  thrown  over  his 
body  three  or  four  pails  of  water  at  a  temperature  of  form  20  to  25  degrees 
of  the  Centigrade  thermometer.  The  continuance  of  the  affusion  is  from  a 
quarter  of  a  minute  to  one  minute,  which  latter  is  the  maximum  duration. 
The  patient  is  immediately  afterwards  put  hack  to  bed,  without  being  dried, 
but  being  wrapped  up  in  blankets  and  properly  covered.  Reaction  is  gen- 
erally established  within  fifteen  or  twenty  minutes.  Theaffusion  is  repeated 
once  or  twice  in  twenty-four  hours,  according  to  the  severity  of  the  symp- 
toms. Tins  treatment  ought  at  once  to  be  resorted  to,  when  the  nervous 
phenomena  assume  such  intensity  as  to  threaten  imminent  danger,  and  they 
ought  to  he  repeated  at  proper  intervals  till  the  symptoms  have  so  fa r 
abated  as  to  relieve  the  physician  from  serious  anxiety. 

This  practice  must  be  carried  out  in  watchfulness.  It  is  above  every- 
thing essentia]  not  to  require  the  support  of  public  opinion  to  justify  your 
instituting  a  method  of  treatment  which  has  the  appearance  of  being  so 
audacious.     You  must  he  actuated  by  a  profound  sense  of  duty  to  venture 

tOOppose  the  popular  prejudice — a  most  disastrous  prejudice— which  insists 
upon  patients  with  eruptive  fevers  being  kept  on  hot  drink-,  and  wrapt  up 
in  a  more  abundant  supply  of  blankets  than  they  were  accustomed  to  when 
in  health.  I  say  that  there  is  no  popular  prejudice  more  disastrous,  for 
there  is  none  which  so  often  occasions  the  death  of  patients.  Nevertheless, 
the  mighty  voice  of  Sydenham,  who  though  dead  two  hundred  years  still 
speaks,  and  the  authority  of  the  most  mature  modern  physicians,  ceaselessly 
oppose  it  without  avail.  Hence  the  difficulties  which  the  young  physician 
has  to  encounter,  when  he  feels  that    it    is  his  duty  to  have  recourse  to  cold 

affusions  in  scarlatina.  These  difficulties  are  all  the  greater,  that  it  is  in 
cases  which  threaten  to  prove  fatal  that  the  treatment  is  indicated.    When 


SCARLATINA.  161 

you  adopt  it,  you  know  that  the  disease  only  presents  you  with  one  chance 
of  recovery  against  two  of  death  :  and  you  can  foretell  the  reflections  of  the 
family  in  the  event  of  your  efforts  not  being  crowned  with  .success! 

I  have  long  beeu  in  the  habit  of  employing  cold  affusions.  I  used  them, 
however,  in  my  private  bef'jre  administering  them  in  my  public  practice, 
because  I  never  venture  for  the  first  time  upon  a  new  mode  of  practice  upon 
my  hospital  patients.  I  declare  to  you  that  I  have  never  resorted  to  the 
employment  of  cold  affusions  without  obtaining  beneficial  results.  I  am 
far  from  pretending  that  all  my  patients  so  treated  have  recovered :  like 
my  colleagues,  I  have  lost  the  greater  number,  but  even  those  who  died 
experienced  a  temporary  relief  from  suffering,  and  the  affusion,  so  far  from 
proving  injurious  to  them,  always  moderated  the  symptoms,  and  also  seemed 
always  to  retard  the  fatal  termination.  The  adoption  of  this  practice  sub- 
jected my  popularity  as  a  practitioner  to  great  risks,  and  my  resorting  to  it, 
from  a  profound  conviction  that  it  was  right,  has  often  been  badly  recom- 
pensed. But  still,  I  have  always  firmly  continued  in  the  line  traced  out 
for  me  by  duty,  and  now  I  do  not  hold  to  it  with  less  determination,  that  I 
am  less  afraid  than  formerly  of  incurring  responsibility.  I  perfectly  appre- 
ciate your  alarms:  not  because  I  suppose  you  doubt  the  goodness  of  a  mode 
of  treatment  which  perhaps  you  would  not  dare  to  resort  to,  but  because  I 
imagine  that  whilst  consulting,  in  the  first  instance,  the  interests  of  your 
clients,  you  will  naturally  desire  to  protect  your  professional  reputation,  so 
liable  to  be  blasted  at  the  beginning  of  your  career.  However,  remember 
that  when  the  voice  of  duty  commands,  when  your  conscience  tells  you  that 
the  cold  affusion  ought  to  be  administered,  you  must  not  flinch  from  having 
recourse  to  this  method  of  treatment  because  it  is  opposed  to  the  prejudices 
of  the  public.  But  in  place  of  fighting  face  to  face  with  prejudice,  in  place 
of  taking  the  bull  by  the  horns — pardon  me  the  phrase — evade  the  diffi- 
culty, by  adopting  such  manipulations  as  will  lead  the  patient,  and  still 
more  those  in  attendance,  to  believe  that  the  affusions  are  warm  and  not 
cold. 

I  have  already  repeatedly  said  that  scarlatina,  especially  when  its  form 
is  malignant,  is  of  all  diseases  that  in  which  the  temperature  of  the  body 
rises  to  the  highest  point.  Very  often  it  rises  to  forty-one  degrees,  which  is 
three  degrees  above  the  normal  standard.  Very  well,  then  :  in  place  of 
giving  your  patients  cold  affusions,  give  them  mere  lotions  of  water  at 
twenty-five  degrees — that  is,  of  water  fifteen  degrees  under  the  temperature 
of  the  skin  in  scarlatina,  and  therefore,  relatively  to  it,  cold.  Let  the  pa- 
tient be  placed  on  a  folding-bed  :  and  then,  let  the  entire  body,  first  the 
anterior  and  then  the  posterior  surface,  be  rapidly  wetted  with  sponges 
soaked  in  this  water  at  twenty -five  degrees ;  and  when  this  has  been  clone, 
let  him  be  rolled  up  in  blankets  and  put  back  into  his  own  bed,  follow- 
ing the  same  rules  as  after  the  cold  affusion.  Though  these  tepid  lotions 
are  less  efficacious  than  the  cold  affusions,  they  are  productive  of  real  bene- 
fit. Consequent  upon  their  employment,  the  following  effects  are  observed. 
The  skin  previously  characterized  by  extreme  aridity  and  stinging  heat,  in 
half  an  hour  becomes  cooler  and  moist.  The  diminution  in  the  rapidity  of 
the  pulse  is  a  still  more  remarkable  phenomenon :  from  between  160  and 
180  in  children,  it  falls  to  140  or  130;  and  from  140  or  150  in  adults,  to 
120  or  115:  there  being  consequently  a  fall  ranging  between  30  and  40 
beats.  Simultaneously  with  these  amelioriations,  the  severity  of  the  cere- 
bral symptoms  diminishes,  and  there  is  a  proportionate  decrease  in  the  pro- 
fuse diarrhoea  and  excessive  vomiting,  symptoms  dependent  upon  disturb- 
ance of  the  ganglionic  nervous  system.  You  thus  obtain — for  a  very  limited 
time  I  admit — a  remarkable  sedative  effect  from  the  tepid  bathing.  The 
vol.  i. — 11 


162  SCARLATINA. 

benefits,  I  say,  are  not  long  continued,  for  sometimes  in  two  or  three  hours 
the  symptoms  have  returned.  It  is  necessary,  in  point  of  fact,  to  renew  the 
lotions  or  the  cold  affusions  two,  three,  or  four  times  in  the  twenty-four 
hours,  and  sometimes  to  continue  to  employ  them  for  five  or  six  consecutive 
days. 

I  saw,  very  lately,  along  with  my  excelleut  friend  Dr.  Baret,  a  lad  of  thir- 
teen suffering  from  very  severe  scarlatina.  From  the  third  day  of  the  attack, 
the  nervous  symptoms  assumed  so  formidable  a  character  that  Dr.  Baret 
contemplated  the  employment  of  cold  lotions:  I  also  believed  them  to  be 
indispensable.  The  relations  were  terrified,  but  with  that  resignation  so 
becoming  in  intelligent  persons  who  feel  their  absolute  incompetence  to 
judge  medical  questions,  they  allowed  the  proposal  to  be  carried  out.  Each 
bathing  was  followed  by  considerable  amendment;  and  at  the  end  of  four 
days,  when  the  lad  was  out  of  danger,  they  loudly  proclaimed  that  he 
owed  his  life  to  the  cold  applications. 

Relatives  are  much  reconciled  to  the  use  of  the  cold  affusions  and  cold 
lotions  by  the  circumstance,  that  the  skin,  pale  before,  almost  always  In- 
comes much  redder  after  they  have  been  employed — there  is  more  eruption 
seen.  This  method  of  treatment,  so  far  from  effacing  the  eruption,  increases 
it.  This  is  so  palpable  that  it  is  noticed  by  the  relatives  of  the  patient,  who 
will,  so  long  as  danger  lasts,  often  be  the  first  to  solicit  the  renewed  appli- 
cation of  cold  water,  so  evident  to  them  is  the  amendment  which  lias 
resulted  from  the  treatment,  and  so  struck  are  they  by  the  material  fact  of 
a  brighter  red  having  been  imparted  to  the  eruption.  It  is  nevertheless 
true,  that  if  the  amendment  noticedis  not  perfected  by  recovery,  if  death 
come,  in  the  inevitable  march  of  events,  they  too  often  forget  the  encourage- 
ment they  gave  to  your  proceedings. 

Some  of  you,  gentlemen,  recollect  a  case  which  I  am  now  going  to  relate 
in  detail.  On  the  10th  of  May,  1857,  a  stout,  fine  girl  of  twenty  came 
into  Professor  Bostan's  wards  with  scarlatina,  in  an  exceedingly  severe 
form:  she  had  been  ill  for  two  days.  My  honorable  colleague  had  the 
goodness  to  show  me  this  patient,  and  to  propose  that  she  should  be  received 
into  in v  wards.  She  had  violent  delirium  and  excessive  restlessness:  her 
pulse  was  144  in  the  minute  ;  there  was  great  heat  of  skin,  and  scarlatinous 
sore  throat  of  aggravated  character.  The  restlessness  and  delirium  were 
serious  and  threatening  symptoms.  Professor  Rostan  wished  to  have  my 
opinion  as  to  the  treatment  to  lie  adopted:  he  inclined  towards  bloodletting ; 
and  I  proposed  cold  affusions.  The  patient  was  received  into  my  wards. 
On  her  admission,  1  had  her  put  into  an  empty  bath  ;  to  accomplish  this, 
it  was  necessary  to  have  the  assistance  of  four  persons,  so  great  was  her 
violence.  I  then,  somewhat  slowly,  poured  over  her  body  two  ewers,  each 
containing  about  two  Litres  of  water,  at  a  temperature  of  about  1">  Centi- 
grade [59 J  F.].  1  at  the  same  time  watered  the  face  and  limbs:  alter  this 
treatment,  without  being  dried,  she  was  wrapped  up  in  a  blanket  and  put 
back  iii  her  bed.  Her  violence  was  by  this  time  sensibly  calmed,  the  pulse 
hail  fallen  ten  heats,  and  there  was  less  of  a  burning  character  in  the  heat 
of  skin.  I  advised  my  chef  de  clinique,  Dr.  Blondeau,  to  see  her  again 
towards  evening,  and  repeat  the  affusion,  if,  as  I  hoped,  the  first  application 
had  produced  a  change  for  the  better.  In  the  evening,  the  affusion  was 
repeated  as  in  the  morning,  the  patient  offering  less  resistance.  Soon  after 
the  evening  affusion,  the  beal  of  skin  subsided  -really:  ami  the  pulse  fell 
to  120;  in  the  morning,  as  already  stated,  the  pulse  was  111.  The  delirium 
ceased;  she  passed  a  quiet  nighl  ;  and  at  the  visit  next  morning  answered 
my  questions  intelligently.  The  disease  had  resumed  its  normal  course, 
disentangled  from  all  complications.     Although   this  patient   had  slighl 


SCARLATINA.  103 

albuminuria  for  eight  days,  she  left  the  hospital  quite  recovered  from  her 
attack,  and  in  penect  health,  at  the  beginning  of  July.  Desquamation 
was  not  completed  till  oear  the  end  of  June,  forty-five  days  after  the  onsel 
of  the  attack  of  scarlatina. 

There  arc  two  cardinal  points  in  this  case,  gentlemen,  to  which  I  wish  to 
call  your  attention :  the  first  embraces  the  diminution  of  the  febrile  heat, 
the  lessening  of  the  rapidity  of  pulse,  the  cessation  of  delirium  and  restless- 
ness; and  the  second  is  the  increase  of  the  eruption.  The  cold  affusion,  .so 
far  from  driving  in  the  eruption,  brings  it  out  more  vividly.  The  young 
woman  whose  case  I  have  just  detailed  was  at  the  end  of  the  third  day  of 
the  attack  when  I  saw  her.  and  the  eruption,  therefore,  was  at  its  maximum 
of  intensity  :  nevertheless,  it  became  more  vivid  after  the  application  of  the 
cold  water.  With  respect  to  the  diminution  in  the  frequency  of  the  pulse, 
the  lowering  of  the  temperature,  and  the  cessation  of  delirium — ataxic 
symptoms  which  as  a  rule  increase  in  severity  up  to  the  sixth  or  seventh 
day  of  the  disease — they  did  not  merely  remain  stationary,  which  would 
have  been  a  relative  benefit,  but  they  became  more  moderate,  and  ultimately 
ceased. 

A  few  days  later,  on  the  23d  May,  1857,  another  opportunity  was  afforded 
in  my  wards  for  employing  the  same  treatment ;  but  the  case  was  of  so  com- 
plicated a  nature  that  we  could  not  hope  for  similar  success.  The  patient 
was  a  woman  of  24  years  of  age,  who  ten  days  previously  had  given  birth 
to  a  healthy  infant,  and  four  days  after  her  confinement  was  attacked  by 
scarlatina.  There  were  no  symptoms  specially  dependent  on  recent  delivery 
— no  signs  of  peritonitis  or  phlebitis — but  the  patient  wTas  not  the  less  in  a 
puerperal  condition  when  the  exanthematous  fever  declared  itself  with  great 
violence.  "When  admitted  into  our  wards,  she  was  suffering  from  great 
excitement  and  delirium.  The  skin  was  very  hot,  and  covered  with  a 
vivid  red  eruption  ;  the  tongue  was  dry  and  black  ;  there  was  considerable 
oppression  at  the  chest,  and  the  pulse  was  136.  Without  being  deterred  by 
her  puerperal  state,  and  the  lochial  discharge  which  was  flowing  in  a  nor- 
mal manner,  my  chef  de  clinique,  Dr.  Blondeau,  who  saw  her  in  the  evening, 
had  her  subjected  to  the  cold  affusion  :  I  approved  of  the  treatment,  which 
I  would  myself  have  ordered.  Immediately  after  the  affusion — during 
which  she  had  a  faintingfit — this  unfortunate  woman  felt  much  better:  the 
delirium  subsided  as  if  by  enchantment ;  there  was  relief  from  the  violent 
pains,  chiefly  in  the  loins,  of  which  she  had  been  complaining;  and  she 
expressed  herself  as  grateful  for  this  rapid  relief.  A  few  hours  later,  how- 
ever, there  was  a  return  of  the  nervous  symptoms.  She  passed  a  very  bad 
night,  and  at  my  visit  next  morning,  the  delirium,  excitement,  and  oppres- 
sion at  the  chest  were  extreme.  The  pulse,  which  had  in  the  evening,  after 
the  affusion,  fallen  from  136  to  120,  had  returned  to  its  former  frequency. 
The  eruption  continued  at  least  as  vivid  as  before  the  employment  of  the 
cold  affusion.  I  administered  a  second  affusion :  the  delirium  ceased  at 
once,  and  the  excitement  became  less.  The  patient  again  experienced  a 
feeling  of  improvement,  similar  to  that  which  she  had  felt  after  the  treat- 
ment on  the  previous  evening,  and  the  recollection  of  that  feeling  always 
present  to  her  mind,  caused  her  during  her  lucid  moments  to  ask  for  the 
cold  water.  Those  of  you,  gentlemen,  who  were  present  at  the  visit  can 
testify  to  the  beneficial  effects  which  resulted  from  the  treatment ;  the  pulse 
again  fell  from  136  to  122,  but  the  great  oppression  at  the  chest  continued, 
and  could  not  be  in  any  way  explained  by  the  state  of  the  thoracic  organs, 
auscultation  presenting  nothing  particular.  This  symptom  gave  us  serious 
anxiety  as  to  the  issue  of  the  disease  which  was  in  so  formidable  a  manner 
complicating  the  puerperal  condition.     I  seize  this  opportunity  of  telling 


164  SCARLATINA. 

you  how  very  perilous  scarlatina  is  when  associated  with  the  puerperal 
state :  the  patients  either  succumb  under  aggravated  nervous  symptoms 
which  leave  no  lesions  appreciable  on  dissection,  or  from  inflammations  of 
the  serous  membranes — the  pleurae,  pericardium,  or  peritoneum — passing 
rapidly  iuto  suppuration. 

In  1828,  Drs.  Ramon,  Leblanc,  and  I  were  sent  by  M.  de  Martignac, 
then  Minister  of  the  Interior,  to  study  the  epidemics  and  epizootic  preva- 
lent in  old  Sologne,  that  part  of  France  which  lies  between  the  rivers  Cher 
and  Loire,  extending  from  Blois  to  Gien.  AVe  saw  occurring  simultane- 
ously with  severe  cases  of  scarlatina,  numerous  cases  of  membranous  sore 
throat.  Scarlatina  was  particularly  severe  at  Cour-Cheverny,  a  commune 
situated  four  miles  south  of  Blois :  and  it  had  proved  so  specially  fatal  to 
puerperal  women,  that  even  the  very  poorest  were  leaving  the  place  and 
going  to  Blois  to  be  confined.  The  district  physician  informed  us  that  he 
had  lost  nine  cases.  Now,  as  you  knowT,  puerperal  epidemics  are  very  rare 
in  country  places.  Generally  speaking,  pregnant  women  are  proof  against 
epidemic  influences,  but  in  thirty-six  cases,  forty-eight  hours  after  delivery, 
the  scarlatinous  eruption  showed  itself,  and  in  a  few  days  the  patients  were 
dead. 

The  puerperal  state,  therefore,  is  a  very  serious  complication  of  scarla- 
tina. This  was  seen  in  our  patient  in  number  19.  The  disease  called 
puerperal  fever  was  prevailing  in  Paris.  The  Maternity  Hospital  had  in 
consequence  been  recently  closed,  and  I  had  cases  of  this  formidable  malady 
in  my  wards  in  the  Hotel-Dieu.  New-born  infants  were  carried  off  by 
erysipelas  of  bad  type,  a  manifestation  of  puerperal  fever  in  young  subjects, 
and  which  proves  fatal  to  them  without  leaving  any  appreciable  lesions  in 
internal  organs.  Our  patient  you  see  was  in  the  most  unfavorable  circum- 
stances. Oppression  at  the  chest,  when  unconnected  with  any  material 
affection  of  the  respiratory  passages,  is  an  exceedingly  serious  symptom  in 
a  great  number  of  septic  diseases,  particularly  in  puerperal  fever,  typhoid 
fever,  and  cholera,  indicating  a  profound  disturbance  of  innervation.  This 
kind  of  dyspnoea,  unconnected  with  any  appreciable  lesion  of  the  lungs, 
pleurae,  heart,  pericardium,  or  great  vessels,  is  one  of  the  most  unfavorable 
symptoms  which  can  occur.  The  symptoms  referable  to  the  nervous  system 
became  more  formidable,  and  our  patient  died  during  the  day. 

On  opening  the  body,  our  attention  was  chiefly  directed  to  the  lungs, 
heart,  and  membranous  coverings  of  the  encephalon.  I  was  the  more 
desirous  to  discover  whether  there  was  any  Lesion  in  these  latter  organs,  as 
in  the  girl  who  was  the  subject  of  our  first  case,  the  nervous  symptoms  were 
referred  to  the  meninges.  The  autopsy,  which  was  carefully  math',  revealed 
nothing.  The  encephalon,  attentively  examined,  presented  no  trace  of 
lesion;  and  in  the  lungs,  there  was  nothing  found  except  slight  congestion, 
such  as  we  find  in  persons  who  have  died  a  violent  death.  The  heart, peri- 
cardium; and  large  vessels  were  in  a  perfectly  healthy  state.  The  results 
of  the  microscopic  examination  did  not  surprise  me,  lor  1  had  often  ex- 
amined the  bodies  of  persons  carried  oil'  under  similar  circumstances,  and 
had  never  met  with  any  appreciable  alterations   in    the   encephalon.  which, 

however,  is  not  equivalenl  to  saying  that  it  is  uever  the  seat  of  any  organic 

changes.      These  morbid   changes   are   met  with    in   connection  with  certain 

Bvmptoms  referable  to  the  nervous  Bystem,  bul  essentially  differenl  from 
the  symptoms  presented  by  the  patient  whose  organs  are  now  under  our 
consideration,  and  which  organs  had  no  trace  in  them  of  the  Bymptoms 
which  had  occurred  during  life. 

We,  therefore,  had  to  do  in  this  case  with  the  delirium  to  which  our 
predecessors  gave  the  name  of  delirium  sine  materia  -cerebral  disturbance 


SCARLATINA.  165 

without  appreciable  lesion  of  the  brain.  We  all  form  a  strange  conception 
of  the  nature  of  delirium.  When  it  occurs  in  the  course  of  an  acute  affec- 
tion, we  at  once  explain  it  by  invoking  cerebral  hyperemia,  and  ourtheory, 
which  has  in  it  something  of  the  leaven  of  the  old  physiology,  ia  based  on 
a  belief  in  the  irritation  of  the  organ  of  the  function  which  is  disordered. 
Such  was  the  language  used  in  1820,  1*24.  and  1825;  and  at  the  present 
day,  these  ideas  exist  in  a  modified  form.  There  is,  it  appears,  therefore, 
a  desire  to  attribute  functional  disturbance  to  a  state  of  congestion  leading 
to  inflammation.  The  simplicity  of  the  theory  certainly  makes  it  attrac- 
tive. A  man  is  delirious,  he  coughs,  he  vomits  bile:  nothing  is  easier  than 
to  say  that  he  has  cerebral,  pulmonary,  or  hepatic  hyperemia.  But  at  the 
autopsy,  the  aspect  of  the  case  is  changed,  when  the  examination  of  organs 
frequently  demonstrates  that  an  erroneous  opinion  has  been  formed.  The 
supposed  hyperemia  does  not  in  any  way  reveal  its  past  existence:  reason- 
ing, moreover,  shows  a  connection  between  the  phenomena  during  life  and 
appearances  after  death*  appreciable  to  the  senses. 

Is  not  anaemia — the  condition  exactly  the  opposite  of  hyperemia — accom- 
panied by  similar  symptoms?  Do  not  the  animals  whose  throats  are  cut 
in  the  slaughter-houses  die  in  convulsions  from  loss  of  blood?  What  are 
these  convulsions,  if  they  be  not  a  sort  of  delirious  action  of  the  muscles? 
Why  may  not  anaemia  produce  in  the  same  way  a  delirious  action  of  the 
intellect?  A  woman,  in  consequence  of  profuse  metrorrhagia,  is  attacked 
Avith  great  functional  disturbance  of  the  cerebro-spinal  centres :  in  such  a 
case,  it  is  clear  that  hyperemia  cannot  be  assigned  as  the  cause  of  the 
nervous  symptoms.  In  such  cases,  wre  have  an  absolute  demonstration  of 
the  fact,  that  anaemia  can  produce  convulsions,  coma,  and  delirium.  We 
have,  therefore,  no  right  to  assert,  as  one  is  too  often  tempted  to  do,  that 
these  symptoms  depend  on  congestion  of  the  nervous  system.  There  is  no 
doubt  evidence  to  show  that  they  sometimes  depend  on  that  state,  and  on 
meningitis;  but  meningitis  is  far  from  being  a  condition  essential  to  their 
production. 

In  septic  diseases,  the  conditions  are  very  different,  for  then  we  have  to 
do  with  real  cases  of  poisoning.  Whether  the  blood  undergoes  a  great 
change  under  the  influence  of  the  toxic  principle,  or  whether  it  is  only  the 
medium  by  which  the  poison  is  carried  to  the  centres  of  nervous  power, 
there  to  originate  disordered  action,  still,  the  same  thing  wThich  happens  in 
septic  diseases  also  occurs  when  we  administer  drugs  having  an  action  on  the 
nervous  system,  such  as  belladonna,  henbane,  mandrake,  thorn-apple,  and 
hemlock,  substances  which  cause  delirium  varying  in  character  according  to 
the  individual  substance  given.  The  delirium  caused  by  opium  is  different 
from  that  caused  by  members  of  the  family  Solinacee,  and  they  again  do 
not  produce  the  same  kind  of  delirium  as  is  determined  by  the  Uinbellifera?. 
The  differences  in  the  character  of  the  nervous  symptoms  resulting  from 
the  administration  of  different  drugs  are  so  distinctive,  that  a  physician 
acquainted  with  their  respective  modes  of  action  will,  from  the  form  in 
which  the  convulsions  or  delirium  show  themselves,  be  able  to  recognize 
the  particular  substance  which  has  produced  them.  The  septic  poisons  of 
scarlatina,  measles,  small-pox,  malignant  pustule,  dothienteritis,  or  puer- 
peral fever,  have  also  their  special  action  on  the  nervous  system.  Why, 
therefore,  should  we  be  surprised  to  see  these  poison-diseases  accompanied 
by  delirium  ?  To  explain  this,  is  it  necessary  to  have  recourse  to  hyper- 
emia, seeing  that  it  is  not  taken  into  account  in  considering  cases  of  poison- 
ing with  vegetable  substances?  In  both  classes  of  cases,  the  symptoms 
arise  independently  of  hyperemia;  and  our  inability  to  discover  their  cause 
is  no  reason  whv  we  should  be  forced  to  admit  the  existence  of  an  unknown 


166  SCARLATINA. 

action  which  we  cannot  explain.  Moreover,  delirium  and  other  nervous 
symptoms  may  occur  irrespective  altogether  of  any  toxic  or  septic  cause : 
they  may  be  produced  by  mere  tickling,  using  the  word  [yellieatioii]  in  the 
acceptation  of  the  Latin  verb  vellicare. 

Cases  are  mentioned  in  which  persons  have  caused  women  to  die  by 
tickling  the  soles  of  their  feet.  The  unfortunate  victims  became  exhausted 
and  fell  into  a  state  of  violent  delirium,  accompanied  by  extraordinary 
nervous  phenomena.  Tickling  may  by  itself,  then,  produce  delirium,  or 
an  exaggerated  state  of  innervation  caused  by  forced  excitement  of  the 
nervous  system,  similar,  for  example,  to  a  condition  almost  physiological, 
that  which  exists  in  the  act  of  copulation.  This  tickling  \_rel/ieatioit~\ — to 
continue  the  use  of  the  word — this  unnatural  excitement  of  the  sensibility, 
due  perhaps  to  reflex  action,  is  equally  liable  to  occur  in  the  nervous  ap- 
paratus of  organic  life,  and  in  that  which  regulates  relative  life.  It  is  thus 
that  we  can  explain  certain  formidable  symptoms  in  children,  such  as 
delirium,  convulsions,  paralysis,  and  loss  of  vision,  caused  by  the  presence 
of  intestinal  worms,  even  when  the  worms  occasion  no  decided  pain  in  the 
abdominal  viscera.  In  these  cases,  cerebral  hyperemia  plays  no  part ;  and 
even  in  other  cases  where  the  brain  is  directly  implicated,  congestion  has 
no  share  in  the  production  of  the  nervous  phenomena  to  which  I  am  now 
calling  your  attention.  In  the  insane,  in  individuals  who  during  many 
years  have  had  frequent  attacks  of  delirium,  we  occasionally  find  on  dissec- 
tion lesions  indicative  of  chronic  inflammation  having  "existed,  but  most 
frequently  we  meet  with  no  traces  of  hyperemia.  Still  less  will  hyperemia 
explain  that  sort  of  delirium,  or  transient  disturbance  of  the  intellectual 
powers,  to  which  men  of  the  greatest  abilities  and  best  regulated  minds  arc 
sometimes  subject. 

Let  us  now  return  to  the  treatment  of  scarlatina  by  cold  affusions.  You 
must  quite  understand  that  I  do  not  employ  them  indiscriminately  in  all 
ordinary  cases  of  the  disease,  as  is  the  practice  of  the  extreme  partisans  of 
the  treatment :  I  only  use  them  to  subdue  serious  nervous  complications — 
formidable  ataxic  symptoms. 

We  may  also  beneficially  combat  ataxic  symptoms  by  internal  remedies. 
In  their  first  rank  stand  ammonia,  and  its  preparations  carbonate  of 
ammonia  and  spirit  of  Mindererus.  the  hitter  being  a  mixture  of  acetate  of 
ammonia  with  some  einpyreuinatie  products.  Both  preparations  in  doses 
of  from  two  to  four  grammes,  ami  the  solution  of  ammonia  in  doses  of  from 
ten  to  twenty  drops  may  prove  very  useful.  1  may  say  the  same  of  musk, 
which  is  prescribed  in  doses  of  twenty,  thirty  and  forty  centigrammes,  and 
of  which  as  much  as  a  gramme  may  he  given  in  twenty-four  hour.-.  Some 
prudence  is  required  in  the  tnanagemenl  of  these  remedies:  they  constitute 
an  accessory  means  of  treatment  in  the  eases  iii  which  we  use  the  cold 
affusions  ;  and  when  for  any  reason  the  a  I  In -ions  are  not  employed,  ammonia 
and  musk  are  our  principal  therapeutic  agents. 

Scarlatinous  sore  throat  accompanied  by  fibrinous  exudation  does  not 
involve  absolute  danger,  unless  the  exudation  is  excessive.  Under  obser- 
vation of  the  followers  of  any  clinical  practice,  1  have  allowed  patients 
laboring  under  this  affection  to  remain  without  treatment  ;  and  this  absti- 
nence from  interference  was  very  conspicuous  in  the  case  of  a  lad  who 
occupied  bed  No.  L7  in  St.  Agnes's  Ward.  In  his  case,  the  fibrinous  exuda- 
tions and  the  pappy  patches  on  the  tonsils  disappeared  spontaneously 
within  lour  or  live  days. 

Though  this  kind  of  sore  throat  undergoes  spontaneous  cure  in  simple 
scarlatina,  the  throat  affection  is  generally  intractable  in  the  malignant 

form  of  the  disease.      I   have   tried   cauterization  with  nitrate  of  silver  and 


SCARLATINA.  167 

with  hydrochloric  acid;  I  have  tried  borax  washes;  I  have  prescribed 
chlorate  of  potash  in  gargles  and  potions;  and  I  declare  that  they  have  all 
frequently  failed  to  produce  any  beneficial  results  in  the  sore  throat  of 
malignant  scarlatina.     The  least  untrustworthy  of  these  therapeutic  agents 

is  hydrochloric  acid,  which  when  applied  twice  a  day  has  appeared  to  have 
some  efficacy.  This  caustic  requires  to  be  employed  with  prudence  and 
precaution.  In  children  struggling  to  resist  the  application,  there  is  a  risk 
of  burning  the  tongue,  injuring  the  teeth,  and  touching  the  internal  surface 
of  the  mouth,  thereby  almost  always  aggravating  the  evil  without  properly 
effecting  the  cauterization.  But  by  holding  the  child  in  a  convenient 
position,  and  separating  the  jaws  by  means  of  a  tongue-depressor,  it  is  pos- 
sible exactly  to  touch  the  affected  parts  with  a  hair-pencil  soaked  in  the 
acid.  Good  results  are  sometimes  obtained  by  cauterizations  effected  in 
this  manner  twice  in  twenty-four  hours  for  five  or  six  days. 

Insufflation  of  alum  and  tannin,  practiced  alternately,  are  also  very 
useful. 

When  this  bad  form  of  the  affection  of  the  throat  is  met  with  after  the 
acute  stage  of  the  attack,  coming  on  suddenly  about  the  ninth  or  tenth  day 
with  copious  discharge  from  the  nose,  deafness  and  acute  pain  in  the  ears, 
horrible  fetor  of  the  breath,  great  frequency  of  the  pulse,  and  depression  of 
the  vital  power,  I  look  upon  it  as  a  diphtheritic  complication  of  the  erup- 
tive fever.  I  have  found  that  all  means  directed  against  it  prove  ineffectual. 
Styptic  nasal  injections  of  solutions  of  sulphate  of  copper,  sulphate  of  zinc, 
nitrate  of  silver,  of  decoction  of  rhatany,  and  of  tannin,  as  "well  as  energetic 
cauterizations  of  the  throat,  have  all  failed :  whatever  was  done,  the  pa- 
tients almost  invariably  died.  In  these  cases,  the  general  treatment  is  the 
most  important :  we  must  chiefly  rely  on  diffusible  stimulants,  sulphate  of 
quinine,  infusion  of  coffee,  and  especially  on  a  system  of  tonic  alimentation: 
but  it  too  often  happens  that  these  measures  prove  of  no  avail. 

"We  must  now  consider  the  treatment  of  scarlatinous  anasarca  and  its 
complications.  As  I  have  already  remarked,  anasarca  occurs  perhaps  less 
frequently  after  severe  cases  than  during,  or  at  the  decline  of,  mild  attacks. 
It  is  sometimes  a  very  formidable,  and  at  other  times,  not  at  all  a  serious 
complication.  When  the  anasarca  is  slight,  hygienical  measures,  rest  in 
bed,  tepid  drinks,  and  moderate  diet  are  all  that  is  required ;  and  even  in 
slight  anasarca  associated  with  some  hematuria,  the  symptoms  may  be 
easily  subdued  by  acid  drinks,  lemonade,  decoction  of  uva  ursi  sweetened 
with  spirit  of  turpentine,  small  doses  of  foxglove,  and  mild  laxatives.  But 
when  the  anasarca  increases  very  rapidly,  it  is  necessary  to  have  recourse 
to  other  means  for  the  prevention  of  the  "troublesome  symptoms  which  then 
threaten.  As  the  treatment  required  in  the  two  forms  of  the  affection  is 
different,  you  require  to  keep  both  present  to  the  mind.  When  the  anasarca 
is  accompanied  by  a  real  febrile  reaction  characterized  by  heat  of  skin, 
quickness  of  pulse,  oppressed  breathing,  thirst  and  dry  tongue,  antiphlogis- 
tic treatment  is  necessary,  and  you  may  with  great  benefit  bleed  from  the 
arm  once  or  even  twice  :  the  relief  afforded  by  the  bloodletting  is  shown  by 
a  diminution  of  the  phenomena  of  reaction.  By  following  up  the  abstrac- 
tion of  blood  by  the  administration  of  calomel  in  minute  doses — a  specially 
excellent  antiphlogistic  measure — you  deprive  the  anasarca  of  its  acute 
chai-acter,  while  at  the  same  time,  by  the  purgative  action  of  the  medicine, 
you  lessen  the-  oedema.  This  result  may  now  be  accelerated  by  giving  di- 
uretics, although  before  the  institution  of  the  autiphlogistric  treatment  they 
had  been  of  no  use. 

Should  the  oedema  be  of  a  cold  character,  unaccompanied  by  fever,  you 
must  abstain  from  bloodletting,  and  promptly  administer  those  purgatives 


168  SCARLATINA. 

which  cause  the  intestinal  raucous  membrane  to  pour  forth  serosity  in  such 
abundance  as  to  bring  about  the  cessation  of  the  anasarca,  and  you  will  also, 
with  the  same  object,  stimulate  the  urinary  secretion  by  diuretics,  If  the 
relaxation,  the  loss  of  tone  in  the  tissues,  should  be  very  great,  it  will  be 
advantageous  to  combine  the  employment  of  tonics,  particularly  quinine, 
with  the  treatment  now  recommended,  or  to  give  large  doses  of  the  iodide 
of  potassium,  a  remedy  much  lauded  in  such  cases  by  Graves. 

The  acute  form  of  anasarca  is  often  preceded  or  accompanied  by  hsema- 
turia,  or  at  least  by  the  passing  of  some  of  the  constituents  of  the  blood  with 
the  urine.  All  pathologists  are  agreed  in  attributing  this  passing  of  blood 
or  of  its  elements  to  hyperemia  of  the  kidneys,  often  inflammatory  in  char- 
acter, as  is  evident  from  its  attendant  febrile  reaction.  Measures  of  general 
depletion,  such  as  I  have  recommended  in  the  acute  form  of  the  anasarca, 
have  a  very  beneficial  influence  on  this  kind  of  renal  congestion.  I  concur 
with  the  unanimous  opinion  of  clinical  teachers  that  diuretics  do  harm  by 
increasing  the  renal  hypersemia,  and  consequently  augmenting  the  quantity 
of  blood  passed  with  the  urine.  Benefit  is  often  derived  from  the  use  of 
haemostatics,  such  as  sulphuric  acid  or  alcoholized  sulphuric  acid  [eau  de 
Babel] — the  latter  in  doses  of  two,  three,  or  four  grammes  a  day,  in  a  tisane 
sweetened  with  syrup  of  rhatany. 

Among  the  complications  of  scarlatina,  anasarca  is  that  which  is  most 
frequently  brought  on  by  exposure  to  cold.  It  is  necessary,  therefore,  to 
protect  patients  as  much  as  possible  from  this  influence,  particularly  at  the 
epochs  of  the  disease  at  which,  according  to  statistical  data,  the  swelling 
is  most  liable  to  occur ;  that  is  to  say,  during  the  second  and  third  week, 
and,  in  a  very  special  manner,  immediately  before  the  fourteenth  and 
twenty-first  day.  The  precautions  to  be  taken  will  be  more  or  less  rigor- 
ous according  to  the  season  of  the  year. 

There  is  no  similarity,  but  on  the  contrary  curious  differences  between 
small-pox,  measles,  and  scarlatina,  in  their  relation  to  the  injurious  influ- 
ence of  cold.  Sydenham  thought  that  small-pox  patients  ought  to  get  up 
every  day,  even  when  the  eruption  was  at  its  height :  and  nothing  hap- 
pened to  show  that  patients  treated  in  this  way  were  disposed  at  any  period 
of  the  malady  to  contract  intercurrent  affections  through  chills.  Patients 
Buffering  from  measles  are  neither  so  little  affected  by  exposure  to  cold  as 
variolous  patients,  nor  so  susceptible  to  it  as  scarlatinous  patients.  Upon 
some  persons  suffering  from  measles,  cold  seems  to  produce  no  impression, 
whilst  it  increases  in  others  the  bronchitis,  the  inseparable  companion  of 
the  eruption  :  this  affection  may  extend  to  the  minutest  bronchial  ramifi- 
cations, and  to  the  pulmonary  tissue,  giving  rise  to  capillary  bronchitis  or 
a  special  form  of  pneumonia,  the  two  most  serious  complications  of  measles. 
The  pulmonary  complication  sometimes  supervenes  during  a  slight  attack 
of  anasarca.  The  susceptibility  to  cold  is  at  its  maximum  in  scarlatinous 
patients.  Hence  it  is  necessary  to  take  the  greatesl  possible  precautions 
to  protect  the  patients  from  exposure  to  chills.  But  in  saying  this,  1  do 
not  mean  to  imply,  t  hat  it  is  ever  right,  at  any  stage  of  the  disease,  to  shut, 
up  the  patient  in  a  suffocating  atmosphere,  to  load  him  with  blankets,  and 
excite  him  with  hot  drinks.     A  moderate  temperature,  no  more  blankets 

than  he  is  accustomed  to  iii  health,  and  the  use  of  tepid  beverages,  acidu- 
lated and  slightly  cooling,  arc  the  most  appropriate  measures.  It  is  neces- 
sary,  however,  to  Confine  scarlatinous  convalescents  to  their  rooms  for  a 
long  lini",  to  save  them  IVoin  the  risk  of  exposure  to  sudden  transitions  of 
temperature,  currents  of  cold  air,  and  damp;  for  from  such  causes  arise 
ana-ana,  hematuria,  effusion  into  the  pleura'  and  pericardium,  or  still 
worse  into  the  ventricles  of  the  brain. 


SCARLATINA.  1G9 

Extensive  anasarca,  coming  on  rapidly,  is  often  accompanied  by  con- 
vulsions which  sometimes  prove  fatal  in  their  first  attack.  Brisk  purga- 
tives are  useful  in  these  cases  by  stimulating  the  intestine  to  discharge  a 
part  of  the  serosity  effused  into  the  cellular  tissue.  The  patient  should  be 
placed  ou  the  edge  of  the  bed  with  the  legs  hanging  over  it,  and  ought 
to  have  the  head  propped  up  by  pillows.  By  these  means  an  impending 
attack  of  convulsions  may  be  warded  off.  But  sometimes,  from  the  con- 
vulsions occurring  without  the  slightest  premonitory  signs,  no  preventive 
means  can  be  attempted.  The  patient  complains  of  intense  headache,  im- 
perfect vision  in  one  or  both  eyes,  ringing  in  the  ears,  and  very  obvious 
deafness.  In  these  cases  scarifications  of  the  inferior  extremities  may  be 
useful,  by  producing  disengorgement.  This  object,  however,  is  more  suc- 
cessfully attained  by  applying  very  large  blisters  to  the  legs — not  to  the 
thighs.  In  seven  or  eight  hours,  phlyetaense  are  formed  :  by  opening  them, 
an  exit  is  afforded  to  a  stream  of  serosity,  by  which  discharge  the  patient 
is  wonderfully  relieved,  and  enabled  to  tide  over  the  most  perilous  crisis 
of  his  anasarca. 

When  convulsions  occur  during  the  disease,  give  rausk  in  combination 
with  small  doses  of  belladonna.  To  children  between  eight  and  ten  years 
of  age,  give  the  musk  in  doses  of  from  twenty-five  to  forty  centigrammes, 
and  the  belladonna  in  doses  not  exceeding  one  centigramme,  in  the  form 
of  a  draught.  At  the  same  time  that  you  employ  these  medicines,  you 
ought  also  to  practice  compression  of  the  carotids,  a  means  which  I  have 
extolled  for  twenty  years,  and  which  has  rendered  very  great  services  to 
me  and  other  physicians.  The  compression  requires  to  be  performed  with 
care  and  according  to  rule.  If  one  side  is  more  affected  than  the  other 
by  epileptiform  convulsion,  it  is  on  the  opposite  side  that  the  compression 
ought  to  be  most  specially  applied.  If  the  convulsion  predominates  on 
the  right  side,  you  compress  the  left  carotid ;  and  if  it  predominate  on  the 
left  side,  you  compress  the  right  carotid.  If  both  sides  are  equally  con- 
vulsed, you  compress  each  carotid  alternately.  Of  course  I  am  speaking 
of  the  common  carotids.  The  compression  must  be  effected  in  such  a  way 
as  to  interfere  as  little  as  possible  with  the  respiration  of  the  child.  The 
compression  of  these  vessels  is  much  easier  than  you  might  suppose.  You 
place  yourself  in  such  a  position  as  will  enable  you  to  compress  the  right 
carotid  with  the  left  hand,  and  the  left  carotid  with  the  right  hand.  You 
keep  apart  the  bellies  of  the  sterno-cleido-mastoid  muscle ;  and  then,  at 
the  same  time  that  you  isolate  the  windpipe,  using  the  back  of  the  distal 
phalanx,  you  feel  the  pulsations  of  the  artery,  which  is  very  mobile.  You 
then  seize  the  artery  with  the  cushioned  extremities  of  the  fingers,  push  it 
a  little  backwards,  and  press  it  against  the  vertebral  column.  You  imme- 
diately find  that  the  vessel  is  compressed,  by  observing  that  there  is  an 
absence  of  pulsation  in  the  corresponding  temporal  artery,  and  perhaps 
also  by  seeing  a  sudden  paleness  take  the  place  of  the  previous  red  color 
of  the  child's  face.  Sometimes,  also,  you  have  the  satisfaction  to  find  that 
no  sooner  is  the  compression  established  than  the  eclampsia  entirely  ceases. 
You  maintain  the  pressure  for  fifteen  to  twenty  minutes,  first  on  one  artery 
and  then  on  the  other.  It  is  useful  to  have  the  co-operation  of  an  assistant 
in  this  irksome  operation.  Mothers,  who  through  affectionate  anxiety  for 
their  children  become  so  intelligent,  may  take  your  place  for  a  time.  You 
may  thus,  by  exercising  the  necessary  patience,  in  a  few  hours,  in  a  certain 
number  of  cases,  put  a  stop  to  the  convulsions  which  accompany  scarlati- 
nous anasarca. 

Serous  effusion  into  the  pleurse  and  pericardium,  formidable  complica- 
tions which  occur  in  the  last  stage  of  scarlatina,  about  the  same  period  as 


170  MEASLES. 

anasarca,  ought  to  be  treated  by  a  succession  of  large  flying  blisters.  If 
the  hydrothorax  or  peri  cardie  effusion  be  considerable,  tapping  will  be 
useful.  When  the  pleural  effusion  is  very  great,  paracentesis  is  sometimes 
a  necessity  after  a  few  days.  But  it  often  happens,  as  I  have  already  ob- 
served to- you,  that  at  the  first  tapping,  even  when  the  effusion  is  not  of 
older  date  than  ten,  fifteen,  or  twenty  days,  you  may  find  the  serosity  lac- 
tescent, and  even  containing  formed  pus :  you  have  then  to  do  with  veri- 
table empyema,  a  formidable  complication  which  is  often  curable  in  young 
subjects  by  tapping  and  frequent  iodinous  injections;  but  which,  notwith- 
standing the  use  of  these  means,  rarelv  terminates  favorablv  in  adults. 


LECTURE  VI. 

MEASLES ; 
AND   IN   PARTICULAR  ITS  UNFAVORABLE  SYMPTOMS  AND  COMPLICATIONS. 

Normal  Measles. — Period  of  Invasion  is  longer  than  in  any  other  Eruptive 
Fever. —  Complications  of  the  Period  of  Invasion. —  Convulsions  at  the 
Beginning  of  the  Attack. — False  Croup. — Suffocative  Catarrh. — Epis- 
taxis. —  Otitis. — Diarrhoza. —  Complications  of  the  Eruptive  Stage,  and  of 
the  Last  Stage. 

Gentlemen  :  In  speaking  of  measles,  I  shall  not  go  into  the  subject  with 
that  circumstantial  detail  with  which  I  have  treated  scarlatina.  There  is 
no  eruj)tive  disease  which  assumes  such  strange  forms,  and  furnishes  mate- 
rials for  so  much  pathological  discussion  as  scarlatina  :  measles  has  not  the 
same  claims  on  our  attention.  I  shall,  therefore,  only  trace  rapidly  the 
symptoms  of  measles  in  its  normal  form,  and  specially  enlarge  upon  the 
unfavorable  symptoms  and  complications  which  may  accompany  or  follow 
an  attack  of  that  disease.  These  unfavorable  symptoms  ami  complications 
are  unfortunately  too  little  known  to  young  physicians,  as  1  have  often  had 
occasion  to  point  out  to  you.  You  are  aware,  gentlemen,  that  it  is  not  for 
me  in  a  course  of  clinical  lectures  to  give  you  a  complete  history  of  measles : 
that  duly  belongs  to  the  professor  of  medical  pathology.  But  I  wish  to 
make  you  acquainted  with  the  complications  of  this  exanthematous  pyrexia, 
explaining  to  you  their  mode  of  evolution  by  analyzing  and  discussing 
cases  selected  for  that  purpose  in  the  wards.  \  must,  however,  in  a  sum- 
mary manner,  recall  to  your  recollection  the  ordinary  phenomena  of  the 
different  Stages  of  measles,  which,  when  they  become  exaggerated,  constitute 
whal   we  call  the  complications. 

From  the  very  heginning  of  the  attack,  in  the  simplest  forms  of  the  dis- 
ease, symptoms  present  themselves  in  the  mucous  membranes  of  the  eye 
and  respiratory  passages,  which  are  perfectly  well  known  to  those  who  have 

once  observed  them.  They  consist  in  lachrymation,  injection  of  the  eyes, 
and  slight  intolerance  of  light  ;  in  coryza,  characterized  by  a  flow  of  acrid 
tenacious  mucus,  frequenl  sneezing,  and  often  accompanied  by  profuse 
epistaxis;  and  in  a  severe  cough, at  times  a  little  hoarse, and  at  other  times 
very  violent  and  very  harassing.  The  mucous  membranes  of  the  ej  es,  oose, 
larynx,  and  bronchial  tubes  are  affected,  therefore,  from  the  earliest  days 
of  an  attack  of  measles.     From  the  very  first  day,  a-  in  scarlatina,  they 


MEASLES.  171 

show  the  presence  of  the  eruption  ;  and  before  there  is  any  exanthem  on 
the  skin,  you  see  the  disease  inscribed  on  the  pharynx,  tonsils,  and  veil  of 
the  palate. 

In  this  stage — the  stage  of  invasion — the  lever  has  nor  the  same  char- 
acter as  in  small-pox,  in  which  disease,  from  the  very  outset  of  the  first 
febrile  symptoms  up  to  the  appearance  of  the  eruption,  the  fever  is  con- 
tinuous, always  lasting  at  least  till  the  day  on  which  the  pustules  come  out. 
In  measles,  the  febrile  symptoms  follow  an  entirely  different  course,  which 
.sometimes  singularly  misleads  physicians.  Sometimes  the  fever  continues 
up  to  the  period  of  eruption  ;  at  other  times,  it  only  lasts  one  or  two  flays, 
abating  very  much,  and  sometimes  ceasing  entirely  on  the  third  day,  leav- 
ing the  patient,  whether  adult  or  child,  with  only  a  slight  feeling  of  dis- 
comfort ;  it  reappears,  however,  with  great  intensity,  on  the  day  the  eruption 
comes  out.  It  begins  with  slight  rigors,  recurring  from  three  to  six  times 
in  the  twenty-four  hours,  which,  as  they  are  followed  by  hot  fits  and  sweat- 
ing, simulate  the  paroxysms  of  the  remittent  and  intermittent  fevers,  which 
have  a  tendency  to  become  continued,  and  are  rather  common  in  the  begin- 
ning of  attacks  of  dothienteritis.  In  the  absence  of  lachrymation,  coryza, 
epistaxis,  and  cough,  one  is  very  often  embarrassed  as  to  the  diagnosis,  and 
does  not  recognize  the  existence  of  measles  at  the  beginning  of  the  attack, 
unless  guided  by  other  circumstances  than  those  which  belong  to  the  dis- 
ease itself,  such  as  some  of  the  family  having  measles,  or  its  being  at  the 
time  prevalent  as  an  epidemic.  The  duration  of  the  period  of  invasion  is, 
therefore,  a  material  circumstance  in  relation  to  the  diagnosis. 

The  period  of  invasion  is  ionger  in  measles  than  in  any  other  eruptive 
fever.  In  scarlatina,  on  the  other  hand,  it  is  shorter  than  in  any  other 
eruptive  fever,  its  duration  sometimes  not  exceeding  a  few  hours  or  a  few 
minutes.  Xext  comes  confluent  small-pox,  the  invasion  stage  of  which 
continues  three  days,  the  pustules  appearing  very  regularly  at  the  end  of 
the  third  or  beginning  of  the  fourth  day.  The  cutaneous  exanthem  of 
measles  does  not  appear  till  the  fourth  or  fifth  day,  and  sometimes,  even  in 
perfectly  uncomplicated  cases,  not  till  the  sixth,  seventh,  or  eighth  day. 
We  have  just  had  an  example  of  this  in  the  workman  of  twenty-eight  years 
of  age  who  occupied  bed  Xo.  18,  St.  Agnes's  Ward.  In  his  case  I  completely 
mistook  the  nature  of  the  disease,  as  the  eruption  of  measles  did  not  appear 
till  the  seventh  day :  notwithstanding  the  delay  in  the  eruption,  the  case  , 
was  free  from  any  complication.  In  rare  and  exceptional  cases  of  scarla- 
tina and  small-pox,  when  serious  complications  supervene  at  the  beginning 
of  the  attack,  the  appearance  of  the  eruption  is  retarded  :  in  measles  the 
general  rule  is  that  the  duration  of  the  period  of  invasion  is  four  or  five 
days,  irrespective  of  all  complications. 

During  the  period  of  invasion,  at  the  very  time  when  the  fever  seems  to 
be  subsiding,  it  suddenly  acquires  a  considerable  renewal  of  its  intensity. 
The  lachrymation,  coiyza,  and  cough,  after  having  been  for  a  very  brief 
space  of  time  in  abeyance,  return  with  extreme  severity;  and  simultaneously 
with  this  exacerbation  of  symptoms,  very  profuse  diarrhoea  .-upervenes  in 
the  majority  of  cases.  This  phenomenon — the  simultaneous  advent  of  erup- 
tion and  diarrhoea — belongs  essentially  to  measles,  a  fact  which  has  not  been 
sufficiently  pointed  out  by  authors.  The  occurrence,  though  not  invariable, 
is  common  enough  to  demand  special  notice.  A  child  will  have  from  four 
to  fifteen  stools  in  the  twenty-four  hours.  In  some  cases  the  diarrhoea  is 
not  only  serous,  but  likewise  glairy  and  bloody,  caused  by  an  inflammatory 
affection  of  the  colon,  which  continues  for  a  (lay  or  two.  If  the  diarrhoea 
continue  for  more  than  twenty-four  hours,  it  may,  in  very  young  children, 


172  MEASLES. 

become  a  source  of  danger,  and  ought,  therefore,  to  be  checked  as  quickly 
as  possible. 

The  eruption  first  appears  on  the  face,  next  day  (the  fifth  or  sixth  of  the 
attack  |  it  invades  the  trunk,  and  on  the  following  day  the  limbs,  after 
which  it  is  general.  I  perceive,  gentlemen,  that  I  am  causing  you  to  take 
up  an  erroneous  impression.  I  already  hear  some  of  you  reminding  me, 
that  I  have  several  times  shown  you  in  our  nursery  wards  infants  in  whom, 
at  the  second  day  of  the  fever  of  measles,  small  efflorescences  were  visible, 
in  situations  where  the  skin  was  hot  and  covered  with  perspiration.  On 
the  next  day,  or  the  day  after  the  next,  there  was  scarcely  a  trace  of  these 
efflorescences  to  be  found  ;  and  on  the  regular  day  of  the  eruption  becom- 
ing due,  it  appeared  with  its  precise  characters  well  marked.  I  must  here 
repeat  what  I  have  already  said  to  you  beside  the  cradles  of  our  little 
patients,  regarding  the  limits  of  the  law  of  evolution  in  the  exanthem  of 
measles.  But  in  many  cases  analogous  to  those  which  I  have  just  brought 
before  you,  the  efflorescences  mentioned  were  nothing  more  than  sudorific 
exanthemata,  an  eruption  not  to  be  confounded  with  the  specific  exauthems 
of  measles. 

So  long  as  the  eruption  of  measles  remains  bright  and  blooming  [yive  et 
fleurie]  the  fever  continues  very  intense.  This  is  also  the  case  in  scarlatina  ; 
but  the  opposite  is  the  rule  in  distinct  small-pox,  in  which  the  fever  at  once 
subsides  when  the  pustules  appear,  to  be  rekindled,  however,  on  the  eighth 
day  of  the  disease,  the  commencement  of  the  period  of  maturation.  In 
measles,  then,  the  fever  goes  on  for  two  or  three  days  after  the  appearance 
of  the  eruption:  it  then  subsides  because  the  eruption  subsides:  should  it 
not  then  subside,  there  is  reason  to  fear  the  occurrence  of  complications. 

To  increased  lachrymation,  coryza,  and  cough,  there  are  generally  added 
a  little  deafness,  sometimes  acute  pain  in  the  ears,  in  consequence  of  the 
Eustachian  tubes  being  affected  like  the  other  passages  lined  by  mucous 
membrane. 

The  eruption  in  its  simplest  form,  particularly  when  examined  on  the 

chest  and  abdomen  rather  than  on  the  face,  presents  a  crop  of  small,  red, 

velvety  elevations,   having  neither  the  roughness  to  the  touch  nor  the 

wrinkled  aspect  so  often  met  with  in  the  eruption  of  scarlatina.     They  have 

a  certain  similarity  to  the  elevations  of  urticaria:  both  the  dermis  and  epi- 

.  dermis  are  raised  up,  and  the  elevations  are  even  more  appreciable  by  touch 

than  sight.     The  elevations  are  generally  of  unequal  shape,  ami  somewhat 

variable  in  size,  being  about  as  large  as  a  grain  of  rice  or  wheat,  and  so 

placed  as  to  circumscribe  portions  of  skin  free  frum  the  eruption.     The 

j  elevations  are  at  first  separate  and  disappear  under  pressure  made  by  the 

I  finger,  to  reappear  when  that  pressure  is  removed:  they  afterwards  become 

I  grouped  together  in  irregular  patches  unequally  cut  up  into  little  crescents. 

When  the  eruption  is  very  confluent,  the  redness  is  diffuse  and  uniform, 
sometimes  rendering  the  diagnosis  difficult.  Occasionally,  particularly 
f  in  summer,  when  patients  have  been  too  much  clothed  and  perspire  pro- 
fusely, vesicles  appear:  tlnv  are  acuminated,  generally  contain  a  puriform 
fluid,  have  an  inflamed  base ;  and  they  are  much  larger  than  the  vesicles 
which  are  noted  as  occurring  in  scarlatina  :  in  measles  a  vesicular  eruption 
is  exceptional,  but  in  scarlatina  it  is  the  rule. 

The  morbillous  patches  arc  sometimes  so  elevated  above  the  cutaneous 
surface  as  to  have  almost  a  papular  character.  When  this  character  pre- 
dominates in  the  eruption,  the  case  is  -aid  to  he  one  of  pimply  measles 
[rougeole  bovtonneuse]. 

It   frequently    happen-    that    when    the   eruption    has   been   very   violent, 

patches  of  a  violet-red  color  are  Been,  particularly  on  the  extremities:  they 


MEASLES.  173 

are  evidently  ecchymotic,  for  they  do  not  disappear  under  the  pressure  of 
the  finger  like  the  exanthematic  patches.  These  spots  of  purpura  remain 
for  seven,  eight,  or  ten  days  after  the  disappearance  of  the  morbillous  erup-  /  ~ 
tion,  leaving  behind  them  greenish-yellow  stains.  This  form  of  measles  is 
more  severe  than  the  other,  inasmuch  as  the  eruption  is  more  violent;  be- 
cause it  is  a  general  rule  in  eruptive  fevers — in  small-pox,  scarlatina,  and 
measles — that  the  gravity  of  the  attack  is  proportionate  to  the  intensity  of 
the  eruption.  It  is  most  frequently  met  with  during  the  predominance  of 
certain  medical  constitutions  of  the  atmosphere,  and  it  may  then  become 
one  of  the  most  seriously  complicated  kinds  of  measles. 

Generally  speaking,  during  the  periods  of  invasion  and  eruption,  on  aus- 
cultating the  chest,  we  hear  sibilant  rales  which  on  the  day  of  eruption  very 
often  become  subcrepitant,  and  which,  sometimes  general  throughout  the 
whole  extent  of  both  lungs,  are  accompanied  by  a  degree  of  oppression  in 
breathing:  we  have  subcrepitant  rales,  which  indicate  that  the  morbillous 
catarrh  already  occupies  the  minute  bronchial  tubes.  This  catarrh  may 
be  serious  from  the  first,  and  may  go  on  increasing  in  severity  up  to  the 
eighth  or  ninth  day  of  the  disease,  then  culminating  in  an  affection  of  intense 
severity.  The  subcrepitant  rales  usually  heard  at  the  time  the  eruption  is 
coming  out  need  occasion  no  alarm,  even  though  they  are  very  fine,  pro- 
vided the  other  symptoms  are  not  serious:  as  in  general  they  either  disappear 
or  diminish  about  the  seventh  or  eighth  day,  when  coarse  mucous  rales  are 
again  heard,  then  sibilant  rales,  and  finally  the  sounds  become  normal. 

Morbillous  catarrh  gives  rise  to  a  characteristic  expectoration.  I  speak 
of  what  is  seen  in  adults  and  in  children  of  the  third  age.  As  you  knowr, 
infants  at  the  breast,  and  children  under  four  or  five  years  of  age,  do  not 
expectorate.  The  sputa,  at  first  mucous,  clear,  and  limpid,  become  thick, 
globular,  greenish-yellow,  perfectly  isolated  from  one  another,  swimming  in 
more  or  less  glairy  slightly  opalescent  mucus :  they  are  nummular,  as  in 
some  phthisical  cases. 

On  the  eighth  day,  the  eruption  begins  to  disappear:  it  leaves  the  face 
and  fades  on  the  trunk.  On  the  ninth  day,  it  has  completely  left  the  limbs. 
The  symptoms  which  then  remain  are  slight  ophthalmia,  coryza,  deafness, 
and  cough,  which  go  on  gradually  decreasing  for  seven  or  eight  days,  when 
they  totally  cease. 

The  period  of  desquamation  now  commences.  Classical  authorities  speak 
of  a  furfuraceous  desquamation  consisting  of  an  epidermic  dust  resembling 
small  scales  of  bran;  but  if  you  minutely  examine  what  is  taking  place, 
you  will  find  that  there  is  not  one  in  ten  patients  who  exhibit  a  trace  of 
this  sort  of  descpuamation.  However,  when  the  skin  is  covered  with  per- 
spiration— and  perspiration  is  not  uncommon  in  measles — the  epidermic 
scales  adhere  to  the  linen,  because  the  exfoliation  is  exceedingly  thin.  The 
desquamation  is  best  seen  on  the  face,  because  the  face,  where  there  is  less 
perspiration  than  on  other  parts  of  the  body,  is  not  covered.  But  even  there, 
the  desquamation  is  often  imperceptible:  when  it  is  apparent  on  the  face,  it 
is  at  the  eighth  day,  just  as  the  eruption  is  beginning  to  fade,  and  then  you 
may  see  the  little  exfoliations  of  which  I  have  been  speaking. 

A  diagram  of  the  actual  range  of  temperature  in  a  case  of  measles,  ex- 
actly corresponds  with  what  one  would  suppose,  from  clinical  observation, 
to  be  correct;  and  it  graphically  represents  to  the  eye  the  course  of  the 
fever.  In  the  prodromic  period,  during  from  one  to  four  days,  the  tem- 
perature gradually  rises,  and  does  not  attain  its  maximum  elevation  till  the 
eruption  has  reached  its  maximum  development.  I  have  already  said  that 
the  defervescence  and  the  fading  of  the  eruption  are  coincident:  I  now  add, 
that  when  we  look  at  the  diagram  of  the  range  of  temperature,  wre  see  that 


174  MEASLES. 

the  defervescence  is  so  rapid,  so  sudden,  that  in  one  night  the  natural  tem- 
perature of  the  body  is  established.  In  severe  cases,  the  defervescence  is 
not  quite  so  abrupt,  though  still  very  rapid,  and  during  the  subsidence  of 
the  fever,  slight  exacerbations  occur  from  twenty-four  to  forty-eight  hours. 
You  see,  therefore,  that  defervescence  in  measles  is  not  lagging  as  in  scar- 
latina: the  very  opposite  is  its  character.  >So  essentially  characteristic  of 
measles  is  this  rapid  defervescence,  that  it  may  be  concluded  that  the  case 
is  anomalous,  and  that  complications  are  going  to  arise,  whenever  the  tem- 
perature remains  high  after  the  eruption  has  begun  to  fade.  The  highest 
temperature  observed  has  been  42.8°.  In  the  researches  of  Dr.  Hugo 
Siegel,  the  most  common  range  was  between  39.4°  and  40.6°. 

I  have  now,  gentlemen,  briefly  described  the  course  of  normal,  simple, 
regular  measles.  Having  given  this  rapid  sketch,  we  are  now  better  ena- 
bled to  study  the  unfavorable  symptoms  and  complications,  because  thev 
are  related  to  the  normal  phenomena  of  the  disease. 

In  children,  the  principal  complications  are  convulsions  and  false  croup; 
both  in  children  and  in  adults,  catarrh  and  epistaxis.  During  the  period 
of  invasion,  children  are  frequently  carried  off  by  convulsions  and  catarrh. 

On  the  first  day,  at  the  very  onset  of  the  fever,  convulsions  often  attack 
children  having  a  tendency  to  nervous  affections.  Such  subjects  are  liable 
to  be  seized  with  convulsions  when  fever  is  setting  in,  whether  that  fever  be 
dependent  upon  measles,  small-pox,  scarlatina,  an  intestinal  affection,  or  a 
simple  pulmonary  catarrh,  just  at  the  moment  of  the  first  rigor  announcing 
the  febrile  condition.  I  say  just  at  the  moment  of  the  rigor;  and  I  will  tell 
you  why  I  say  so.  If  you  reflect  on  the  nature  of  a  rigor,  you  will  perceive 
that  it  is  really  a  convulsion.  Study  it  isolated  in  a  "particular  part  of  the 
body — for  example,  in  the  lower  jaw.  The  rigor  shows  itself  by  the  chat- 
tering of  the  teeth,  caused  by  alternate  contraction  and  relaxation — more 
or  less  rapid — of  the  muscles  which  raise  the  lower  jaw;  the  muscular  con- 
tractions are  involuntary  and  violent.  This,  as  you  know,  is  precisely  the 
definition  of  a  convulsion.  When  the  shivering  is  general,  it  is  accom- 
panied by  headache,  violent  pains  along  the  vertebral  column,  and  shaking 
of  the  whole  body  produced  by  the  violent  and  convulsive  jerks  of  the  mus- 
cles. We  have,  in  fact,  real  fits  of  continuous  eclampsia,  less  the  cerebral 
phenomena.  How  easy  then  is  the. transition  from  a  rigor  to  a  fit  of  con- 
vulsions! This  consideration  will  lead  you  to  understand  why  it  is  gener- 
ally at  the  very  first  rigor  of  a  lever,  when  the  nervous  system  is  in  a  spe- 
cially excited  state,  thai  convulsions  occur.  When  once  the  stir-up  is  given 
to  the  nervous  system,  the  first  attack  is  followed  by  a  second,  and  by  suc- 
ceeding fits,  which  recur  under  the  influence  of  any  moral  or  physical  ex- 
citement, or  in  consequence  of  a  somewhat  decided  external  impression, 
such  as  is  Celt  on  awaking  from  sleep,  when  the  nervous  system  emerges 
from  the  state  of  repose  in  which  it  had  been  wrapped. 

Convulsions  at  the  beginning  of  an  attack  of  measles,  unless  they  recur 
frequently,  are  not  of  very  serious  import.  During  the  period  of  invasion, 
two  or  three  fits  are  not  in  themselves  alarming;  hut  if  they  go  on  continu- 
ously for  one  or  two  days,  the  child  may  be  carried  off  in  one  of  them. 
Unfortunately,  medical  intervention  has  a  large  share  in  the  misfortunes 
which  follow  in  the  train  of  eclampsia.     Nothing  alarms  a  family  so  much 

as   convulsions;   and    nothing,  I    confess,  is   mere   frightful.      Medical    men 

are -'Hi  for  in  every  direction :  the  practitioner  arriving  at  the  end  of  the 
crisis  and  observing  only  the  apoplectic  phenomena,  loses,  sometimes,  Belf- 
possession,  and  in  the  flurry  of  t  he  moment  is  liable  to  make  many  mistakes. 
He  begins  by  applying  four,  six,  or  eighl  Leeches  behind  the  ear :  he  sees 
in  the  case  cerebral  congestion,  which  seems  urgently  to  demand  abstrac- 


MEASLES.  175 

tion  of  blood,  with  a  view  to  diminish  the  vascular  engorgement.  It'  the 
patient  is  a  child  under  tour  years  of  age,  this  treatment  will  render  him 
anaemic,  ami  so  place  him  in  the  wry  condition  most  apt  to  produce  the 

evil  from  which  it  was  intended  to  save  him.  Perhaps  he  orders  cold 
baths,  and  prescribes  cold  water  to  be  affused  over  the  head  and  shoulders 

of  the  child  when  in  the  hath.  The  baths  ami  affusions  are  repeated  two 
or  three  times  during  the  course  of  the  day.  Nevertheless,  at  this  very 
time,  the  patient, perhaps, had  the  coryza  and  pulmonary  catarrh.  A  cold 
affusion,  it'  accomplished  in  a  tew  seconds,  might  do  no  harm  under  such 
circumstances;  but  that  cannot  be  said  of  prolonged  immersion,  and  far 
less  of  the  application  of  ice  to  the  head,  which  is  often  prescribed  in  such 
cases.  The  morbillous  catarrh,  always  in  itself  an  affection  sufficiently 
severe  to  make  us  endeavor  to  moderate  it,  cannot  but  increase  under  the 
influence  of  such  measures.  There  is,  unfortunately,  no  exaggeration  in 
what  I  have  now  said.  How  many  physicians  who,  though  doubtful  of  the 
utility  of  the  means  they  order,  yield  to  the  demands  by  the  relatives  of  the 
patient  for  active  treatment — for  something  energetic — for  a  great  demon- 
stration— in  cases  where  the  disease  itself  is  terrible  and  rapid.  The  treat- 
ment by  leeches  and  baths,  though  a  murderous  treatment,  is  so  entirely  in 
accord  with  the  theories  and  prejudices  of  the  public — always  ready  to 
dogmatize  in  medical  matters — that  were  it  not  for  the  grave  objections  to 
its  employment,  it  would  often  be  difficult  to  abstain  from  having  recourse 
to  it.  The  danger  is  increased  by  the  ignorance  of  some,  and  the  want  of 
energy  of  other  practitioners. 

In  other  cases,  persons  who,  though  physicians,  are  strangers  to  our  art 
act  in  a  way  still  more  disastrous.  They  pour  boiling  water  upon,  and 
surround  with  cloths  soaked  in  boiling  water,  the  legs  of  unfortunate 
children,  and  so  determine  in  them  the  occurrence  of  evils  worse  than  those 
which  they  seek  to  avert.  Who  has  not  heard  of  the  frightful  accident.-, 
the  horrible  scalds  caused  by  the  medical  application  of  water  or  some 
other  boiling  fluid,  which  annually  result  in  the  death  of  many  children? 
"Who  among  us  has  not  had  occasion  to  see  or  to  hear  related  such  cases  ? 
But  how  oblivious  of  them  are  many  practitioners  when  called  in  to 
children  in  convulsions — how  they  hasten  to  have  recourse  to  that  brutal 
treatment  which  I  now  so  emphatically  condemn  !  The  contact  of  towels 
soaked  in  boiling  water  with  the  skin  is  much  more  prolonged  than  the 
contact  which  takes  place  in  accidental  scalding.  In  an  accidental  scald, 
the  subject  is  conscious :  at  the  first  sensation  of  pain  he  proceeds  to  tear 
off  his  clothes,  and  to  beseech  others  to  help  him  in  doing  so.  But  in  the 
coma  consecutive  to  convulsions,  the  patient  feels  nothing;  and  by  allowing 
the  scalding  cloths  to  remain  so  long  in  contact  with  the  skin  those  who 
ought  to  afford  succor  kill,  when  they  believe  they  are  saving.  When 
patients  sacrificed  by  this  treatment  do  not  succumb  under  the  influence  of 
pain,  they  are  either  carried  off  by  the  violence  of  the  inflammation,  or 
they  sink  exhausted  by  the  suppuration.  Those  who  recover,  have  cica- 
trices of  greater  or  less  depth,  which  may — according  to  their  situation — 
give  rise  to  very  great  deformities.  I  have  several  times  seen  untoward 
occurrences  of  this  description.  Among  other  examples,  I  saw  one  in  the 
person  of  a  man  who  was  at  one  time  my  master,  and  who  stood  in  a 
similar  relation  to  some  of  you.  Marjolin,  in  the  course  of  an  attack  of 
typhoid  fever,  fell  into  a  profound  coma,  to  rouse  him  from  \vhich,  boiling 
water  was  applied  to  his  thighs.  He  retained  to  the  last  the  deep  scars 
which  resulted  from  this  medication,  and  which  singularly  complicated  his 
malady,  and  long  retarded  his  convalescence. 

When  a  child  is  seized  with  convulsions  at  the  onset  of  measles,  have 


176  .  MEASLES. 

the  wisdom  to  wait :  abstain  from  boisterous  practice :  inquire  whether  the 
patient  is  subject  to  eclampsia,  aud  whether  the  firs  pass  off  without  the 
interference  of  art.  If  your  inquiries  are  answered  in  the  affirmative,  very 
little  treatment  will  be  necessary;  for  in  general,  the  initiatory  convulsions 
of  eruptive  fevers  subside  spontaneously,  without  our  requiring  to  interfere. 
Abstraction  of  blood,  prolonged  baths,  scaldings  with  boiling  water,  blisters 
(which  act  in  a  manner  analogous  to  scaldings),  and  active  purging,  far 
from  being  useful,  aggravate  the  disease;  they  trammel  its  progress,  retard 
the  period  of  eruption,  and  originate  complications  which  are  often  fatal. 

There  are  exceptional  cases,  in  which  a  first  fit  of  convulsions  at  the 
beginning  of  an  eruptive  fever  is  fatal.  I  have  often  related  the  particu- 
lars of  a  case  which  occurred  under  my  own  observation  in  the  Necker 
Hospital.  A  child  of  two  years  of  age,  who  presented  no  symptoms  of 
cerebral  affection,  was  seized  with  convulsions,  when  I  was  in  the  very  act 
of  examining  him.  I  stated  to  the  pupils  then  present  at  the  visit,  the 
probable  course  of  the  symptoms:  I  spoke  to  them  of  the  tonic,  which  pre- 
ceding the  clonic  form  would  last  fifty  or  sixty  seconds,  involving  the  mus- 
cles of  the  extremities,  chest,  and  abdomen,  and  keeping  them  in  a  rigid 
state  as  at  the  commencement  of  an  attack  of  epilepsy.  But  on  two  min- 
utes having  elapsed  without  the  rigidity  giving  way,  I  began  to  be  alarmed  : 
ere  half  a  minute  more  had  passed,  we  observed  the  face  become  suddenly 
blue,  and  the  blue  color  gradually  got  deeper ;  when,  all  at  once,  the  mus- 
cles became  relaxed.     The  child  was  dead. 

However  exceptional  this  and  similar  cases  may  be,  you  may  meet  with 
cases  of  the  same  kind  in  your  practice.  It  is  essential,  therefore,  to  be 
able  to  foresee  the  chances  of  bad  luck,  and  to  make  reservations  in  an- 
nouncing your  prognosis.  I  am  now  speaking  only  of  convulsions  at  the 
beginning  of  measles  and  small-pox;  for  convulsions  at  the  onset  of  scar- 
latina are  not  exceptionally  but  always  very  unpropitious. 

You  have,  gentlemen,  very  recently  seen  in  our  nursery  wards,  two 
children,  one  of  whom  recovered, 'after  having  had  all  the  symptoms  of 
croup,  but  of  false  croup,  at  the  beginning  of  an  attack  of  measles  ;  and 
the  other  died  of  croup,  but  of  true  croup,  during  convalescence  from  the 
exanthematous  disease. 

I  cannot  tell  you  how  often  families  are  dismayed  at  the  explosion  of 
these  unfavorable  symptoms  during  the  first  four  or  live  days  of  an  attack 
of  measles  in  which  no  eruption  has  yet  appeared.  The  child,  after  hav- 
ing in  the  first  instance  shown  nothing  more  than  the  symptoms  of  a  slight 
catarrh,  is  suddenly  seized  with  alarming  oppression  of  the  chest,  accom- 
panied by  a  hour-''  cough,  wheezing  inspiration,  very  Laborious  respiration, 
and  fever.  If  there  are  no  cases  of  measles  among  those  with  whom  the 
patient  is  living,  the  diagnosis  i-  very  embarrassing,  and  one  is  apt  to  be- 
lieve that  the  malady  is  I  hat  formofacute  laryngitis  known  by  the  name  of 
j »seu do-croup.  This  error  will  be  immaterial,  unless  the  practitioner  inter- 
feres, as  sometimes  happens, in  a  deplorably  hurtful  manner.  The  mistake 
will  not  prove  injurious,  provided  he  acl  under  the  correct  conviction  that 
pseudo-croup  is  seldom  a  bi  rious  affection,  and  thai  after  some  agonizing 
moments,  more  terrible  perhaps  to  the  heart  of  the  mother  than  hazardous 
to  the  life  of  the  child,  the  unfavorable  symptoms  subside. 

1  shall  afterwards  have  to  return  to  the  differential  diagnosis  of  acute 
laryngitis  ancf  croup.  I  presume,  however,  thai  it  is  a  subject  with  which 
you  are  familiar.  Bui  when  you  have  diagnosed  pseudo-croup,  take  care 
thai  you  do  no!  allow  yourselves  to  be  worked  upon  by  the  anxieties  of  a 

dismayed    family;    take  Care  thai    you    do  not    yield    to    their  very  natural 

impatience;  take  special  care  thai  you  do  doI   commit  the  too  common 


MEASLES.  177 

blunder  of  applying  leeches  to  the  neck  or  the  base  of  the  chest.  In  itself, 
and  in  the  treatmeot  of  false  croup,  this  proceeding  is  not  necessarily  dan- 
gerous ;  but  if  the  loss  of  blood  should  be  great — as  it  may  be — it  may 
involve  danger.  You  very  often  cannot  tell  in  a  child  when  the  bleeding 
will  stop;  and  excessive  bleeding  will  produce  anaemia,  which  will  inter- 
fere with  the  natural  course  of  the  disease,  of  which  the  laryngitis  was 
only  the  precursor.  Besides,  though  the  treatment  may  not  in  itself  be 
dangerous,  it  is  useless,  and  for  that  reason  ought  not  to  be  employed. 
Graves,  who  was  not  well  acquainted  with  diphtheritic  affections,  having 
seen  but  few  cases,  pointed  out  a  method  of  treating  false  croup,  similar  to 
that  which  I  recommended  to  you  :  it  consists  in  gently  pressing  a  sponge 
soaked  in  warm  water — very  warm,  but  not  hot  enough  to  scald — under 
the  chin,  and  on  the  front  of  the  neck.  This  operation  is  repeated  in  ten 
or  fifteen  minutes  :  it  produces  a  sort  of  determination  to  the  skin,  under 
the  influence  of  which  the  symptoms  subside  in  a  remarkable  manner,  the 
cough  at  the  same  time  losing  its  hoarseness.  In  addition  to  great  efficacy, 
this  medication  has  the  recommendation  of  extreme  simplicity  :  by  it  un- 
aided we  can  generally  remove  symptoms,  for  which  without  it  we  should 
have  to  administer  emetics.  My  remark  only  applies  to  the  laryngeal 
symptoms ;  for  when  they  disappear,  there  still  remains  the  bronchial  ca- 
tarrh, the  constant  comjjanion  of  morbillous  fever,  and  which,  in  the  prog- 
ress of  the  case,  may  become  a  threatening  feature. 

Suffocative  catarrh  is  often  a  serious  complication  of  measles,  both  in 
adults  and  children.  About  three  or  four  days  prior  to  the  development 
of  the  eruption,  the  fever  becomes  exceedingly  violent,  oppression  of  the 
chest  supervenes,  accompanied  by  a  moist  cough,  which,  in  children,  suc- 
ceeds the  hoarse  cough  of  laryngismus  stridulus  ;  and  auscultation  informs 
us  of  the  existence  of  subcrepitant  rales  throughout  the  whole  extent  of 
the  lungs.  When  these  symptoms  occur  at  the  second  or  third  day  of  the 
period  of  invasion,  they  generally  imply  danger ;  but  the  subcrepitant  rale, 
if  unaccompanied  by  oppression  of  breathing,  is  not  so  alarming. 

Capillary  catarrh,  unconnected  with  any  specific  cause,  is  a  very  serious 
malady,  particularly  in  children.  It  is  much  more  dangerous  than  lobular 
pneumonia  or  pleurisy.  There  is  nothing  to  cause  surprise  in  the  state- 
ment, that  when  it  is  under  the  dominion  of  a  specific  poison,  such  as  the 
morbillous  poison,  it  is  a  still  more  formidable  affection.  The  skin  is  either 
almost  or  altogether  free  from  eruption ;  for  the  whole  force  of  the  disease 
is  directed  to  the  bronchial  apparatus.  Under  such  circumstances,  patients, 
especially  children,  sink  in  three  or  four  days,  without  any  cutaneous  erup- 
tion having  appeared.  The  malady  might,  therefore,  be  mistaken  for 
simple  catarrh,  though  really  morbillous  catarrh.  It  is  often  absolutely 
impossible  to  establish  a  differential  diagnosis  between  the  two  affections, 
unless  we  have  some  characteristic  symptoms  to  guide  us,  such  as  epistaxis, 
coryza,  otitis,  or  lachrymation ;  and  this  difficulty  is  enhanced  when  we  do 
not  know  whether  there  are  any  cases  of  measles  in  the  patient's  family  or 
neighborhood. 

In  the  adult,  the  form  which  this  catarrh  takes  is  pretty  nearly  the  same 
as  in  children.  The  oppression  of  breathing  is  quite  as  great ;  on  the  first 
or  second  day,  the  expectoration  assumes  a  peculiar  character :  at  first  it  is 
thin  limpid  mucus,  but  about  the  third  day  it  presents  a  puriform  aspect, 
the  patient  expectorating  mouthfuls  of  mucus  exactly  like  pus  from  an 
abscess.  The  sputa  are  not  nummular,  and  floating  in  a  slightly  opalescent 
serosity  like  the  sputa  of  normal  measles  on  the  seventh,  eighth,  ninth,  and 
tenth  days  of  the  disease,  often  unnecessarily  frighten  both  patients  and 

vol.  i. — 12 


178  MEASLES. 

their  physicians ;  but  they  are  rnuco-purulent,  like  the  sputa  accompauyhig 
the  suffocative  catarrh  of  the  aged. 

Although  the  suffocative  catarrh  of  measles  is  a  somewhat  less  dangerous 
affection  in  adults  than  in  children,  it  must  still  be  looked  upon  in  adults 
as  exceedingly  dangerous,  and  as  resisting  the  most  energetic  treatment. 
It  generally  proves  fatal  in  a  few  days;  but  sometimes  the  patients  go  on 
for  a  week  or  more,  in  which  case  the  capillary  bronchitis  becomes  peri- 
pneumonia, pseudo-lobular  pneumonia,  or  lobular  pneumonia.  The  latter 
may  be  either  complicated  or  not  complicated  with  pleurisy,  and  when  un- 
complicated in  this  way,  it  is  much  less  dangerous. 

Emetics,  with  ipecacuanha  at  the  head  of  the  list,  antimonials,  the  pre- 
cipitated sulphuret  of  antimony,  and  a  succession  of  large  blisters  to  the 
chest,  are  the  therapeutic  means  to  employ  in  this  fatal  form  of  catarrh, 
and  in  the  forms  of  pneumonia  by  which  it  is  followed.  Too  often  they 
are  powerless. 

Urtication  is  another  means  of  treatment  which  may  produce  immediate 
benefit  in  certain  cases.  When  the  eruption  has  not  appeared  on  the 
fourth  day,  and  catarrhal  symptoms  are  present,  I  order  the  body  of  the 
patient  to  be  scourged  with  nettles  twice  or  thrice  in  the  twenty-four  hours, 
so  as  to  produce  an  abundant  eruption  on  the  skin.  This  urtication  is  less 
painful  than  might  be  supposed,  and  produces  an  immediate  effect.  Al- 
though the  fever  does  not  subside,  the  oppression  of  breathing  diminishes 
gradually  as  the  determination  to  the  skin  augments.  It  is  a  curious  fact 
that  on  the  second  day  of  this  treatment,  the  nettle-rash,  even  when  the 
small  nettle  urtica  urens  (more  active  than  the  large  nettle  urtlca  dioica) 
has  been  used,  is  notably  less,  and  at  last,  after  three  or  four  days,  the 
application  produces  no  effect.  This  arises  from  the  system  having  become 
habituated  to  the  poison,  and  not  from  the  vitality  being  so  impaired  that 
the  organism  is  no  longer  acted  upon  by  it.  We  see  precisely  the  same 
tolerance  of  this  poison  exhibited  by  country  girls  who  take  hold  of,  and 
carry  in  their  naked  arms  with  impunity,  the  very  same  nettles  which  at 
first  stung  them  smartly.  Urtication  then  is  of  some  use  in  children,  and 
still  more  in  adults,  in  the  treatment  of  morbillous  catarrh.  The  difference 
in  the  degree  of  efficacy  probably  depends  upon  the  affection  being  more 
severe  in  the  former  than  in  the  latter. 

There  are  other,  though  less  important  complications  of  the  onset  of 
measles.     I  refer  to  epistaxis  and  otitis:  the  latter  is  often  misunderstood. 

Epistaxis  is  an  ordinary  phenomenon  of  measles,  and  when  moderate,  is 
certainly  not  a  serious  symptom;  but  it  is  sometimes  so  profuse  as  to  en- 
danger the  child's  life,  or  permanently  injure  his  future  health.  It  is  treated 
by  applying  to  the  forehead,  and  causing  to  be  drawn  up  into  the  nose,  ice 
and  iced  water.  These  measures  are  good.  Astringents,  also,  prove  suc- 
cessful. But  the  most  successful  practice  is  to  inject  into  the  nostrils  water 
as  hot  as  the  patient  can  bear.  The  injections  of  strong  solutions  of  sul- 
phate of  copper  and  sulphate  of  zinc,  a  decoction  of  rhatany,  and  a  solution 
of  perchloride  of  iron, are  excellent  hemostatics.  The  perchloride  of  iron, 
however,  has  the  inconvenience  of  causing  (lie  formation  of  a  Large  coagu- 
luni  which  occasions  pain  :  two  or  three  days  Later, on  removing  it, to  relieA  e 

the  patient  from  discomfort,  a  renewal  of  the  hemorrhage  is  apl  to  he  pro- 
duced. Bui  when  other  means  h;i\e  failed,  and  the  case  is  urgent,  I  never 
hesitate  to  use  perchloride  of  iron.      Soniel  inies,  it   is  also  necessary  to  have 

recourse  to  plugging. 

The  diagnosis  of  otitis  is  generally  simple  in  the  adult,  who  can  explain 
what  he  feels;  hut  it  is  not  so  in  the  child  incapable  of  describing  his  sen- 
sations, and  only  making  known  his  Bufferings  by  cries,  Leaving  us  to  6nd 


MEASLES.  179 

out  the  cause  and  seat  of  pain.  The  excessive  pain  produces  delirium, 
which  is  often  of  a  very  violent  character,  and  the  fever  increases.  To 
those  not  previously  instructed  on  the  subject,  the  formidable  army  of 
symptoms  will  appear  inexplicable.  When  a  child  is  beyond  the  age  of 
dentition,  or  when,  though  not  beyond  it,  has  no  determination  of  blood  to 
the  mouth  ;  when  on  careful  examination  we  can  find  no  hernia,  no  disten- 
sion of  the  abdomen,  no  badly  fixed  pin  pricking,  nothing  in  a  word  to  ex- 
plain the  constant  and  piteous  cries,  we  may  conclude  that  there  is  otitis. 
Almost  invariably,  in  thirty-six  or  forty-eight  hours,  this  conclusion  will  be 
confirmed  by  suppuration  showing  itself  in  a  discharge  from  the  ear.  It 
is  important  to  bear  in  mind  these  facts,  so  that  you  may  avoid  erroneous 
therapeutical  measures  and  adopt  a  useful  plan  of  treatment.  You  may, 
therefore,  rest  satisfied  with  injecting  into  the  external  auditory  passage 
some  soothing  balsam,  or  a  little  belladonna  dissolved  in  water  or  oil,  in 
place  of  pursuing  a  too  energetic  practice  to  the  detriment  of  the  patient. 
Belladonna  and  henbane  suffice  to  calm  the  pain  ;  but  unfortunately  they 
are  inadequate  to  prevent  the  serious  evils  which  otitis  brings  in  its  ti-ain, 
and  of  which  I  will  speak  when  considering  the  complications  of  the  third 
period.* 

In  enumerating  the  symptoms  which  accompany  the  eruption,  I  stated 
that  it  was  generally  along  with  it  that  diarrhoea  appeared.  It  is  rarely  a 
serious  symptom :  and  in  simple  cases,  it  even  seems  to  constitute  a  favor- 
able crisis,  when  it  comes  simultaneously  with  the  exanthem  on  the  skin. 
It  would  seem  that  at  the  moment  when  the  morbid  ferment  has  attained 
its  maximum  activity,  at  the  moment  when  the  despumation  (to  use  Syden- 
ham's expression)  is  going  to  declare  itself  with  all  its  energy,  there  cannot 
be  too  many  emunctories  open.  The  diarrhceal  catarrh,  particularly  in 
children,  seems  an  advantageous  addition  to  the  coryza,  ocular  catarrh,  and 
bronchial  catarrh.  In  adults,  diarrhoea  is  an  unusual  occurrence  on  the 
day  of  eruption.  As  I  have  already  said,  this  diarrhoea  is  sometimes  very 
profuse,  the  patients  having  ten  or  even  fifteen  stools  in  twenty-four  hours. 
There  is,  however,  no  cause  for  alarm  at  such  an  occurrence,  provided  the 
eruption,  the  fever,  and  the  other  symptoms  are  following  the  regular 
course ;  but  if  the  intestinal  flux  is  exceedingly  profuse,  and  continues  be- 
yond its  natural  period,  and  if  at  the  same  time  the  eruption  does  not  come 
out  well,  and  the  eyes  have  a  sunken  appearance,  there  is  danger.  We 
must  then  lose  no  time  in  interfering,  because  in  young  children  so  circum- 
stanced, there  is  a  risk  of  the  case  becoming  choleriform.  Even  if  the 
diarrhoea,  lasting  more  than  twenty-four  hours,  is  as  violent  on  the  second 
as  on  the  first  day,  it  becomes  necessary  to  interfere.  The  heroic  remedy 
in  such  cases  is  opium.  It  arrests  the  intestinal  flux ;  and  in  virtue  of  its 
diaphoretic  powers,  favors  the  development  of  the  exanthem,  by  acting  on 
the  skin. 

I  cannot  too  earnestly  impress  upon  you  the  necessity  of  caution  in  ad- 
ministering opium  to  children.  They  are  so  exceedingly  sensitive  to  its 
action  that  an  infant  of  one  year,  or  under  that  age,  may  be  stupefied,  and 
remain  in  a  drowsy  state  for  two  days,  from  taking  a  single  drop  of  lauda- 
num, that  is  to  say,  the  thirtieth  of  a  grain  of  opium.  For  so  young  a 
patient  with  the  diarrhoea  now  under  consideration,  I  prescribe  half  a  drop 
of  the  laudanum  of  Sydenham  to  be  given  in  divided  doses,  in  lime-water, 
during  twenty  hours.  To  prepare  the  potion,  you  add  one  drop  of  lauda- 
num to  two  teaspoonfuls  of  an  infusion  of  coffee  :  having  thrown  away  one- 
half  of  this  mixture  of  laudanum  and  coffee,  you  add  to  the  half  which 

*  See  page  183. 


180  MEASLES. 

remains,  sixty  drachms  of  lime  water.  This  potion  ought  to  be  adminis- 
tered in  spoonful  doses  during  the  twenty-four  hours. 

It  often  happens  that  the  morbillous  catarrh  of  the  intestines  exhausts 
itself  by  attacking  the  large  intestine,  producing  that  special  form  of  colitis 
characterized  by  tenesmus  and  glairy,  bloody  stools.  Let  me  remark  in 
passing  that  the  term  dysentery  applied  to  this  form  of  colitis  is  very  inap- 
propriate. Dysentery  is  an  epidemic  disease — specific,  contagious,  indepen- 
dent, and  special  in  its  character.  If  it  is  colitis,  it  is  colitis  of  an  altogether 
special  nature,  and  quite  different  from  the  colitis  of  measles — as  different 
as  the  morbillous  is  from  the  scarlatinous  exanthem,  though  both  eruptions 
are  cutaneous — as  different  as  eczema  is  from  small-pox,  though  the  pustules 
of  both  greatly  resemble  each  other.  It  is  very  necessary  to  establish  the 
distinction  between  morbillous  colitis  and  dysentery,  for  the  former  is  much 
less  dangerous  than  the  latter.  Morbillous  colitis  generally  terminates  in 
spontaneous  recovery.  When  it  goes  on  too  long,  it  can  be  stopped  by 
administering  albuminous  injections;  or,  if  a  more  rapid  result  be  desired, 
employ  an  injection  of  100  grammes  of  distilled  water  containing  in  solution 
from  5  to  10  centigrammes  of  nitrate  of  silver,  or  an  injection  formed  by 
dissolving  in  the  same  quantity  of  water  from  25  to  30  centigrammes  of 
sulphate  of  copper  or  sulphate  of  zinc.  By  such  means  you  will  be  able 
to  stop  the  diarrhceal  colic,  which  comes  on  at  the  fifth  or  sixth  day  of 
measles,  and  is  seldom  a  more  serious  symptom  than  the  irritation,  often 
rather  violent,  which  affects  the  upper  lip  under  the  influence  of  the  coryza. 
Between  these  two  symptoms  there  is  a  great  analogy ;  they  only  differ  in 
respect  of  their  seat. 

Having  now  passed  in  review  the  different  complications  of  the  period  of 
invasion  in  measles — convulsions,  false  croup,  suffocative  catarrh,  epistaxis, 
otitis,  and  diarrhceal  colic,  I  come  to  the  complications  of  the  second  period, 
called  the  period  of  eruption.  Strictly  speaking,  these  complications  do  not 
belong  to  the  second  stage.  For  example,  the  capillary  catarrh  which 
often  accompanies  this  stage,  began  with  the  disease.  In  many  cases,  no 
doubt,  it  more  specially  belongs  to  the  second  stage,  inasmuch  as,  though  it 
begins  to  show  itself  in  the  first  stage,  it  does  not  assume  a  serious  character 
till  it  bursts  forth  about  the  sixth  or  seventh  day  of  the  disease,  that  is  to 
say,  on  the  second  or  third  day  of  the  second  stage,  or  period  of  eruption, 
taking  the  form  of  suffocative  catarrh,  lobular,  or  pseudo-lobular  pneumonia. 
In  a  word,  simple  catarrh  is  a  symptom  naturally  belonging  to  the  period 
of  invasion,  whereas  suffocative  catarrh,  peripueumonic  catarrh,  and  pure 
pneumonia,  belong  more  to  the  period  of  eruption. 

Peripneumonic  catarrh,  lobular  pneumonia,  and  pseudo-lobular  pneu- 
monia, the  extreme  consequences  of  capillary  catarrh,  are  always  the  most 
formidable  complications  of  measles,  being  much  more  dangerous  than  pure 
pneumonia  or  pleurisy:  it  is  by* capillary  catarrh  and  its  consequences  that 
the  greatest  number  of  morbillous  patients  are  carried  off.  When  in  a  case 
which  has  gone  on  regularly  till  the  seventh  day,  you  then  observe  the 
eruption  grow  pale,  and  next  day  find  an  increase  of  fever,  you  have  reason 
to  apprehend  a  complication  ;  and  almost  invariably  that  complication  will 
be  found  to  be  pulmonary.  In  the  adult,  it  may  he  an  attack  of  pure 
pneumonia;  hut  that  is  not  usual,  broncho-pneumonia  being  the  most  com- 
mon form  of  the  pulmonary  affection.  In  children,  this  broncho-pneu- 
monia, this   peripneumonia  is,  I   may  say,  the  absolute  rule,  BO  rare  are  the 

exceptions:  the  inflammation  of  the  pulmonary  parenchyma  is  merely  an 
extension  of  a  previous  bronchitis,  in  which  the  catarrhal  element  still  pre- 
dominates. It  is  all  the  more  importanl  to  have  clear  views  on  this  point 
in  etiology,  and  upon  the  nature  of  the  pathological   process,  thai   they  a1 


MEASLES.  181 

once  explain  the  cause  of  the  great  danger  of  this  complication  of  measles. 
The  pneumonic  complication  nearly  always  proves  fatal  in  children  under 
three  years  of  age.  In  an  epidemic  which  I  observed  at  the  Necker 
Hospital  in  the  years  IMo  and  1846,  out  of  twenty-four  children  who  had 
measles,  twenty-two  died  of  peripneumonic  catarrh  :  the  other  two  escaped 
the  terrible  thoracic  complication.  This  statistical  fact  enables  you  to 
estimate  the  frightful  severity  of  this  affection,  which,  however,  is  met  with 
much  more  frequently  in  hospital  than  in  private  practice.  Still,  in  some 
epidemics,  it  commits  cruel  ravages  beyond  nosocomial  influences ;  and  the 
physician  who  considered  measles  a  mild  disease  till  he  encountered  one  of 
these  epidemics,  will  afterwards  modify  that  opinion.  Thirty-seven  years 
ago,  when  I  began  the  practice  of  medicine,  the  first  two  patients  to  whom 
I  was  called  were  persons  suffering  from  measles,  one  a  girl  of  eleven,  and 
the  other  a  female  servant  of  twenty-one  years  of  age.  Both  sunk  under 
broncho-pneumonia,  which  in  one  of  the  cases  was  complicated  with  pleurisy. 
At  that  period,  I  came  to  the  conclusion  that  measles  might  prove  a  serious 
malady :  from  that  time,  many  years  elapsed  without  my  losing  a  single 
case,  child  or  adult,  from  the  disease,  and  then  I  met  with  the  disastrous 
epidemic  at  the  Necker  Hospital.  This  year  I  have  again  seen  a  great 
mortality  in  my  own  private  practice,  and  in  consultation  with  my  colleagues, 
both  among  children  and  adults,  from  morbillous  peripneumonic  catarrh. 

Whenever,  therefore,  about  the  eighth  day  of  measles,  the  fever,  which 
'ought  to  subside  on  that  day,  continues  ;  when  the  subcrepitant  rales,  heard 
on  auscultation  from  the  fourth  day  of  the  disease,  and  which  at  the  time 
the  eruption  came  out  (or  at  least  about  the  second  or  third  day  of  the 
period  of  eruption),  ought  to  have  become  less  fine,  do  not  undergo  that 
modification,  there  is  reason  to  fear  untoward  pulmonary  symptoms.  The 
broncho-pneumonia  is  at  first  only  characterized  by  general  signs,  and  by 
the  persistency  and  greater  intensity  of  the  fever  ;  but  by  and  by,  the  bron- 
chial blowing  will  exist  as  a  pathognomonic  indication  of  the  affection, 
under  which,  sooner  or  later,  the  patients  will  succumb. 

The  nature  of  this  complication  explains  its  obstinacy.  Catarrh  is  the 
most  obstinate  of  all  pulmonary  affections,  as  well  as  the  most  uncertain  in 
its  course.  Does  not  the  simplest  cold  sometimes  last  longer  than  a  pneu- 
monia? Do  not  these  inveterate  bronchial  affections  keep  people  coughing 
for  months,  while  a  pure  inflammatory  pneumonia  is  generally  a  transient 
illness?  We  can,  therefore,  understand  the  persistency  of  a  pulmonary 
affection  in  which  the  bronchitic  element  predominates.  Apart  altogether 
from  the  morbillous  influence,  bronchial  catarrh  is  an  exceedingly  tedious 
malady  in  children.  Its  custom  is  to  give  way  for  a  short  interval  and  then 
reappear,  subsiding  and  reappearing,  it  may  be,  two,  three,  or  four  times 
before  final  recovery  is  established  at  the  end  of  two  or  three  months.  Like- 
wise, after  the  lapse  of  two  or  three  months,  it  may  prove  fatal.  As  the 
pulmonary  affection  in  measles  is  essentially  catarrhal,  it  is  not  surprising 
that  the  broncho-pneumonia  should  last  thirty  or  forty  days  both  in  adults 
and  children.  Independent  of  catarrh,  its  essential  element,  morbillous 
broncho-pneumonia  possesses  a  virulence  of  its  own,  which  is  the  expression 
of  a  principle,  specific,  contagious  and  septic,  which  increases  its  obstinacy 
and  severity. 

The  same  obstinacy  wdiich  characterizes  morbillous  peripneumonic  ca- 
tarrh is  met  with  in  other  external  manifestations  of  measles.  Thus,  the 
simple  ophthalmia,  which  is  part  of  the  disease,  may  go  on  fur  months. 
This  exanthematous  ophthalmia,  as  it  has  been  called  by  Wardrop,  is  some- 
times formidable,  leading  to  granular  and  ulcerated  conjunctiva,  phlycta'ii- 
ula,  and  pterygion.     Mackenzie  states  that  he  has  seen  cases  in  which  the 


182  MEASLES. 

eye  was  destroyed  by  violent  muco-purulent  ophthalmia  consequent  on 
measles.  Such  cases,  however,  are  rare.  In  general,  the  affection  is  limited 
to  a  more  or  less  decided  redness  of  the  conjunctiva,  accompanied  by  intol- 
erance of  light,  moderate  pain,  and  lachrymation  :  but  I  repeat,  that  these 
ophthalmic  affections  are  very  obstinate,  from  the  influence  of  the  specific 
morbid  cause  on  which  they  depend.  Cases  of  purulent  ophthalmia  often 
have  their  starting-point  in  measles. 

The  remarks  which  I  have  now  made  on  inflammatory  affections  of  the 
conjunctiva  are  equally  applicable  to  inflammations  of  the  nasal  mucous 
membrane.  Are  there  not  many  children  and  adults  who,  free  before 
measles  from  all  these  evils,  have  afterwards  chronic  eczema  of  the  nasal 
fossae,  eczema  invading  and  causing  tumefaction  of  the  upper  lip,  and  some- 
times extending  into  the  posterior  nares,  even  into  the  Eustachian  tube, 
where  it  occasions  swelling,  which  in  its  turn  causes  deafness? 

These  inflammations  of  the  eyes  and  nose  may  lead  to  serious  conse- 
quences. When  child  or  adult  of  scrofulous  diathesis  is  attacked  by  measles, 
the  latter  may,  like  scarlatina,  give  development  to  the  already  declared  or 
hitherto  latent  morbid  tendencies.  These  morbillous  inflammations  may 
be  the  starting-point  of  the  evolution  of  the  scrofulous  diathesis,  which  will 
put  its  stamp  on  the  lesions  of  which  we  are  speaking,  determining  glan- 
dular swellings  going  on  to  suppuration,  and  leaving  indelible  cicatrices. 

These  manifestations  of  diathesis  are  not  the  only  manifestations  of  this 
kind  to  which  measles  may  give  rise.  In  children  who  have  been  rapidly 
carried  off  by  it,  we  often  find  bronchial  glands  more  or  less  considerablv 
engorged.  Just  as  in  scarlatina,  we  find  engorgement  of  the  glands  of  the 
neck,  and  in  dothienteritis  engorgement  of  the  glands  of  the  mesentery,  so 
in  measles  we  find  engorgement  of  the  bronchial  glands.  This  condition  is 
the  consequence  of  the  inflammation  of  the  bronchial  tubes,  just  as  cervical 
adenitis  is  the  consequence  of  the  pharyngeal  sore  throat  of  scarlatina,  and 
mesenteric  adenitis  the  consequence  of  the  intestinal  inflammation  in  putrid 
fever. 

When  the  catarrhal  inflammation  of  the  bronchial  tubes  is  of  long  dura- 
tion, and  the  patient  is  in  subjection  to  the  tubercular  diathesis,  the  glan- 
dular engorgements  assume  the  characteristics  of  that  diathesis:  ou  dissec- 
tion, we  find  the  glands  converted  into  tubercular  masses.  This  remark  is 
applicable  to  childhood,  adolescence,  and  adult  age.  At  all  ages,  measles 
may  occasionally  become  the  cause  of  the  development  of  tubercles,  when 
the  individual  carries  within  him  the  hereditary  germ  of  the  disease;  and 
tubercular  disease  runs  its  course  with  much  greater  rapidity  when  its  start 
has  been  accelerated  by  the  exanthematoua  fever.  It  is  under  such  circum- 
stances that  phthisis  takes  the  acute  form:  it  is  rapid,  but  it  differs  greatly 
from  the  galloping  consumption  of  typhoid  form,  regarding  which  I  shall 
afterwards  have  to  speak  to  you. 

I  have  already  told  you  that  measles  may  determine  an  attack  of  otitis. 
It  i-  generally  only  a  catarrhal  affection  :  but  the  inflammation  may  ex- 
tend from  the  external  auditory  passage  to  the  middle  ear,  whence   it    may 

be  continued  to  the  mastoid  cells  and  petrous  portion  of  the  temporal  In  me. 
The  situation  of  tic-  patient  i-  then  very  hazardous:  for  caries  of  the  bone 
may  lead  to  abscess  of  the  brain,  and  inflammation  of  the  mastoid  cells 
may  produce  purulent  infection.  One  of  your  masters,  Professor  <<  isselin, 
has  found  that  inflammation  of  the  oss  >ous  tissue,  or  more  correctly  osseous 
phlebitis,  is  the  mosl  active  of  all  the  causes  of  purulent  infection ;  and  this 
condition  exists  when  there  is  inflammation  of  the  mastoid  cells  and  tem- 
poral bone.  I  am  indebted  to  my  former  pupil  Dr.  Peter  for  the  particu- 
lars of  a  case  which  beautifully  illustrate-  what  I  have  now  been  saying. 


MEASLES.  183 

On  the  3d  April,  1865,  Dr.  Peter  was  sent  for  to  Boigneville,  to  see  in 
consultation  a  boy  of  twelve  years  of  age  who  was  dying  from  the  after-dis- 
orders of  measles.  Two  months  previously,  he  had  ha<l  the  eruptive  fever 
at  one  of  the  colleges  of  Paris.  During  his  convalescence,  his  relations  re- 
solved to  take  him  home  with  a  view  to  hasten  his  recovery.  At  that  time 
he  had  no  cough,  nor  other  symptoms  of  thoracic  complication  :  moreover, 
he  was  of  a  robust  breed  ;  and  there  was  nothing  to  lead  to  the  supposition 
that  tuberculosis  was  impending.  All  that  remained  of  his  attack  of  measles 
was  an  inflammation  of  the  left  ear,  from  which  there  was  a  profuse  dis- 
charge of  exceedingly  fetid  greenish  pus.  Six  days  before  the  consultation 
with  Dr.  Peter,  the  young  convalescent  had  been  seized  with  violent  shiver- 
ing, soon  followed  by  sudden  intense  pain  in  the  right  seapulo-humeral  ar- 
ticulation. From  that  time  he  kept  his  bed,  lost  his  appetite,  and  had  daily 
paroxysms  of  fever  with  repeated  rigors.  Four  days  after  the  attack  of 
pain  in  the  shoulder,  he  had  a  similar  seizure  in  the  right  coxo-femoral  ar- 
ticulation. When  Dr.  Peter  saw  the  patient,  there  were  enormous  swell- 
ings in  the  right  shoulder  and  right  haunch,  and  an  cedematous  puffiness 
over  the  chest,  abdomen,  thighs,  and  the  parts  in  the  vicinity  of  the  affected 
joints.  He  could  not  in  any  degree  spontaneously  move  the  affected  joints, 
and  every  movement  communicated  to  them  by  others  occasioned  frightful 
pain.  He  was  in  a  high  fever,  the  pulse  beating  160  in  the  minute:  he  had 
dyspnoea,  with  fine  rales  disseminated  over  the  chest :  and  was  in  a  state  of 
constant  low  delirium.  He  was,  moreover,  suffering  from  jaundice,  the 
date  of  which  could  not  be  ascertained,  and  regarding  which  there  did  not 
seem  to  be  anxiety.  Two  facts  were  elicited  by  percussion  over  the  liver ; 
viz. :  that  it  was  greatly  enlarged,  and  that  at  certain  points  it  was  painful 
on  pressure.  Dr.  Peter,  connecting  the  jaundice  with  the  state  of  the  liver, 
the  state  of  the  liver  with  the  articular  lesions,  the  articular  lesions  with 
the  pains  which  had  preceded  and  the  shivering  which  had  accompanied 
them,  concluded  that  it  was  a  case  of  purulent  infection ;  and  he  likewise 
inferred  that  there  were  metastatic  abscesses  in  the  liver,  perhaps  also  in 
the  lungs,  and  that  there  was  unquestionably  suppuration  in  the  joints. 
Without  hesitation  he  recognized  as  the  starting-point  of  the  purulent  in- 
fection, the  deepseated  otitis,  with  its  associated  caries  of  the  mastoid  cells 
and  petrous  portion  of  the  temporal  bone.  Everything  concurred  to  justify 
this  induction.  There  was  the  character  of  the  suppuration — its  profuse- 
ness,  and  excessive  fetor  (so  characteristic  of  osseous  suppuration),  and  its 
abrupt  suppression  on  the  occurrence  of  the  shivering  and  articular  pains. 
This  diagnosis  was  accepted  by  the  physician  in  charge  of  the  case,  who 
had,  however,  at  first  concurred  with  a  physician  of  a  neighboring  town  in 
the  perfectly  inadmissible  hypothesis,  that  it  was  a  case  of  acute  tubercu- 
losis of  the  articular  extremities.  The  unhappy  parents,  dismayed  at  Dr. 
Peter's  prognosis,  called  in  my  friend  Dr.  Blache  next  morning,  who  made 
exactly  the  same  diagnosis.     The  patient  died  during  the  day. 

I  entirely  concur  in  Dr.  Peter's  diagnosis.  I  feel  convinced  that  there 
was  purulent  infection  in  this  case;  and  making  a  retrospective  review  of 
other  cases  I  have  seen,  but  have  not  very  exact  notes  of,  I  explain  them 
in  the  same  way.  Be  guarded  then,  gentlemen,  in  your  prognosis,  when 
you  meet  with  deepseated  otitis  as  a  sequel  of  measles  or  scarlatina  :  be  as- 
sured that  the  inflammatory  action  is  not  simple,  that  it  derives  an  excep- 
tional gravity  from  the  eruptive  fever,  and  exists  in  a  subject  whose  or- 
ganism has  been  thereby  seriously  impaired. 

Gangrene  of  the  mouth  and  vulva  occur  as  sequela?  of  measles,  particu- 
larly in  hospitals  appropriated  to  young  children.  These  affections  are 
well  known  to  the  sisters  attached  to  the  service  of  the  hospital  in  the  Rue 


184  MEASLES. 

de  Sevres :  when  they  have  to  nurse  cases  of  measles,  they  take  double  pre- 
cautions to  secure  cleanliness,  particularly  in  respect  of  the  little  girls  under 
their  charge.  When  these  precautions  are  neglected,  small  excoriations 
are  seen  on  the  vulva.  In  themselves,  there  is  nothing  serious  in  these 
excoriations,  which  are  produced  the  more  easily  that  the  mucous  mem- 
brane of  the  genitals  is  not  more  exempt  thau  the  other  mucous  membranes 
from  morbillous  influences.  But  if  the  patient  is  in  the  midst  of  concen- 
trated epidemic  influence,  such  as  too  commonly  exists  in  a  children's  hos- 
pital, the  excoriations  on  the  vulva  may  become  a  way  of  entrance  for 
gangrene.  The  affection  may  at  first  escape  notice,  but  a  considerable 
swelling  soon  appears  at  the  side  of  the  labia  majora  aud  probably  extends 
into  the  groin.  The  skin  over  the  tumor  is  of  a  bright  red  color,  the  sub- 
jacent tissues  are  hard,  and  examination  by  the  touch  leads  to  the  diagnosis 
of  a  deepseated  abscess.  On  separating  the  vulva,  we  discover  pultaceous 
concretions  of  a  whitish,  sometimes  of  a  grayish  color:  they  have  generally 
a  very  fetid  odor,  and  sometimes  extend  back  to  the  anus.  Under  such 
circumstances,  there  is  no  time  for  temporizing:  energetic  treatment  must 
be  immediately  resorted  to.  The  day  after  the  appearance  of  the  concre- 
tions, the  cellular  tissue  may  be  in  a  state  of  gangrene,  and  the  labium 
sphacelated  in  its  entire  thickness.  The  gangrene  may  invade  the  vagina, 
and  even  perforate  the  peritoneum,  in  which  case  death  rapidly  ensues. 
The  danger  can  only  be  averted  by  prompt  and  vigorous  treatment.  Cau- 
terize the  parts  with  fuming  hydrochloric  acid,  nitrate  of  silver,  or  sulphate 
of  copper;  and  if  the  caustics  are  not  sufficient  to  stop  the  progress  of  the 
gangrene,  you  must  resort  to  the  actual  cautery,  then  your  sole  resource. 

Diphtheritis  may  sometimes  also  have  measles  as  its  starting-point. 
When  such  is  the  case,  it  generally  assumes  a  malignant  character,  whether 
developed  in  the  mucous  membrane  of  the  vagina,  or  in  the  folds  of  the 
skin,  where  in  children  the  nature  of  the  skin  is  so  similar  to  that  of  mucous 
membrane;  or  whether,  as  is  most  usual,  it  appears  on  the  mucous  lining 
of  the  mouth,  pharynx,  and  nose. 

Purpura  is  another  serious  complication  of  measles,  regarding  which  I 
said  a  word  at  the  commencement  of  this  lecture.  It  presents  itself  in  a 
form  very  different  from  the  morbus  hcemorrhagicus  of  Werlhoff,  and  very 
different  also  from  the  acute  purpura  with  which  we  are  acquainted.  I 
have  only  seen  two  cases  of  this  complication  of  measles. 

Fifteen  or  sixteen  years  ago  I  was  asked  to  meet  Dr.  Coqueret  in  consul- 
tation, in  the  case  of  a  girl  of  five  years  of  age  who  had  just  had  an  attack 
of  measles.  The  fever  had  been  constantly  accompanied  by  stupor,  which 
is  unusual  in  this  disease.  The  eruption  came  out  :  hut  the  exantheniatous 
patches  were  of  a  dark  color — that  hemorrhagic  hue  which  does  not  disap- 
pear under  pressure  of  the  finger.  <  )n  the  eighth  day,  slighl  delirium  super- 
vened, and  epistaxis,  which  had  occurred  with  usual  moderation  during  the 
first  period,  became  much  more  profuse.  The  relations,  alarmed  at  the 
nasal  hemorrhage,  called  me  in.  The  child  had  lost  a  great  deal  of  blood. 
We  recommended  nasal  injections  of  decoction  of  rhatany,  of  very  warm 
water,  of  a  solution  of  Bulphate  of  zinc,  and  of  a  solution  of  sulphate  of 
copper.  The  epistaxis  moderated.  After  some  hours,  however,  other  hem- 
orrhages supervened :  she  had  hsematuria,  hi ly  stools,  and  hsematemesis. 

Finally,  within  two  days,  ecchymotic  spots  appeared  on  the  hack  ;  and  the 

child  -unk  in  a  state  of"  extreme  anaemia.  We  did  not  obtain  an  autopsy  : 
but  judging  from  what  I  have  seen  in  the  bodies  <>f  persons  dying  under 
.similar  circumstances,  I  think  we  should  probably  have  found  ecchymosu 
around  the  kidney.-,  under  the  peritoneum, and  also  perhaps  (as  is  occasion- 


MEASLES.  185 

ally  niet  with)  under  the  coverings  of  the  heart,  and  under  other  visceral 
membranes. 

It  thus  appears,  that  in  certain  conditions,  difficult  to  appreciate,  but  in 
which  very  probably  the  epidemic  constitution  plays  its  part,  the  poison  of 

measles  may  impart  a  special  character  to  this  terrible  form  of  hemorrhage;, 
just  as  small-pox  does  sometimes,  with  this  difference,  that  in  black  small- 
pox the  hemorrhages  generally  occur  in  the  first,  and  in  measles,  in  the 
last  period  of  the  disease. 

Dr.  Chairou  in  a  remarkable  work,  to  which  a  prize  was  adjudged  by 
the  Academy  of  Medicine,  has  given  the  history  of  a  very  severe  epidemic 
of  measles  which  prevailed  at  Rueil  in  1862.  It  was  characterized  by  the 
exanthem  not  having  much  intensity,  and  in  being  accompanied  by  profuse 
perspiration,  and  a  vesicular  eruption  analogous  to  the  miliary  rash  of 
lying-in  women.  Dr.  Chairou  proposed  to  give  it  the  name  of  sweating- 
measles  \_rongeole-sxiette).  For  my  own  own  part,  I  do  not  believe  in  such 
a  complication  of  measles  as  sweating  properly  so  called,  any  more  than  I 
believe  in  lying-in  women  being  attacked  by  miliary  fever.  However,  the 
Rueil  epidemic  was  characterized  by  very  unusual  phenomena.  From  the 
first,  in  addition  to  epistaxis  and  vomiting,  typhoid  complications  were  ob- 
served, and  at  a  later  period  of  the  attack,  thrush,  aphthous  ulcerations, 
and  ulceration  of  the  periosteum  leading  to  necrosis  of  the  maxillary  bones. 
Numerous  abscesses  in  the  face  and  neck  were  seen,  such  as  are  often  ob- 
served in  small-pox  and  scarlatina.  The  other  mucous  membranes  were 
often  coated  with  diphtheritic  secretion,  and  the  skin,  under  the  influence 
of  blisters  or  from  other  causes,  was  liable  to  excoriations.  To  these  symp- 
toms, convulsions  were  frequently  added,  and  their  occurrence,  even  at  the 
beginning  of  the  attack,  almost  invariably  foretold  a  fatal  issue.  The  mor- 
tality from  this  epidemic  of  measles  was  as  great  as  that  resulting  from 
ordinary  epidemics  of  typhoid  fever. 

As  I  have  already  stated,  the  nervous  complications  of  measles  generally 
occur  at  the  beginning  of  the  attack  :  they  may,  however,  recur  in  the  last 
stage  of  the  disease,  when  they  are  not  dependent  on  the  fever  itself,  but  on 
some  superadded  cause.  For  example,  when  broncho-pneumonia  and  peri- 
pneumonia supervene  in  children  who  have  had  convulsions  at  the  period 
of  invasion,  these  pulmonary  affections  may  occasion  a  return  of  the  con- 
vulsions, which  are  then  preceded  and  followed  by  cerebral  disturbance, 
characterized  by  stupor.  The  fits  last  for  two,  three,  or  four  days,  or  some- 
times only  for  a  few  hours  or  minutes  :  they  generally  carry  off  the  patient. 
The  nervous  complications  of  the  last  stage  of  measles,  which  originate  gen- 
erally in  a  formidable  chest  affection,  are  never  met  with  in  infants. 

Measles,  then — the  complications  of  which  I  have  now  reviewed — may 
terminate  in  convulsions ;  but  it  must  be  remembered  that  convulsions  at 
the  beginning  of  the  disease  are  not  serious,  whereas,  in  the  last  stage — that 
is,  after  the  eighth  day — they  involve  the  worst  possible  prognosis. 


186  KUBEOLA. 


LECTURE  VII. 

RUBEOLA. 

Very  different  Disease  from  Measles. — Stands  in  the  same  relation  to  Measles 
as  Chicken-pox  to  Small-pox.— -Does  not  produce  Catarrh  of  the  Mucous 
Membranes. — JVo  serious  sequela. — May  attack  the  mine  person  more  than 
once,  and  does  not  confer  exemption  from  Measles. 

Gentlemen:  A  great  many  physicians  fell  into  the  same  sort  of  confu- 
sion regarding  rubeola  as  that  which  still  prevails  regarding  chicken-pox. 
Rubeola  was  once  considered  a  modified  form  of  measles,  just  as  chicken- 
pox  has  been  looked  on  as  modified  small-pox.  Although  some  authors 
still  confound  variola  and  varicella,  all  agree  that  there  is  an  essential 
difference  between  rugeola  and  rubeola.  Though  they  admit  that  there  is 
at  first  view  an  apparent  similarity  between  the  latter  two,  they  describe 
rubeola,  the  exanthematous  fever,  about  which  I  am  now  going  to  Bay  a 
few  words,  as  a  perfectly  distinct  nosological  species.  This  disease  was 
known  to  old  authors  under  the  various  names  of  rubeola,  roseola,  and  exan- 
theme  fugace :  it  is  called  essera  Vogelii  by  Borsieri. 

Rubeola  is,  like  measles,  characterized  by  an  exanthematous  eruption 
consisting  of  irregular  spots,  the  outbreak  of  which  is  almost  always  pre- 
ceded by  febrile  phenomena.  The  general  symptoms  which  show  themselves 
usually  for  one  or  two,  and  rarely  for  three  or  four  clays,  are  much  less 
marked  than  in  other  eruptive  fevers.  Sometimes  they  do  not  amount  to 
more  than  a  slight  feeling  of  discomfort.  Generally,  however,  the  feeling 
of  discomfort  is  considerable,  and  is  accompanied  by  well-marked  fever, 
rigors,  headache,  loss  of  appetite,  urgent  thirst,  excitement,  or,  it  may  bo, 
by  great  prostration.  In  very  young  children  it  is  not  unusual  for  the  dis- 
ease to  set  in  with  vomiting,  diarrhoea,  and  convulsions. 

The  circumstances,  however,  which  at  once  distinguishes  rubeola  from 
measles  is  the  absence  in  the  former  of  catarrh  ( ocular,  nasal,  and  bronchial  I, 
an  essential  prodromic  phenomenon  of  morbillous  fever.  The  )achryma- 
tion,  coryza,  and  cough  which  belong  to  measles  are  never  seen  in  rubeola. 

Then.'  is  a  great  difference  been  the  eruption  of  the  two  diseases.  The 
rubeolic  do  not,  like  the  morbillous  patches,  projecl  from  the  surface  of 
the  skin.  The  rubeolic  patches  are  paler,  larger,  more  distinct  from  one 
another,  and  more  isolated  by  intervals  of  unaffected  skin:  they  disappear 
under  pressure  by  the  finger,  and  immediately  reappear  when  the  pressure 
is  removed  :  they  occasion  intense  itching,  and  arc,  to  use  Vogel's  expres- 
sion, "/•'/'  ntes  et  pruru  ntes. 

They  are  situated  on  all  parts  nf  the  body,  bul  arc  most  abundant  on 
the  trunk  and  limbs.  They  do  not  present  the  regularity  of  the  morbillous 
patches  in  the  way  they  come  out,  their  progress,  and  mode  of  disappear- 
ing. Exceedingly  fugitive,  remaining  visible  for  twenty-four  or  forty- 
eighl  hours,  they  in  some  cases  disappear,  without  desquamation  and  with- 
out leaving  any  trace  of  their  passage;  and  they  disappear  and  reappear 

alternately  for  seven  days. 

When  once  the  eruption  has  finally  disappeared,  the  malady  is  at  an 
end,  and  there  i-  aothing  to  fear  from  complications  bo  threatening  in  con- 


ERYTHEMA    NODOSUM.  187 

valescence  from  measles.     Nor  are  there,  as  in  the  latter,  any  unfavorable 

symptoms  to  he  dreaded  in  the  prodromio  or  eruptive  Stages. 

Rubeola  is  the  mildest  of  the  eruptive  fevers.  It  is  never  a  serious 
malady,  and  always  terminates  spontaneously  without  the  physician  being 
required  to  interfere.  It  has  sometimes  prevailed  as  an  epidemic,  as  Frank 
statts;  and  though  the  contrary  has  been  held,  I  believe  that  it  is  a  con- 
tagious  disease.  I  do  not  say  that  it.  is  contagious  in  the  same  degree  as 
measles,  but  among  the  various  causes  of  rubeola,  I  hold  that  contagion 
ineontestably  has  a  place. 

The  leading  fact  which  enables  us  to  separate  rubeola  from  rugeola,  is 
that  an  attack  of  the  one  does  not  protect  from  an  attack  of  the  other,  any 
more  than  an  attack  of  varicella  protects  from  an  attack  of  variola,  or  of 
variola  from  varicella.  Again,  the  same  person  does  not  generally  contract 
measles  more  than  once ;  but  one  attack  of  rubeola  does  not  protect  from 
other  attacks.  Borsieri,  indeed,  has  said  that  a  person  who  has  had  it 
once  is  more  liable  to  have  it  again  :  "  Qui  semel  Us  laboravit,  facile  iterum 
pluriesque  prehenditur." 

Persons  of  all  ages  and  both  sexes  take  rubeola ;  but  women  are  more 
susceptible  to  it  than  men,  and  children  are  more  susceptible  that  either 
A  hot  season,  or  to  speak  more  correctly,  a  high  temperature,  by  exciting 
to  copious  perspiration,  has  a  great  influence  upon  the  production  of  the 
rubeolie  exanthem.  I  shall  have  occasion  to  return  to  this  subject  when 
I  specially  discuss  the  question  of  sudoral  eruptions.  I  will  then  tell  you 
how  to  distinguish  the  varieties  of  rubeola  occurring  in  the  course  of  other 
diseases.  For  the  present,  I  will  only  remark  that  syphilitic  rubeola  can- 
not be  included  among  them.  Nature,  pre-eminently  specific,  has  placed 
a  special  stamp  upon  the  venereal  disease  of  which  a  form  of  rubeola  is  a 
characteristic  manifestation  :  the  course  and  duration  of  rubeola  syphilitica 
point  out  that  it  is  not  a  variety  of  the  exanthematous  fever  I  have  been 
speaking  of,  but  an  affection  belonging  to  another  nosological  group. 


LECTURE  VIII. 

ERYTHEMA  NODOSUM. 

A  Specific  and  Separate  Disease. — Successive  Eruptions. — Articular  Pains. — 
General  Symptoms — A  Possible  Manifestation  of  the  Rheumatic  Dia- 
thesis. 

Gentlemen  :  You  will  only  find  a  few  lines  devoted  to  the  subject  of 
erythema  nodosum  [erythhne  noueux]  in  your  pathological  text-books.  Au- 
thors seem  only  to  mention  it,  that  it  may  be  remembered  as  one  of  the 
principal  varieties  of  erythema,  the  whole  history  of  which  they  give  in  one 
short  chapter.  Their  descriptions  appear  to  me  insufficient;  for  the  malady, 
a  case  of  which  I  am  going  to  show  you  in  the  wards,  deserves  to  occupy  a 
much  larger  space  in  nosological  manuals. 

Correctly  speaking,  and  notwithstanding  the  generic  title  by  which  it  is 
known,  and  to  which  for  want  of  a  better  name  I  adhere,  erythema  nodosum 
in  no  more  a  variety  of  erythema  than  small-pox  is  a  variety  of  ecthema, 
although,  considered  by  itself,  the  variolous  pustule  often  resembles,  and 


188  ERYTHEMA    NODOSUM. 

may  be  mistaken  for,  a  pustule  of  erythema.  Erythema  nodosum  is  a  spe- 
cific and  separate  disease,  which  manifests  itself  locally  by  characters  so 
precise  as  not  to  admit  of  being  mistaken.  It  also  presents  a  group  of  gen- 
eral symptoms  necessary  to  be  taken  into  account.  They  almost  always 
precede  the  appearance  of  the  erythematous  eruption,  and  are  no  more  de- 
pendent upon  the  local  cutaneous  affection,  than  the  prodromic  fever  of 
small-pox  or  measles  is  subject  to  the  influence  of  the  eruption  which  is 
going  to  come  out. 

The  local  manifestations  of  the  erythematous  eruption  seem  so  very  well 
known,  that  it  might  be  sufficient  to  indicate  them  in  a  few  words.  I  think, 
however,  that  it  will  be  useful  to  describe  them  in  detail.  Any  one  of  you 
will  be  able  to  recognize  at  a  glance  the  spots  more  or  less  regularly  oval, 
elevated  towards  the  centre,  the  size  of  which  varies  from  that  of  a  few  mil- 
limetres to  two  or  three  centimetres,  of  the  diameter  of  a  pea,  a  hazel-nut, 
or  even  a  walnut.  They  project  above  the  skin,  forming  real  knobs  or 
nodes.  They  rapidly  increase  in  their  elevation  above  the  skin,  and  be- 
come small  hard  tumors  of  peculiar  aspect.  They  are  circumscribed  in  such 
a  way  as  to  look  as  if  their  base  was  set  in  the  thickness  of  the  skin  and 
cellular  tissue,  and  as  if  they  could  be  seized  between  the  fingers.  On  their 
first  appearance,  they  are  of  a  red  color,  which  is  the  brighter  the  less  the 
distance  is  from  the  centre,  and  this  coloration  extends  beyond  the  nodosity. 
Passing  from  red  to  violet-red,  it  afterwards  acquires  a  yellowish  ecchymotic 
tint,  or,  gradually  fading,  gives  place  to  a  bluish  tint,  most  decided  towards 
the  circumference  of  the  nodosity,  and  easily  disappearing  under  the  pres- 
sure of  the  finger.  I  have  never  seen  these  tumors  pass  into  a  state  of  sup- 
puration, although  on  pressing  them  I  have  felt  a  sensation  of  deepseated 
fluctuation  :  in  a  few  days  spontaneous  resolution  has  taken  place.  Accord- 
ing to  Professor  A.  Hardy,  however,  erythema  nodosum  may  become  chronic 
by  the  appearance  of  a  succession  of  eruptions  during  several  months,  or 
even,  it  may  be,  during  one  or  two  years.  When  the  disease  takes  this 
chronic  form,  the  nodes  on  the  legs  sometimes  become  elongated,  and  then 
soften  and  ulcerate.  The  ulcerations  are  round,  excavated,  and  of  a  grayish 
color  at  the  bottom:  they  resemble  syphilitic  ulcers.  The  attentive  obser- 
vation of  the  patient,  the  existence  of  non-ulcerated  nodes,  and  an  exami- 
nation of  the  history  of  the  case  will  prevent  you  making  an  error  in  diag- 
nosis. This  unusual  aspect  of  the  disease,  this  chronicity  of  erythema 
nodosum  whether  accompanied  or  not  by  ulceration,  according  to  my  col- 
league of  the  St.  Louis  Hospital,  is  dependent  on  a  scrofulous  taint.  I  dare 
niii  affirm,  gentlemen,  that  the  chronic  erythema  which  I  have  described 
to  yon  is  the  same  disease  of  which  M.  Hardy  speak-.  Possibly,  an  anoma- 
lous cutaneous  affection  suggested  to  that  able  physician  an  opinion  which 
I  hesitate  to  adopt. 

The  favorite  -eat-  of  erythema  nodosum  are  upon  the  legs  and  arm-,  in 
situations  where  the  -kin  i-  separated  from  the  hone  by  a  very  thin  layer  of 
.-oft   parts — on    the   forearm  at  the   posterior   edge  of  the   internal  asped  of 

the  ulna,  and  on  the  leg  on  the  inner  aspecl  of  the  crest  of  the  tibia.     It  is 

in  this  latter  .-it nation  that  the  characteristic  nodulated  form  of  the  tumors 

is  mosl  conspicuous.    Bo  sensitive  to  pressure  Bometimea  are  the  node-  over 

the   tibia,  even  when    lightly  pressed,  thai   the    patients   cannot   tolerate  the 

pain  caused  by  the  weight  of  the  bed-clothes.  The  node.-  are  usually  dis- 
seminated, separate  [discrites,  distinctce],  and  few  in  number;  but  at  other 
times,  they  are  more  numerous,  and  in  Borne  cases  become  confluenl  from 
new  node-  springing  up  beside  former  ones,  and  the  two  sets  getting  blended 
together,  bo  as  to  form  patches  of  greater  or  less  size,  of  a  more  or  less  bright 


ERYTHEMA    NODOSUM.  189 

red  color,  with  irregular  edges,  somewhat  resembling  erysipelas,  in  their 
general  appearance 

Although  erythema  nodosum  has  a  predilection  for  the  situations  I  have 
mentioned,  it  not  only  appears  on  all  parts  of  the  skin,  hut  also  on  the 
mucous  membranes.  In  a  woman,  whose  case  I  am  about  to  recall  to  your 
recollection,  you  saw  an  erythematous  patch  on  the  conjunctiva  of  the  left 
eye.  This  patch  on  the  conjunctiva  is  a  pimple  rather  than  a  true  node; 
and  the  spots  on  the  thighs,  arms,  neck  and  face  in  erythema  nodosum  are 
generally  papular.  By  and  by,  when  I  come  to  speak  of  papular  ery- 
thema, I  will  recall  to  your  recollection  the  differences  between  the  two 
forms  of  erythema,  mentioning  at  the  same  time  the  phenomena  common 
to  both,  and  by  which  they  seem  to  be  assimilated  ;  but  I  will  now  antici- 
pate what  I  have  to  say  by  remarking,  that  it  is  very  rare  to  see  a  case  of 
erythema  nodosum  without  pimples,  while  nodes  are  seldom  seen  in  papular 
erythema. 

The  eruption  does  not  always  all  come  out  at  once,  but  sometimes  in 
successive  crops,  fresh  nodes  appearing  in  succession  before  their  predeces- 
sors have  faded.  New  crops  go  on  appearing  at  longer  or  shorter  inter- 
vals, the  period  of  eruption  being  sometimes  thus  prolonged  to  twenty-one 
days.  The  duration  of  the  acute  stage  of  the  disease  is  from  one  to  twen- 
ty-one days.  So  long  as  the  general  symptoms  continue,  and  the  fever 
does  not  abate,  the  appearance  of  new  spots  may  be  expected. 

I  shall  now  state  what  took  place  in  the  case  to  which  I  have  just 
alluded.  The  patient,  a  woman  of  57  years  of  age,  was  admitted  on  the 
loth  December  to  bed  No.  25  bis  in  our  St.  Bernard  Ward.  She  said  that 
she  had  been  ill  for  ten  days  :  she  complained  of  general  discomfort,  head- 
ache, articular  pains  in  the  left  shoulder,  and  want  of  appetite :  the  tongue 
was  red,  the  skin  hot,  and  the  pulse  100.  I  detected  erythematous  spots 
on  the  right  thigh,  and  internal  aspect  of  the  right  elbow.  No  abnormal 
sound  was  heard  in  the  heart  on  careful  auscultation.  Next  day,  a  spot 
appeared  on  the  right  arm,  and  a  new  spot  on  the  left,  in  the  same  situa- 
tion as  the  other.  In  respect  of  hardness,  the  spots  resembled  syphilitic 
gummse.  On  the  17th  December,  the  eruption  appeared  on  the  external 
aspect  of  the  left  thigh,  and  the  fever  continued  unabated.  On  the  18th, 
the  spots  were  still  more  abundant,  and  some  of  them  were  papular.  The 
tongue,  red  at  the  point  and  edges,  was  covered  with  a  whitish  fur.  The 
pulse  was  still  100,  and  the  skin  hot.  On  the  20th  December,  we  observed 
spots  on  both  arms  over  the  inferior  portion  of  the  ulna.  On  the  thighs, 
the  spots  were  confluent ;  and  round  one  of  the  knees,  the  confluence  was 
so  great  as  at  a  first  glance  to  suggest  erysipelas.  This  was  the  day  on 
which  we  saw  an  erythematous  spot  on  the  conjunctiva,  at  the  outer  angle 
of  the  left  eye.  There  was  some  abatement  of  the  fever :  but  on  the  22d, 
it  had  regained  its  former  intensity.  On  the  same  day  there  was  a  fresh 
crop  of  spots ;  and  the  patches  on  the  right  thigh,  some  of  which  were  as 
large  as  a  five-franc  piece,  were  bright  red,  and  very  painful.  The  pain 
in  the  shoulder  was  more  violent  than  when  my  attention  was  originally 
directed  to  it,  and  it  was  increased  by  the  slightest  pressure.  The  ery- 
thematous spot  on  the  eye  had  faded,  and  there  only  remained  in  its  place 
a  little  injection  of  the  conjunctiva.  On  the  23d  and  24th,  new  spots 
appeared  on  the  legs  :  on  the  24th,  however,  the  fever  subsided  consider- 
ably, and  the  pain  in  the  shoulder  greatly  diminished.  No  fresh  spots 
appeared  after  the  25th.  From  that  day  the  patient  felt  much  better,  and 
convalescence  began.  She  left  the  Hotel-Dieu,  completely  recovered, 
during  the  first  week  of  January. 


190  ERYTHEMA    NODOSUM. 

Convalescence,  gentlemen,  is  sometimes  tedious,  almost  as  protracted  as 
in  some  putrid  fevers. 

The  articular  pains  which  precede  and  accompany  the  eruption  seem  to 
me  to  be  characteristic  of  erythema  nodosum.  The  general  symptoms  con- 
sist in  a  universal  feeling  of  discomfort,  in  lassitude  and  aching  of  the  legs, 
headache,  want  of  appetite,  and  a  loaded  state  of  the  digestive  canal ;  and 
in  fever  more  or  less  severe  during  a  prodromic  period  which  varies  in  du- 
ration from  one  to  five  days.  When  once  the  eruption  is  accomplished, 
recovery  generally  takes  place  in  one,  two,  or  three  weeks ;  but  again  I 
repeat,  that  the  duration  of  the  malady  may  be  much  more  protracted, 
and  that  so  long  as  the  general  symptoms  continue  new  eruptions  may  be 
looked  for. 

Articular  pains  are  complained  of  almost  at  the  same  time  that  the  gen- 
eral symptoms  set  in  ;  they  sometimes  continue  as  long  as  the  eruption  lasts, 
and  even  after  it  has  disappeared.  They  come  on  spontaneously,  are  aggra- 
vated by  pressure,  are  sufficiently  acute  to  hinder  movements,  and  some- 
times even  entirely  to  prevent  them,  as  was  the  case  in  a  young  woman  in 
our  St.  Bernard  Ward,  who  kept  her  fingers  flexed  from  inability  to  extend 
them.  They  are  sometimes  limited  to  a  single  articulation,  and  in  other 
cases,  as  in  the  young  woman  just  referred  to,  they  extend  to  all  the  joints. 
The  pain  is  sometimes  as  acute  as  in  pure  rheumatism  ;  but  I  have  never 
seen  redness  or  swelling  in  the  situation  of  the  affected  parts ;  nor  have  I 
ever  found  signs  of  cardiac  lesion. 

The  existence  of  these  articular  pains  seems  to  indicate  that  erythema 
nodosum  is  of  the  nature  of  rheumatism.  The  best  authors  have  pointed 
out  the  mutual  relations  of  rheumatism  and  erythema  nodosum.  This  lias 
been  done  in  France  by  Dr.  Bouillaud,*  and  in  Germany  by  Professor 
Schoenlein,  who  has  given  to  erythema  nodosum  the  name  of  rheumatic 
purpura.  Dr.  Bazin,  an  accomplished  physician  of  the  St.  Louis  Hospital, 
has  not  hesitated  to  place  it  at  the  head  of  his  pseudo-exanthematic  ery- 
thematous arthritides;  and  Rayerf  has  described  a  papular  erythema  oc- 
curring in  persons  suffering  from  acute  rheumatism,  which  to  the  eyes  of 
Dr.  Bazin  is  erythema  nodosum  itself. 

I  was  formerly  in  the  habit  of  attaching  a  great  deal  of  importance  to 
the  articular  pains,  and  tried  to  subdue  them  by  giving  preparations  of 
sulphate  of  quinine,  or  veratria.  Afterwards,  from  a  study  of  the  natural 
course  of  the  disease,  I  perceived  that  they  generally  yielded  without  the 
intervention  of  art,  and  I  then  restricted  my  treatment  to  keeping  the 
patients  in  bed,  and  telling  them  to  avoid  chills.  These  hygienical  means 
ami  cooling  drinks  now  constitute  my  whole  treatment  of  these  pains. 
When  tin-  .-tools  are  slimy,  and  indicate  a  loaded  state  of  the  digestive 
canal,  1  endeavor  to  correct  that  state  by  administering  mild  purgati\ 

Erythema  nodosum  is  nut  a  common  disease  of  children,  but  I  cannot 
exactly  say  that  it  is  rare  among  them.  One  of  my  pupils  lately  told  me 
that  he  had  seen  it  in  two  brothers,  one  aged  two  and  a  half,  and  the  other 
four  years  of  age. 


•••■   lioni.i.Ar i) :  Traitfi  Clinique  du  Rhumatisme  Articulaire.     Paris,  1840. 
f  Rater:  Traite"  dea  Maladies  de  la  Peau,     Paris,  L886. 


ERYTHEMA    PAPULATUM.  191 


LECTURE  IX. 

ERYTHEMA   PAPULATUM. 

Differs  from  Erythema  Nodosum  in  the  Form  and  Seat  of  the  Eruption,  and 
in  the  Severity  of  the  Symptoms. — Rheumatic  Character. 

Gentlemen  :  Although  erythema  papulatum  [erythhne  papuleux]  and 
erythema  nodosum  have  obvious  affinities  with  each  other,  I  should  not 
wish  you  to  take  up  the  idea  that  they  are  identically  the  same  disease. 
They  have  undoubtedly  something  in  common,  just  as  small-pox  and 
chicken-pox  have  something  in  common ;  but  in  my  opinion  they  possess 
characteristic  differences  which  allow  us  to  regard  them  as  two  distinct 
species.  Recall,  gentlemen,  the  marked  difference  between  the  physiognomy 
of  disease  in  two  women  whom  you  saw  with  erythema  nodosum,  and  in 
three  patients  with  erythema  papulatum,  two  of  whom  are  in  the  St.  Ber- 
nard Ward,  and  one  in  the  St.  Agnes  Ward.  The  patients  with  erythema 
nodosum  presented,  relatively  to  the  other  group,  very  mild  symptoms, 
though  the  eases  wTere  severe  for  the  affection ;  while  the  three  with  erythema 
papulatum  had  very  formidable  symptoms,  so  formidable  in  one  of  them  as 
to  occasion  death.  Do  not  suppose,  gentlemen,  that  the  disease  is  formid- 
able in  proportion  to  the  intensity  of  the  eruption,  as  is  the  case  in  small- 
pox and  scarlatina.  The  forms,  the  seat,  and  the  mode  of  evolution  of  the 
eruption  are  so  various  as  to  establish  the  diversity  of  the  nature  of  the 
two  diseases.  Again,  erythema  papulatum  is  accompanied  by  serious  pul- 
monary lesions,  and  sometimes  by  articular  rheumatism  and  endocarditis, 
whereas  erythema  nodosum  has  no  such  accompaniments,  or  at  least  is  not 
attended  by  pulmonary  lesions.  You  will  easily  understand  this  distinction 
when  I  recall  to  your  recollection  the  history  of  cases  which  you  have  had 
an  opportunity  of  studying  with  me  in  the  clinical  wards,  and  which  you 
will  be  able  to  compare  with  the  history  of  cases  of  erythema  papulatum. 
Let  me  first  recapitulate  the  case  of  the  man  who  occupied  bed  No.  24  in 
St.  Agnes's  Ward. 

He  was  an  assistant-cook,  who  had  lived  in  Paris  for  the  four  months 
preceding  his  attack,  during  which  period  he  had  enjoyed  good  health.  He 
was  admitted  into  hospital  on  a  Friday.  On  the  previous  Sunday,  he  had 
felt,  as  precursory  symptoms,  stiffness  and  pricking  in  the  eyes.  He  also 
experienced  pains  in  the  wrist  and  joints  of  the  middle  finger,  which  on  the 
following  day  became  so  violent  as  to  interfere  with  the  movements  of  the 
parts  affected,  to  the  extent  of  preventing  him  from  opening  and  shutting 
the  hand.  In  the  evening  of  the  same  day,  he  had  pains  in  the  knee. 
There  were,  however,  neither  fever  nor  loss  of  appetite.  From  the  Sunday 
also,  he  had  perceived  on  his  hands  an  eruption  of  uniform  redness.  On 
the  Tuesday,  the  backs  of  both  hands,  the  cheeks,  and  the  forehead  were 
covered  with  pimples,  and  there  was  some  fever.  Upon  his  admission  into 
hospital,  I  observed  this  papular  eruption,  upon  a  ground  of  a  winy-red  hue, 
raised  above  the  parts  of  the  skin  "which  were  not  affected.  Besides  some 
pustules  of  acne  on  the  inferior  extremities,  we  saw  a  small  patch  of  ery- 
thema nodosum  on  the  left  leg:  this  patch  was  painful.  In  no  other  situa- 
tion than  those  named  did  we  find  any  trace  of  eruption,  except  in  both 


192  ERYTHEMA    PAPULAIUM. 

conjunctivae,  the  scleroties  of  which  were  injected  with  livid  red.  The  edges 
of  the  eyelids  were  also  red.  On  the  Thursday  following — the  seventh  day 
after  admission  and  the  twelfth  from  the  beginning  of  the  attack — I  observed 
a  little  obstruction  of  the  lungs  characterized  by  cough  and  mucous  sub- 
crepitant  rales  in  the  posterior  part  of  the  base  of  the  left  lung.  The 
patient,  nevertheless,  asked  for  food  and  did  not  remain  in  bed.  Two  days 
afterwards — on  the  fourteenth  day  of  the  malady — the  erythematous  patches 
were  much  paler,  but  new  pimples  had  come  out  in  the  situations  in  which 
they  had  been  first  seen.  For  forty  days,  his  general  condition  ws!s  very 
unfavorable,  and  the  fever  continued.  There  were  five  or  six  successive 
eruptions.  The  patient  became  exceedingly  thin ;  and  on  the  sixtieth  day 
from  his  seizure,  he  was  as  weak  as  if  he  had  had  an  aggravated  attack  of 
dothienteria. 

In  connection  with  the  case  now  detailed,  I  will  relate  that  of  a  woman 
Avho  lay  in  bed  No.  11  of  St.  Bernard's  Ward,  in  whom  the  disease  proved 
rapidly  fatal.  Her  age  was  sixty.  She  had  long  suffered  from  pulmonary 
emphysema,  and  on  admission  had  bronchitis  accompanied  by  fever,  and  a 
state  of  stupor  which  to  me  did  not  seem  to  be  dependent  on  the  state  of 
the  bronchial  tubes.  For  several  days,  the  chest  was  auscultated  with  very 
great  care,  with  a  view  to  discover  whether  there  was  any  point  affected 
with  peripneumonia.  Three  days  after  admission,  erythema  nodosum  was 
detected  on  the  legs  and  erythema  papulatum  on  the  backs  of  the  hands. 
This  woman,  by  occupation  a  washerwoman,  had  had  several  attacks  of 
rheumatism,  and  it  was  through  exposure  to  cold  and  damp  that  she  had 
contracted  the  catarrh  which  brought  her  to  the  hospital.  The  bronchitis 
soon  became  general,  and  on  the  twentieth  or  twenty-first  day  terminated 
fatally,  having  become  complicated  with  double  hypostatic  pneumonia.  On 
examination  after  death,  we  found  sero-sauguinolent  engorgement  of  the 
lower  third  of  both  lungs,  and  a  muco-purulent  fluid  in  the  minute  bron- 
chial tubes. 

You  have  lately  watched  the  evolution  of  erythema  papulatum  in  a 
woman  who  occupied  bed  No.  33  of  the  same  ward,  and  whose  life  was  in 
great  jeopardy  for  more  than  fifteen  days.  I  regard  her  case  as  one  of  the 
most  conclusive  I  have  met  with  in  support  of  my  opinion,  that  erythema  is 
essentially  a  constitutional  affection.  Here  are  the  facts  drawn  up  by  M. 
Dumontpallier: 

"A  young  woman  of  thirty-eight  years  of  age,  who,  though  a  rheumatic 
subject,  had  enjoyed  very  fair  health  for  several  years,  was  admitted  to  the 
St.  Bernard  Ward  with  all  the  symptoms  of  an  attack  of  fever.  She  had 
general  prostration,  lassitude,  pains  in  the  legs,  quick  pulse,  foul  tongue, 
nausea,  sweating,  and  constant  headache.  The  patient  had  had  these 
symptoms  for  several  days,  but  there  was  nothing  in  their  duration,  nor  in 
the  predominance  of  any  one  of  them,  to  had  us  to  suppose  that  the  case 
was  an  eruptive  fever;  nor  was  there  any  ground  for  believing  that  an 
organic  lesion  existed.  She  merely  -land  thai  some  days  before  she  came 
into  hospital,  she  had  had  pain  in  both  knees.  <  >n  the  day  of  her  admis- 
sion, there  wa.-  no  trace  of  articular  swelling,  and  do  joint  was  the  seal  of 
decided  pain;  nevertheless,  the  persistence  of  the  sweating  and  fever,  com- 
bined with  the  dull  white  color  of  the  skin,  suggested  rheumatic  fever. 
There  was  from  her  firel  day  in  hospital,  moreover,  a  Blight  Mowing  Bound 
audible  over  the  apex  of  the  heart.  The  question  arose:  Was  this  abnormal 
sound  the  resull  of  a  lesion  originating  in  previous  rheumatism,  or  was  it  de- 
pendent upon  existing  suliacute  endocarditis?  She  had  neither  palpitation 
nor  pain  in  the  regiou  of  the  heari.  Nbl  finding  anything  to  account  satis- 
factorily for  the  continuance  of  the  general  symptoms  for  so  many  days,  and 


ERYTHEMA     PAPULATUM.  193 

having  abandoned  the  hypothesis  that  they  belonged  to  an  eruptive  fever, 
I  examined  the  skin,  to  .-re  whether  I  could  discover  any  trace  of  an  ephem- 
era] eruption.  The  examination  was  not  without  results:  on  the  arms 
and  forearms,  as  well  as  on  the  thighs  and  legs,  I  observed  an  eruption  of 
papules  of  various  sizes.  On  the  external  aspect  of  the  middle  of  the  left 
arm,  they  formed  slightly  elevated  confluenl  patches:  they  were  of  a  rosy 
color,  soft  to  the  touch,  and  disappeared  on  slight  pressure,  reappearing  on 
the  pressure  being  removed:  it  wa.s  observed  that  the  papules  were  in  sev- 
eral places  grouped  in  such  a  way  as  to  present  the  appearance  of  semicir- 
cles. Similar  isolated  patches  were  seen  on  the  palmar  aspect  of  the  left 
arm  and  forearm.  The  patient  was  not  aware  of  the  existence  of  the  erup- 
tion, which  had  occasioned  neither  heat  nor  itching.  On  the  anterior  and 
external  lateral  aspect  of  the  thighs  and  legs,  there  were  a  verv  few  similar 
patches,  which  were  but  little  elevated.  She  was  astonished  when  we  pointed 
out  to  her  nodulated  spots  on  the  anterior  surface  of  the  leg ;  these  spots 
were  pale  red,  elevated  above  the  surface  of  the  skin,  and  rested  on  a  bump 
as  large  as  a  small  filbert-nut :  here  we  undoubtedly  had  erythema  nodosum. 
On  the  following  days  successive  eruptions  appeared,  and  they  were  beyond 
the  possibility  of  doubt  eiythematous.  In  point  of  fact,  new  papules  and 
new  bumps  appeared  in  crops,  just  as  successive  crops  of  eruption  come  out 
in  chicken-pox  on  the  arms  and  legs.  The  bumps  were  confined  to  the  legs 
an'd  one  of  the  thighs.  The  erythema  papulatum  was  particularly  well 
marked  in  the  left  arm,  in  the  situation  of  the  insertion  of  the  deltoid  mus- 
cle: several  crops  of  papules  appeared  there  successively,  and  after  three  or 
four  crops  the  papules  were  as  red  and  raised  as  on  any  other  part  of  the 
body.  Simultaneously  with  each  erythematous  eruption,  there  wTas  a  febrile 
exacerbation,  accompanied  by  rheumatic  pains  in  the  knee-joints,  wrists, 
ankles,  hands,  and  feet.  The  skin  continued  moist.  Auscultation,  which, 
from  the  day  of  the  patient's  admission,  had  revealed  the  existence  of  sub- 
crepitant  rales  throughout  the  whole  of  the  posterior  part  of  the  chest,  soon 
afterwards  disclosed  double  pleurisy,  unaccompanied  by  stitch  in  the  side, 
and  attended  by  very  little  cough.  Over  the  inferior  angle  of  both  scapula;, 
a  blowing  sound  and  egophony  were  heard.  There  was  also  effusion  on 
both  sides  which  did  not  ascend  higher:  it  was  more  persistent  on  the  left 
than  on  the  right  side.  The  fever  lasted  for  fifteen  days  after  her  admis- 
sion. For  the  last  two  days,  however,  of  that  period,  it  was  more  moderate, 
the  perspirations  were  less  profuse,  and  there  were  no  longer  articular  pains. 
There  was  no  fresh  eruption,  and  the  old  papules  had  entirely  disappeared. 
The  bumps  were  no  longer  appreciable  to  the  touch,  and  no  traces  of  their 
former  existence  remained  except  ecchymotic  staining  of  the  skin.  The 
appetite  had  returned,  the  tongue  was  good,  and  the  double  pleurisy  was 
undergoing  resolution." 

Upon  comparing  with  each  other  all  the  facts  in  this  case,  you  will  find 
that  they  possess  a  common  physiognomy.  There  was  violent  and  contin- 
uous fever,  profuse  perspirations,  particularly  at  night,  a  very  formidable 
pulmonary  affection,  and  an  illness  lasting  much  longer  than  could  have 
been  anticipated  from  the  first  symptoms. 

I  do  not  wish,  gentlemen,  to  omit  stating  some  circumstances  which  seem 
to  tell  against  my  opinion.  As  I  mentioned  to  you  already,  I  have  often 
met  with  erythema  nodosum  and  erythema  papulatum  differing  from  each 
other,  but  have  never  seen  a  case  of  erythema  nodosum  in  which  there 
were  not  numerous  papules,  and  I  have  sometimes  met  with  true  nodes  in 
erythema  papulatum.  Again,  in  both  we  meet  with  articular  pains,  and 
even  endocarditis,  though  not  so  frequently  in  erythema  nodosum  as  in 
erythema  papulatum.  I  do  not  consider,  however,  that  because  these  phe- 
VOL.  i. — 13 


194  ERYTHEMA    PAPULATUM. 

noraena  are  common  to  both  diseases,  both  are,  therefore,  identical.  It  is 
no  more  necessary  to  believe  that,  than  to  hold  that  scarlatina  and  small- 
pox are  identical  because  a  scarlatiniform  eruption  has  been  seen  at  the 
beginning  of  an  attack  of  modified  small-pox.  There  is  unquestionably  a 
great  similarity  between  the  ataxo-adynamic  symptoms  of  typhoid  fever 
and  of  pyaemia,  but  no  one  will  deny  that  these  two  diseases  are  essentially 
distinct  and  different.  In  the  cases  which  I  have  laid  before  you,  it  is 
difficult  to  avoid  seeing  a  confirmation  of  the  views  of  my  colleague  at  the 
St.  Louis  Hospital,  Dr.  Baziu,  regarding  the  arthritides.  According  to  him, 
both  erythema  nodosum  and  erythema  papulatum  are  arthritic  affections. 
Though  they  differ  in  form,  he  holds  that  they  are  identical  in  essence ; 
they  both  spring  from  one  common  diathesis — the  arthritic.  This  doctrine, 
eminently  medical,  explains  our  meeting  with  in  the  same  patient,  on  the 
one  hand,  evidence  of  previous  articular  rheumatism,  and  on  the  other  the 
coexistence  of  the  cutaneous  eruptions  with  cardiac  and  pulmonary  affec- 
tions. It  is  not  then  erythema  papulatum  which  is  formidable,  but  the 
diathesis  of  which  it  is  an  expression. 

There  are,  however,  cases  of  erythema  papulatum  exceptionally  mild, 
which  may  in  this  respect  be  compared  with  cases  of  erythema  nodosum. 
There  is  at  this  very  moment,  in  bed  Xo.  33  of  the  St.  Bernard  Ward,  a 
woman  of  fifty  years  of  age,  in  whom  erythema  papulatum  is  very  con- 
fluent on  the  face  and  neck,  and  still  more  on  the  hands  and  forearms,  but 
who  is  without  fever,  articular  pains,  gastric  or  pulmonary  symptoms. 
Hence  it  is  evident  that  there  are  degrees  of  severity  in  erythema  papu- 
latum, as  in  any  other  eruptive  disease ;  but  this  does  not  in  any  way  g<  i  to 
prove  that,  as  a  general  rule,  one  of  the  two  is  a  much  more  serious  malady 
than  the  other. 

Gentlemen,  erythema  papulatum,  like  erythema  nodosum,  declares  itself 
by  general  symptoms — by  general  discomfort,  fever,  ami  a  saburral  state  of 
the  digestive  canal.  These  prodromic  symptoms  are  usually  met  with, 
though  they  were  absent  in  our  patient  in  the  St.  Agnes  Ward.  The  dura- 
tion of  the  prodromic  period  is  variable,  and  lasts  from  one  to  five  days. 
Along  with  these  general  symptoms,  there  set  in,  as  in  erythema  nodosum, 
articular  pains,  which  are  sometimes  of  such  severity  as  to  impede,  or  even 
completely  prevent,  the  movements  of  the  body :  these  pains  continue 
during  the  eruptive  period,  and  are  often  prolonged  till  after  its  conclusion. 
Endocarditis  occurs  in  sonic  cases,  as  you  have  had  an  opportunity  of  ob- 
serving. Erythematous  rheumatism,  like  scarlatinous  rheumatism  (which 
is  much  less  severe  and  less  obstinate  than  acute  articular  rheumatism!, 
often  assumes  an  exceptionally  intense  form. 

The  eruption  consists  of  patches  of  a  winy  redness,  sometimes  placid  near 
each  other,  and  sometimes  disseminated;  they  may  he  either  quite  round, 
or  thev  may  be  of  irregular  shape.  These  patches,  constituted  primarily 
by  small  tumors,  painful  to  the  touch,  fade,  flatten,  and  pass  from  a  red  to 

a  violet-red  color.  .M.  Hardy  says  thai  the  patches  are  sometimes  complete 
circles  surrounding  portions  of  sound  skin.  The  eruption  end-  with  slight 
desquamation.    Vesicles  have  been  observed  on  the  patches;  their  duration 

L6  viiv  ephemeral  ;  they  dry  up   quickly,  leaving  no  trace  behind,  whether 

they  Durst  or  whether  they  disappear  in  consequence  of  their  serous  con- 
tent- being  absorbed.  The  eruption  is  often  indolent.  It  may  be  accom- 
panied  by  a  feeling  of  heat,  burning,  or  itching.     It   is  a  characteristic 

circumstance  that  the  eruption    has  a    preference    for   the   hand.-,  forearms, 

face,  and  neck.  It  is  lcs>  frequently  seen  on  the  interior  extremities,  differ- 
ing in  this  respect  from  erythema  nodosum,  which  prefers  the  continuity  of 

the  Limbs,  and  particularly  the  parts  where  there   is  only  a  wry  thin   sepa- 


ERYSIPELAS.  195 

ration  between  the  skin  and  the  bone.    Erythema  papulatum  lasts  for  fifteen 
or  sixteen  days. 

The  treatment  ought,  as  in  simple  erythema  nodosum,  to  be  restricted  to 
precautionary  and  hygienical  measures.  When  the  articular  pains  are  not 
severe,  no  interference  is  called  for.  When  the  thoracic  complications 
assume  a  formidable  character,  and  when  the  rheumatism  becomes  general 
and  invades  the*heart,  the  treatment  required  will  just  be  that  which  is 
appropriate  in  cases  of  pleurisy,  broncho-pneumonia,  or  polyarthritic  rheu- 
matism. 


LECTURE  X. 

ERYSIPELAS ; 

AND   IN    PARTICULAR    ERYSIPELAS    OP    THE    FACE. 

Pathology  of  Erysipelas. — Almost  always  an  Exciting  Cause,  independent  of 
Individual  Predisposition  and  General  Cause. — May  Supervene  in  the 
Course  of  Epidemics. — Severity  increased  by  Traumatic  Influence. — 
General  Symptoms  dependent  on  Inflammation  of  Wound  and  Lymph- 
atic Vessels. — Delirium  has  not  the  Signification  attributed  to  it  in 
Erysipelas. — Erysipelas  sometimes  Contagious. —  When  not  a  Compli- 
cation of  another  Disease  is  a  Mild  Affection  which  Subsides  Spontane- 
ously.— The  Treatment  ought  to  be  Expectant. 

Gentlemen  :  We  have  at  present  several  patients  affected  with  erysipe- 
las— a  young  girl  in  bed  No.  6  of  the  St.  Bernard  Ward,  a  young  woman  of 
twenty  in  bed  No.  10  of  the  same  ward,  and  a  young  man  between  twenty- 
five  and  twenty-six  years  of  age,  occupying  bed  No.  8  in  the  St.  Agnes 
Ward.  The  manner  in  which  these  three  persons  were  seized  was  very 
nearly  similar,  and  in  all  of  them  the  erysipelas  of  the  face  has  assumed 
the  same  form.  In  bed  No.  4  of  the  men's  ward  we  have  seen  a  fourth 
patient  with  erysipelas ;  but  his  case  has  been  invested  with  special  interest 
in  consequence  of  the  course  which  the  disease  has  taken. 

This  man,  from  the  date  of  his  admission,  had  a  very  violent  sore  throat, 
with  consequent  affection  of  the  submaxillary  glands.  At  my  first  exami- 
nation of  him  I  predicted  that  by  the  next  visit  the  case  would  have 
declared  itself  as  erysipelas  of  the  face ;  and  the  event  justified  my  prog- 
nosis. My  opinion  was  founded  on  the  presence  of  certain  phenomena,  to 
which  I  directed  your  special  attention.  Three  clays  previously,  the  patient 
had  experienced  exceedingly  severe  pain  in  the  throat :  next  day,  the  sore 
throat  was  well  marked ;  and  on  the  day  following,  the  severity  of  the 
pain  had  increased,  while  at  the  same  time  intense  fever  set  in  and  a  large 
glandular  swelling  formed  at  the  angle  of  the  lower  jaw.  On  depressing 
the  tongue  and  examining  the  pharynx,  we  found  a  vivid  redness  of  the 
uvula,  veil  of  the  palate,  and  pillars  of  the  tonsils.  From  these  symptoms, 
I  came  to  the  conclusion,  that  the  case  was  either  catarrhal  sore  throat,  or 
erysipelatous  inflammation  of  the  pharynx.  But  as  catarrhal  sore  throat 
is  in  general  not  nearly  so  painful  as  erysipelas  of  the  pharynx ;  as  the 
swelling  was  not  so  great,  as  the  redness  was  less  vivid,  as  the  fever  was 
more  severe  and  the  cervical  glands  more  swollen  than  is  usual  in  the 
former,  my  ultimate  diagnosis  was  erysipelas.     With  my  diagnosis  thus 


196  ERYSIPELAS. 

settled,  T  had  to  wait  till  the  malady  should  proceed  to  the  nasal  fossae, 
and  by  that  route  reach  the  face.  Well !  the  erysipelas,  which  during  the 
night  had  begun  to  appear  at  the  orifices  of  the  nostrils,  forthwith  extended 
to  the  nose ;  next  morning,  the  pain  of  the  throat  and  the  redness  of  the 
pharynx  had  disappeared,  and  the  malady  pursued  precisely  the  same 
course  which  we  see  it  follow,  when  we  watch  its  evolution  on  the  skin. 
From  the  nose,  it  extended  to  the  cheeks,  from  the  cheeks  to  the  eyelids 
and  forehead,  whence  it  advanced  to  the  hairy  scalp,  aud  so  on  it  proceeded, 
till  it  had  made  the  circuit  of  the  head,  resting  from  two  to  four  days  in 
one  situation  and  then  invading  the  adjoining  place. 

It  is  very  important  to  be  acquainted  with  this  line  of  march  which 
erysipelatous  inflammation  follows.  Ten  years  ago,  my  friend  Dr.  Gubler 
was  the  first  to  point  out  that  erysipelas  of  the  face  is  only  a  propagation 
of  the  disease  from  the  pharynx,*  and  not  a  metastasis  as  had  before 
that  been  often  repeated.")"  The  propagation  may  proceed,  as  was  also 
shown  by  the  same  able  physician,  in  an  inverse  order;  that  is  to  say,  the 
ervsipelas  may  begin  in  the  skin,  and  proceed  from  it  to  the  mucous  mem- 
branes. Erysipelatous  inflammation  of  mucous  membranes  must  not  be 
confounded  with  other  kinds  of  inflammation  to  which  they  are  liable. 
In  a  practical  point  of  view  this  is  very  important.  No  doubt,  I  shall 
have  occasion  to  return  to  this  topic  in  the  course  of  my  lectures.  But 
to-day,  gentlemen,  the  subject,  on  which  I  have  to  address  you  is  erysipelas 
of  the  face. 

Do  not  suppose  that  it  is  my  intention  to  give  you  a  complete  history  of 
the  disease ;  for  that  you  will  find  in  the  text-books  which  are  in  the  hands 
of  all  of  you.  Chomel  and  Blache,  in  the  Diction  naire  de  Mrdecine,  and  MM. 
Hardy,  Behier,  and  Valleix,  in  their  treatises  on  internal  pathology,  have 
given  exhaustive  descriptions  of  erysipelas.  I  only  propose,  therefore,  to 
speak  at  present  upon  some  specialties  in  its  pathogeny  and  treatment. 

Surgeons  for  the  most  part  are  agreed  that  when  erysipelas  appears  in 
the  wards  of  a  surgical  hospital,  its  presence  is  dependent  upon  traumatic 
influences.  A  patient,  for  example,  after  having  undergone  a  trifling 
operation,  such  as  the  opening  of  an  abscess  with  the  lancet,  or  the  making 
of  a  small  cut  in  the  skin  for  some  other  purpose,  is,  after  an  interval, 
affected  with  general  discomfort:  the  glands  in  the  vicinity  of  the  wound 
become  enlarged,  those  of  the  groin  for  instance,  when  the  wound  is  on  the 
inferior  extremity,  and  those  of  the  elbow  and  axilla,  when  it  is  on  the 
hand.  The  erysipelatous  redness  soon  appears.  In  such  eases,  the  cause 
of  the  affection  is  evident :  everybody  readily  recognizes  its  mode  of  develop- 
ment: the  existence  of  a  predisposing  cause  either  in  the  individual  or  in 
the  circumstances  with  which  he  is  surrounded  is- admitted:  the  existence  is 
admitted  of  an  epidemic  constitution  of  the  atmosphere  in  consequence  of 
which  the  most  insignificant  operation,  at  other  time-  unattended  by  any  such 
risk,  is  immediately  followed  by  erysipelas.  Bui  the  affection  so  arising 
is  always  traumatic,  ami  you  must  he  careful  to  distinguish  it  from  what  is 
called  iiiciUnif  erysipelas. 

Many  physicians  are  of  opinion  that  medical  erysipelas  is  not  under  the 
law  to  which  surgical  erysipelas  is  Bubject.     According  to  Chomel  and 

Blache,  erysipelas   is   never   the   resull  of  an   external   cause,  and   they  say 


*  Gubler:  Soci6t6  de  Biulogie,  1866. 

f  Up"ti   this  Biibject,  see  the   more  recent   researches   >>(   V.  Cornil,  entitled, 
''Observations  pour  Btrvir  a  I'histoire  de  1' Erysipelo  du  Pharynx  "  |  Archives  l 
rales  de  Midecine,  1862] j  iind  .).  Ciure  :   "De  I'EryBipele  du   Pharynx  "     |  i 
Inaugurate].     Paris,  L864, 


ERYSIPELAS.  197 

that  if  sometimes  an  accessory  cause  contribute  to  its  production,  it  is  only 
in  a  secondary  manner.  I  think  it  is  nearer  the  truth  to  say,  that  in  the 
immense  majority  of  cases  both  classes  of  causes  are  in  operation.  It  is  so, 
in  the  circumstances  to  which  I  have  just  alluded,  when  during  an  epidemic, 
cases  of  erysipelas  seem  to  arise  spontaneously;  that  is  to  say,  without  any 
appreciable  exciting  cause.  Such  of  you  as  have  attended  the  surgical 
wards  know,  that  one  or  two  years  may  elapse  during  which  an  attack  of 
erysipelas  is  an  unusual  occurrence  after  an  operation  however  serious,  and 
that  at  other  times,  the  surgeon  cannot  make  the  slightest  use  of  the  bis- 
toury without  exposing  his  patient  to  this  risk.  This  is  the  present  state 
of  matters.  There  is  also  now  prevailing  one  of  the  severest  epidemics  of 
puerperal  fever  which  has  in  recent  times  desolated  the  Maternity  Hospital, 
where  sixty  patients  have  died  within  ten  mouths  from  this  terrible  pesti- 
lence. At  the  very  time  when  prudence  compelled  the  physicians  of  that 
establishment  to  shut  it  up,  and  send  the  women  to  be  confined  in  the  other 
hospitals,  erysipelas  broke  out  in  a  severe  form  in  a  great  many  of  the  sur- 
gical services,  among  those  who  had  wounds.  The  coincidence  of  puerperal 
fever  and  traumatic  erysipelas  has  been  pointed  out  long  ago,  and  Graves 
has  taken  up  the  subject  with  precision  in  his  clinical  lectures:  but  it  is  to 
the  Clinical  Hospital  of  the  Faculty  of  Medicine  of  Paris  that  we  must 
specially  refer  for  proof  of  the  occurrence  of  this  coincidence,  as  there,  under 
the  same  roof,  separate  wards  exist  for  surgical  patients  and  for  lying-in 
women.* 

It  is,  therefore,  an  incontestable  fact  that  under  certain  atmospheric  con- 
ditions— under  the  influence  of  an  unknown  something  in  the  air — indi- 
viduals become  disposed  to  take  erysipelas  from  slight  causes  which  would 
not  have  produced  it  at  other  times.  Graves  believes  in  this,  and  also  in 
contagion.  This  is  a  subject  to  which  I  shall  by  and  by  return,  but  I  may 
now  remark,  that  even  when  contagion  operates,  immediately  exciting 
causes  generally  play  a  part  not  hitherto  sufficiently  appreciated.  Observe 
with  attention,  and  you  will  see,  that  the  erysipelas  described  under  the 
names  of  medical  and  non-traumatic  (in  contradistinction  to  that  termed 
surgical  and  traumatic),  has  almost  always  a  starting-point,  which  though 
it  cannot  strictly  speaking  be  called  a  wound,  is  at  least  a  lesion — a  very 
slight  lesion  it  may  be  in  some  cases.  In  three  of  our  patients,  this  was 
placed  beyond  doubt. 

The  young  girl  of  bed  No.  6  St.  Bernard's  Ward  had  a  suppurating  pimple 
at  the  angle  of  the  eye,  which  she  scratched,  and  so  excited  in  it  an  increase 
of  inflammation.  From  this  little  breach  of  continuity  erysipelas  started, 
which  progressively  invaded  the  cheeks,  forehead,  and  hairy  scalp. 

The  woman  occupying  bed  No.  10  had  long  had  eczema  of  the  nose,  and 
there  it  was  that  the  erysipelas  commenced.  From  the  nose,  it  extended 
to  the  eyes,  face,  and  hairy  scalp ;  in  which  latter  situation  it  is  now  begin- 
ning to  show  itself,  after  having  becoming  extinct  in  the  other  places. 

In  the  young  man  occupying  bed  No.  8  of  the  St.  Agnes  Ward,  erysipelas 
took  the  same  course,  having  had  likewise  eczema  of  the  nose  as  its  exciting 
cause:  and  this  is  the-third  erysipelatous  attack  which  this  young  man  has 
had,  the  starting-point  in  each  of  them  being  his  chronic  eczema  of  the  nose. 

Again,  I  say,  therefore,  observe  carefully  the  cases  you  meet  with,  and 
in  nearly  every  one  of  them  you  will  find  a  small  lesion  of  the  integuments 
at  some  point  on  the  face,  such  as  the  corner  of  the  eye,  the  nose,  the  lips, 

*  See  the  report  of  the  long  discussion  on  puerperal  fever  in  the  Academy  of 
Medicine  :  "  De  la  Fievre  Puerperale,  de  sa  Nature  et  de  son  Traitement :"  Paris, 
1858. 


198  ERYSIPELAS. 

behind  the  ear,  or  in  the  hairy  scalp.  This  you  will  find  in  many  cases  to 
be  a  herpetic  ulceration  of  the  face,  or  of  the  mucous  membrane  of  the 
throat ;  and  sometimes  inflammation  of  the  gums  dependent  on  the  pres- 
ence of  a  carious  tooth.  Finally,  while  it  is  quite  necessary  to  take  into 
account  personal  predisposition,  and  still  more  to  admit  the  influence  of  a 
general  predisposing  cause  (the  nature  of  which  is  unknown  though  its  ex- 
istence is  universally  admitted  by  all  physicians),  a  determining  cause  is  also 
required  for  the  production  of  erysipelas.  This  determining  cause  plays  an 
essential,  and  not  a  secondary  part,  in  the  development  of  the  disease. 

If  we  grant  that  under  certain  circumstances,  under  epidemic  influences, 
erysipelas  is  developed  independently  of  traumatic  causes,  and  quite  spon- 
taneously, it  must  also  be  admitted,  that  there  are  others  in  which  it  may 
at  first  be  supposed  that  the  determining  cause  is  absent,  but  in  which  it  is 
afterwards  discovered. 

You  no  doubt  recollect  a  woman  admitted  into  the  clinical  wards  for 
erysipelas  of  the  face  and  hairy  scalp,  in  whom  there  seemed  no  proof  of 
the  disease  having  had  a  lesion  of  the  integuments  as  its  starting-point. 
Upon  her  admission,  I  carefully  questioned  her,  when  she  denied  having 
had  any  previous  affection  which  could  account  for  the  attack  :  she  affirmed 
that  she  had  had  no  sore  place  on  the  ears,  eyes,  nose,  or  throat,  and  no 
breach  of  continuity  of  any  description  on  the  face  or  head.  Here,  then, 
seemed  a  case  in  which  erysipelas  had  come  of  itself;  but  subsequently, 
upon  resuming  my  interrogations,  the  patient  mentioned  that  she  had  had 
violent  pain  in  the  ear,  which  for  some  time  had  affected  her  hearing,  or, 
to  use  her  own  expression,  had  made  her  hard  of  hearing.  She  then  recol- 
lected that  along  with  the  pain  in  the  ear  and  deafness,  she  had  had  at  the 
same  time  an  affection  of  the  glands  of  the  neck,  that  two  days  afterwards 
there  appeared  behind  the  left  ear  a  red,  smarting  patch  which  successively 
took  possession  of  the  face  and  hairy  scalp;  and  the  presence  of  which  we 
noticed  at  the  time  of  her  admission.  Going  back  thus  to  the  starting- 
point,  we  have  been  enabled  to  follow  the  course  of  the  affection  of  the  skin, 
and  again  to  prove  that  a  case  which  might  have  passed  with  many  physi- 
cians as  belonging  to  the  class  of  erysipelatous  cases  reputed  medical,  bore 
a  great  analogy,  in  respect  of  its  starting-point,  to  what  is  called  .surgical 
or  traumatic  erysipelas. 

There  ends,  however,  the  analogy;  for  that  which  we  call  traumatic  in- 
fluence [traumatisme]  in  speaking  of  erysipelas,  is  a  something  which  imparts 
to  that  disease  a  formidable  character  altogether  special.  The  (ruth  of  this 
proposition  is  demonstrated  by  what  is  seen  after  wounds  of  the  face,  and 
still  more  after  wounds  of  the  hairy  scalp.  The  appearance  of  cerebral 
symptoms  is  looked  upon  as  a  usual  and  unfavorable  occurrence  in  erysipe- 
las of  t  lie  head,  while  iii  reality  such  symptoms  are  not  generally  met  with 
excepl  in  erysipelas  of  traumatic  origin — using  the  term  traumatic  in  its 
strictly  accurate  acceptation.  This  probably  depends  upon  recently  de- 
nuded vessels    becoming   the    seat    of  violent   inflammation   and    producing 

much  greater  disturbance  of  the  economy  than  results  from  erysipelas  deter- 
mined by  a  small  and  partially  cicatrized  excoriation,  or  a  herpetic  ulceration 
of  the  nose,  ears,  or  eyes.     From  this  point  of  view,  but  only  from  this  point 

of  view,  it  is  necessary  to  establish  a  distinction  between  surgical  erysipelas 
which  is  often,  and  medical  erysipelas  which  is  seldom,  fatal.  It  i.-  of  the 
latter  that  I  have  now  to  speak. 

Medical  is  the  name  given  to  the  erysipelas  which  proceeds  from  an  in- 
ternal cause.     One  reason  why  physicians  give  it   this  descriptive   name 

arises  from  the  circumstance  that   in  numerous  cases,  the  appearance  of  the 

cutaneous  inflammation  is  preceded  by  fever,  general  discomfort,  and  dis* 


ERYSIPELAS.  199 

order  of  the  digestive  function,  indicating  the  impress  of  a  pathological 
modality  upon  the  economy.  Considering  erysipelas,  then,  as  an  eruptive 
level-,  if  has,  following  the  example  of  Borsieri,  been  placed  in  the  same 
nosological  category  as  small-pox,  scarlatina,  measles,  and  all  the  exan- 
themata. 

That,  in  my  opinion,  gentlemen,  is  a  mistake.  I  do  not  deny  that  in 
some  cases  the  fever  precedes  the  inflammation,  but  this  is  a  rare  occur- 
rence, the  rule  being  that  the  local  inflammation  precedes  the  general 
febrile  excitement.  It  is  not  sufficiently  observed  that  precisely  the  same 
phenomena  occur  in  erysipelas  of  the  face  as  in  erysipelas  of  other  parts  of 
the  body,  whether  the  cause  be  external  or  internal.  A  person,  for  exam- 
ple, has  a  wound  on  the  foot  or  leg  which  becomes  inflamed  and  very  pain- 
ful, the  lymphatic  vessels  and  glands  connected  with  it  swell,  and  fever 
sets  in,  but  some  days  elapse  before  the  erysipelas  appears  around  the 
wound.  In  this  case,  the  fever  cannot  be  looked  on  as  similar  to  the  pro- 
dromic  fever  of  the  exanthematous  fevers :  its  existence  is  perfectly  explained 
by  the  inflammation  of  the  wound  and  lymphatics.  The  inflammation  of 
the  lymphatic  vessels,  or  at  least  of  the  glands,  precedes  the  appearance  of 
the  erysipelas:  this  is  undeniable.  Even  Borsieri,  while  he  called  erysipelas 
an  eruptive  fever,  stated  that  glandular  engorgement  was  a  symptom  of  the 
beginning  of  the  attack:  in  the  paragraph  which  he  devotes  to  erysipelas 
he  says:  "Illud  etiam  memoria  probe  tenendum  est  quod  crebis  ex  obser- 
vationibus  constitit,  si  erysipelas  artubus  inferioribus  incubiturum  sit,  in- 
guinis  et  femoris  glandulas  conglobatas,  vasis  cruralibus  additas,  antequam 
se  exerat,  leviter  dolere  atque  intumescere  consuevisse,  axillares  vero  ac 
cervicales,  si  brachiis  aid  superioribus  locis  immineat."  Chomel,  too,  with 
whose  views  regardiug  erysipelas  you  are  acquainted,  mentions  that  painful 
swelling  of  the  lymphatic  glands  in  the  neighborhood  of  the  seat  of  the 
disease  is  one  of  its  most  remarkable  and  constant  phenomena. 

On  the  other  hand,  gentlemen,  we  must  not  exaggerate  the  importance 
of  this  fact,  and  say  with  Blandin  that  erysipelas  is  nothing  more  than 
lymphitis.  Velpeau  has  conclusively  shown  that  lymphitis  and  erysipelas 
are  very  different  affections  ;  but  the  renowned  surgeon  of  La  Charite  has  in 
his  turn  fallen  into  the  opposite  extreme,  in  maintaining  that  adenitis  is 
consecutive  to  erysipelatous  inflammation  of  the  integuments.  Resting  my 
opinion  on  my  own  personal  experience,  and  on  the  authority  of  such  ob- 
servers as  Chomel,  I  hold,  that  almost  always  the  glandular  engorgement 
precedes  the  outbreak  of  the  erysipelatous  inflammation,  and  also  that  it  is 
dependent  upon  a  local  lesion  in  the  situation  of  the  lymphatic  vessels 
communicating  with  the  swollen  glands.  Like  the  woman  of  whom  I  have 
just  spoken,  patients  will  tell  you  that  they  have  had,  for  example,  an  ex- 
coriation of  the  ear,  or  that  there  was  something  the  matter  with  the  ear : 
they  will  also  complain  that  the  movements  of  the  neck  are  accomplished 
with  difficulty  and  occasion  pain.  There  is,  therefore,  I  hold,  an  inflam- 
matory action  anterior  to  any  characteristic  manifestation  of  erysipelas  ; 
and  this  action  is  quite  sufficient  to  produce  the  general  symptoms. 

Finally,  the  prodromic  fever  of  erysipelas,  if  this  name  be  allowed,  is  a 
symptomatic  fever  [iinefievre  avec  matiere]  :  it  is  a  fever  symptomatic  of 
the  inflammation  propagated  in  the  lymphatics  communicating  with  the 
local  lesion.  This  fever  continues  for  one,  two,  or  three  days:  the  erysipe- 
las then  appears,  and  forthwith  proceeds  to  the  different  parts  of  the  face 
and  hairy  scalp,  remaining  stationary  in  one  place  for  three  or  four  days, 
and  fading  in  the  rear  of  its  progress  as  it  advances  to  another  point.  It 
advances  rather  slowly,  taking  eight  or  nine  days,  or  sometimes  more,  to 
complete  its  circuit  of  the  head.     In  a  few  exceptional  cases,  when  it  has 


200  ERYSIPELAS. 

gone  once  round  the  head,  it  makes  a  second  circuit,  starting  generally 
from  the  place  first  affected.  This  repetition  of  the  course  is  less  frequently 
seen  in  erysipelas  of  the  face  than  in  that  of  other  parts  of  the  body. 

The  great  severity  of  the  general  symptoms  is  a  remarkable  feature  of 
erysipelas.  There  are  few  diseases  in  which  the  fever  is  so  high,  and  the 
gastric  symptoms  so  urgent.  By  some  the  gastric  symptoms  are  regarded 
as  the  cause  of  the  erysipelas,  but  I  believe  that  the  very  opposite  of  that 
proposition  is  the  truth,  or  in  other  words,  I  hold  that  the  gastric  disturb- 
ance is  dependent  upon  the  inflammation  of  the  skin.  I  have  often  re- 
called to  your  recollection  experiments  of  M.  CI.  Bernard,  which  show  that 
when  fever  is  excited  in  an  animal,  the  normal  gastric  and  intestinal  secre- 
tions are  arrested.  These  results  are  often  confirmed  by  what  we  see  in 
medical  practice  ;  and  in  my  opinion,  the  disturbance  of  the  digestive  func- 
tions, generally  met  with  in  erysipelas,  is  obviously  the  consequence  of  the 
fever. 

Delirium  occurs  in  erysipelas  of  the  face,  independent  of  these  gastric 
symptoms.  It  is,  at  least  in  its  aspect,  a  formidable  symptom.  There  are 
very  few  cases  which  do  not  present  cerebral  symptoms  when  the  erysipela- 
tous inflammation  reaches  the  hairy  scalp.  The  patient  occupying  bed 
No.  8  of  the  St.  Bernard  Ward  has  been  delirious  for  two  days,  and  his 
delirium  will  probably  still  continue  for  two  or  three  nycthemera  :  it  is  not 
likely  to  cease  till  the  erysipelas  has  in  succession  invaded  and  abandoned 
the  different  parts  of  the  skin  of  the  head.  Notwithstanding  their  appar- 
ently serious  character,  the  nervous  symptoms  do  not  alarm  me  :  experience 
has  taught  me  that  what  is  called  medical  erysipelas,  provided  it  be  not 
complicated  with  any  other  disease,  is  not  a  dangerous  malady.  The  prog- 
nosis, however,  is  altogether  different  when  it  supervenes  at  the  close  of  an 
acute  disease,  at  the  close  of  an  attack  of  small-pox,  scarlatina,  dothien- 
teria,  diphtheria,  &c,  or  during  the  course  of  a  chronic  malady  such  as 
phthisis,  when  it  meets  with  a  state  of  profound  cachexia  of  the  system. 

Erratic  erysipelas  [erysipele  ambulant]  is  also  a  more  serious  affection 
than  erysipelas  limited  to  the  head:  it  jumps  from  one  place  to  another, 
and  ranges  over  the  trunk  and  every  part  of  the  body.  The  greater  danger 
of  this  form  of  the  disease  does  not  arise  from  the  symptoms  being  more 
severe  than  when  the  erysipelatous  inflammation  is  confined  to  the  face; 
for  generally  the  fever  is  more  moderate,  and  the  occurrence  of  delirium  is 
not  bo  frequent.  The  greater  danger  consists  in  the  disease  being  pro- 
longed for  one  or  two  months,  ami  so  exhausting  the  patient's  strength  ; 
unless,  indeed,  the  physician,  regardless  of  the  high  fever,  prescribe  nutri- 
tious diet  with  a  high  hand,  there  being  no  other  means  by  which  the 
destruction  of  the  vital  powers  can  be  prevented.  But  there  are  some 
cases  in  which  certain  symptoms  Bupervene  not  sufficiently  noticed  by  our 
classical  authorities:  I  allude  to  the  extension  of  the  erysipelas  to  the 
mucous  membranes  of  the  mouth,  bronchial  tidies,  and  alimentary  canal. 

In  the  course  of  my  lectures,  I  shall,  as  I  have  already  said,  require  to 
••(■turn  to  this  important  subject.      It  is  unnecessary  to  tell  you  that  ill  such 

extensions  of  the  disease  as  I  havejusl  mentioned  erratic  erysipelas  is  diffi- 
cult to  conquer.  Dr.  Peter  gives  cases  in  which  il  passed  from  the  lace 
to  the  pharynx,  and  then  to  the  respiratory  passages:  once  established 
there,  in  obedience  to  the  tendency  of  erysipelas  to  extend,  it  propagates 
itself  by  degrees  in  such  a  way  as  first  to  produce  simple  bronchitis,  then 
capillary  bronchitis,  then  broncho-pneumonia,  and  last  of  all  death.4 

I'i.ili;:   Article   "Am. ink-,"   iii  the  Dictionnaire  Encydopidique  des  Sciences 
Midicales.     T.  iv,  \>  720. 


ERYSIPELAS.  201 

It  has  been  alleged  that  when  erysipelas  begins  in  the  nose  and  then 
appears  on  both  sides  of  the  face,  it  will  not  extend  to  the  hairy  scalp.  1 
have  seen  cases  which  might  be  quoted  in  support  of  this  opinion  ;  hut  I 
have  also  seen  others  in  which  the  erysipelas  began  in  the  nose,  proceeded 
to  both  sides  of  the  face,  took  possession  of  the  hairy  scalp,  and  made  the 
circuit  of  the  head. 

Sometimes  the  danger  of  a  case  of  erysipelas  is  in  the  essential  nature  of 
the  disease.  There  are,  for  example,  cases  proceeding  from  contagion 
which  often  terminate  fatally,  and  from  their  very  commencement  awake 
the  fears  of  the  physician.  There  is  reason  to  believe  that  in  these  cases 
erysipelas  is  only  the  external  manifestation  of  a  primary  general  affection 
of  formidable  character;  or  it  may  behave  like  diphtheria,  which,  in  the 
first  instance  local,  soon  poisons  the  whole  system.  At  the  beginning  of 
1861,  one  of  my  colleagues  mentioned  to  me  that  several  persons  living  in 
the  same  house  were  suffering  from  erysipelas,  which  in  some  had  com- 
menced in  the  pharynx,  and  in  others  at  the  inner  angle  of  the  eyes  or 
external  opening  of  the  nostrils.  The  individual  who  was  first  attacked 
died  :  the  nurse  Avho  waited  on  him  died  soon  after  of  the  same  disease ; 
also,  several  members  of  the  family,  and  the  doorkeeper — who  had  had 
occasion  to  come  in  contact  with  the  deceased — experienced  serious  attacks. 

In  July  of  the  same  year,  1861,  the  Gazette  des  Hopitaux  published  an 
additional  proof  of  the  formidable  character  of  contagious  erysipelas,  in 
the  history  of  the  death  of  two  of  our  young  hospital  pupils,  MM.  Gaston 
Reynier  and  Ernest  Gruteau,  w:ho  were  carried  off  by  this  disease,  con- 
tracted in  the  wards  of  M.  Xelaton  and  M.  Voillemier.  Mrs.  Reynier,  the 
mother  of  one  of  these  unfortunate  young  men,  died  a  few  days  after  her 
son,  from  erysipelas  caught  in  her  attendance  upon  him. 

Some  months  after  these  events,  I  was  called  in  by  my  honorable  friend 
Dr.  Paris,  to  consult  with  him  in  the  case  of  M.  E.,  upon  whom  one  of  our 
ablest  surgeons,  Professor  Nelaton,  had  divided  the  frsenum,  for  the  pur- 
pose of  facilitating  the  introduction  of  lithotriptic  instruments.  M.  E.  died 
from  gangrenous  erysipelas,  of  which  the  starting-point  was  the  trifling 
incision  made  by  M.  Nelaton  in  the  frsenum  of  the  prepuce.  On  the  even- 
ing before  his  death,  his  wife,  who  had  attended  upon  him  with  great 
solicitude,  was  seized  with  rigors  :  next  day,  she  had  violent  sore  throat, 
and  twenty-four  hours  afterwards,  exceedingly  severe  erysipelas  of  the  face, 
which  carried  her  off  at  a  time  when  she  seemed  to  have  entered  upon  con- 
valescence. The  maid  of  this  lady,  who  had  likewise  waited  assiduously 
on  M.  E.,  took  ill  along  with  her  mistress.  Her  attack  was  specially 
characterized  by  violent  sore  throat,  and  erysipelas  limited  to  the  eyelids. 
Finally,  gentlemen,  you  remember  to  have  seen,  in  June,  1862,  in  bed  No. 
-4  of  the  St,  Bernard  Ward,  a  girl  of  twenty-three,  with  moderate  erysipelas 
of  the  face,  which  had  come  on  during  her  attendance  on  her  master  when 
he  was  suffering  from  phlegmonous  erysipelas  of  the  leg. 

Spontaneous  erysipelas,  therefore,  though  generally  a  mild  disease,  is 
sometimes  malignant,  fatal,  and  contagious,  as  was  pointed  out  by  Graves. 
This  malignity  may  either  be  inherent  in  the  contagium,  or  dependent  upon 
a  special  condition  of  the  recipient. 

It  is  traumatic  or  surgical  erysipelas,  specially  infectious,  which  is  also 
so  exceedingly  contagious.  Traumatic  cases  supply  us  with  some  mournful 
series  of  facts  in  proof  of  the  contagious  character  of  erysipelas.  Dr.  Pujos 
of  Bordeaux,  in  a  paper,  to  which  the  Academy  of  Medicine  awarded  a 
prize  in  1866,  has  reported  illustrations  of  this  remark,  which,  with  your 
permission,  I  shall  now  quote  in  an  abridged  form. 

A  sportsman  injured  his  right  foot  with  his  gun.     The  wound,  in  itself 


202  ERYSIPELAS. 

serious,  was  rendered  more  so  by  consecutive  hemorrhage,  and  became 
complicated  with  erysipelas  on  the  fifteenth  day.  The  disease  invaded  the 
entire  limb,  gangrenous  patches  appeared,  and  adynamia  supervened,  which 
led  to  death  ou  the  twentieth  day  from  the  accident.  The  brother,  a 
healthy  young  man,  who  had  ministered  to  deceased  during  his  fatal  ill- 
ness, was  seized,  without  any  local  cause,  with  spontaneous  erysipelas  of 
the  face,  which  extended  to  the  hairy  scalp,  and  became  complicated  with 
adynamic  symptoms.  He  died  on  the  eighth  day.  The  sportsman's  daugh- 
ter, a  child  of  three  years  of  ase,  had  a  slight  burn  on  the  hand  which 
became  the  seat  of  erysipelas.  The  disease  extended  to  the  arm  and  chest. 
the  symptoms  at  the  same  time  assuming  a  formidable  character :  ulti- 
mately, the  extent  of  the  disease  became  limited,  and  the  child  recovered. 
The  family  laundress,  after  washing  the  linen  of  the  household,  was  seized 
with  phlegmonous  inflammation  of  the  hand,  from  which  she  recovered. 
The  sick-nurse  had  erysipelas  of  the  face  and  head  :  she  had  no  ataxic 
symptoms,  and  recovered.  But  this  history  is  not  yet  complete  !  A  sister 
of  charity  who  had  been  intrusted  with  the  irrigation  of  the  foot  of  the 
wounded  sportsman,  was  forced  by  fatigue  to  discontinue  her  duties  :  she 
then  felt  pains  in  the  right  arm,  which  afterwards  became  very  severe,  and 
were  accompanied  by  nausea,  vomiting,  and  prostration.  A  large  phlegmon- 
ous abscess  opened  in  the  arm,  and  was  followed  by  several  others  in  different 
parts  of  the  body  :  there  was  a  profuse  discharge  of  unhealthy  pus  :  sloughs 
formed  :  the  general  symptoms  became  more  and  more  complicated  :  and  at 
last  the  patient  sunk  under  the  most  excruciating  pain.  The  religious 
community  to  which  this  sister  belonged  was  in  excellent  health  when  she 
returned  to  it  unwell.  Upon  her  return,  however,  different  adynamic 
maladies,  of  a  more  or  less  severe  character,  showed  themselves  in  a  form 
at  least  infectious  if  not  contagious.  Health  was  restored  to  the  commu- 
nity by  the  sisters  evacuating  the  convent,  and  going  to  the  country.  Prior 
to  this,  however,  nine  sisters  who  had  waited  upon,  and  dressed  the  ah-, 
of  the  deceased,  or  who  had  attended  upon  some  of  their  sick  sisters,  had 
severe  attacks  of  illness,  from  which  two  of  them  died. 

Dr.  Pujos  also  quotes  the  oase  of  a  woman,  who  died  in  an  adynamic 
state  from  spontantous  erysipelas  of  typhoid  type.  The  physician  and  two 
sick-nurses  who  attended  upon  her  died  of  erysipelas  contracted  during 
their  attendance;  and  a  female  servant  in  the  family  took  the  disease,  but 
recovered  after  having  been  in  great  danger.  Dr.  S.,  successor  to  M.  <;.. 
also  became  ill ;  but  his  malady  was  not  erysipelas,  and  he  recovered  front 
it  by  taking  hygienical  care  of  himself. 

Allow  me  to  quote  some  additional  cases  which  occurred  in  this  sadly 
instructive  epidemic.  At  the  hospital  of  Bourdeaux,  Dr.  6.  observed  a 
man  who  was  admitted  for  an  affection  of  the  eye,  and  placed  near  a  pa- 
tient with  phlyctenoid  erysipelas;  and  who  forthwith  took  erysipelas  in  a 
rather  severe  form.  The  starting-poinl  was  in  tin-  case  a  slight  excoria- 
tion of  the  liji  :  the  disease,  which  was  phlyctenoid,  accompanied  by  intense 
fever,  invaded  the  face  and  hairy  scalp,  ami  then  ceased  without  endanger- 
ing life.  The  father  of  M.  (  '<.,  also  a  physician,  came  to  attend  on  hi-  son. 
On  the  third  day  after  his  arrival,  he  was  seized  with  sore  throat,  which 
was  followed  by  phlyctenoid  erysipelas  of  tie-  face  and  hairy  scalp,  accom- 
panied by  some  general  symptoms.  He  recovered.  The  sister-in-law  of 
M. ' ;..  8<  nior,  having  come  to  Nantes  to  see  him,  tell  ill,  and  passed  through 

a  similar  illness.      She  recovered  her  health,  but  lost  her  hair. 

Another  series  of  contagious  cases  commenced  with  a  sailor  who  had 
erysipelas  of  the  face  around  a  pimple  attributed  to  the  bit''  of'  an  insect. 
There  was  in  the  tir-t    instance  erythema  :   erysipelas    then    declared    it-elf. 


ERYSIPELAS.  203 

which  invaded  the  head,  was  accompanied  by  prostration,  and  speedily 
ended  in  death.  A  woman  wild  had  attended  on  the  sailor,  and  the  wo- 
man's husband,  were  similarly  affected,  and  both  died.  The  captain  of  the 
ship  to  which  the  deceased  sailor  belonged  also  took  erysipelas,  but  soon 
got  well  on  going  to  sea. 

Erysipelas,  as  I  remarked,  is  a  very  dangerous  malady,  when  it  is  a 
complication  of  some  other  disease,  which  from  its  nature,  or  protracted 
duration,  has  already  put  in  hazard  the  patient's  life;  when,  for  example, 
it  occurs  in  children  along  with  typhoid  lever.  It  is  still  more  dangerous 
when  it  supervenes  in  the  course  of  the  adynamic  pneumonia  of  old  people, 
or  when  it  attacks  lying-in  women  and  new-born  infants. 

With  reference  to  what  I  have  already  said  regarding  the  epidemic  in- 
fluences which  prevailed  in  1861,  when  a  terrible  epidemic  of  puerperal 
fever  raged  in  nearly  all  the  asylums  for  women  in  childbed,  erysipelas  of 
the  face,  not  generally  a  dangerous  disease,  often  assumed  a  bad  character, 
and  cruelly  contradicted  our  prognosis.  It  was  also  observed  that  the 
malady  was  to  a  certain  extent  contagious.  One  of  my  medical  colleagues 
has  called  attention  to  some  such  cases,  and  I  have  also  seen  cases  of  the 
same  description.  I  met  in  consultation  my  honorable  colleague  M.  Hig- 
gins  in  the  case  of  a  young  American  lady,  who  in  the  sixth  month  of 
nursing  was  affected  with  abscess  of  the  mamma.  The  abscess  was  opened 
by  M.  Nelaton  :  some  days  afterwards,  erysipelas  appeared  in  the  wound, 
and  then  extended  over  the  chest,  The  husband  of  this  lady,  an  officer  of 
the  United  States  navy,  left  his  ship  in  the  Mediterranean  to  spend  some 
days  with  his  wife.  When  travelling  by  railway,  he  got  an  insignificant 
excoriation  of  the  leg.  In  less  than  two  days  after  his  arrival  in  Paris, 
erysipelas  showed  itself  around  the  little  wound,  which  soon  became  a 
diffuse  abscess ;  and  for  nearly  three  weeks  his  life  was  in  danger. 

Excluding  exceptional  cases,  and  epidemic  influences,  erysipelas  of  the 
head  is  not  a  formidable  disease.  From  1831  to  1835,  a  period  of  four 
years,  during  which  I  acted  as  the  substitute  of  Professor  Recamier  in  this 
hospital,  I  had  only  one  death  in  fifty-seven  cases.  The  patient  who  died 
was  admitted  with  erysipelas  of  the  hairy  scalp,  complicated  with  violent 
delirium :  she  died  two  days  after  admission.  An  acute  disease  in  which 
the  mortality  is  less  than  one  in  fifty,  may  certainly  be  called  benignant  in 
its  nature ;  and  perhaps  you  cannot  name  another  which  is  equally  so. 
For  example,  compare  bronchitis  with  erysipelas,  and  you  will  find — cir- 
cumstances being  the  same  and  the  proportion  being  kept — that  the  former 
kills  more  than  the  latter.  I  am  more  and  more  confirmed  in  this  convic- 
tion by  the  cases  which  I  have  collected  in  my  private  practice,  in  the 
practice  of  my  colleagues,  and  in  the  different  hospital  services  which  I 
have  conducted  during  the  last  twenty-eight  years.  I  have  no  doubt  some- 
times seen  erysipelatous  patients  die,  but  I  must  say  that  the  fatal  issue  has 
been  much  more  frequently  caused  by  the  treatment  than  by  the  disease. 
The  majority  of  those  who  died  had  been  subjected  to  treatment  which 
I  look  on  as  most  deplorable ;  and  to  which  I  cannot  too  earnestly  call 
your  attention,  for  the  purpose  of  .putting  you  on  your  guard  against  em- 
ploying it. 

When  a  patient  suffering  from  erysipelas  is  placed  under  my  care,  my 
rule  is  to  abstain  from  every  kind  of  treatment.  I  prescribe  a  lavement 
for  those  who  are  constipated,  and  if  the  constipation  continue,  I  give  ten 
or  fifteen  grammes  of  castor  oil.  This  is  not  very  active  treatment.  You 
may  call  it  homoeopathy  if  you  like!  Such,  however,  has  been  my  plan 
for  twenty-eight  years ;  and,  thanks  to  it,  I  cannot  recollect  losing  more 
than  three  patients  from   erysipelas  during  that  period.     My  treatment, 


-04  ERYSIPELAS. 

then,  of  erysipelas  of  the  face  is  expectant  I  keep  my  patients  in  hed,  for 
it  is  above  all  things  important,  both  in  the  acute  stage  and  during  con- 
valescence, to  prevent  them  from  catching  cold,  for  exposure  to  cold  leads 
to  relapses.  I  prescribe  slightly  acidulated  diet-drinks  :  if  the  bowels  are 
confined  I  assist  nature  by  giving  laxatives  ;  if  the  vomiting  is  violent,  I 
combat  it  by  purgatives.  But,  gentlemen,  I  give  nourishment — I  give 
nourishment  even  when  there  is  fever — even  when  there  is  delirium.  So  far 
from  prostrating  the  patient  by  withdrawing  blood,  by  bleeding  him  at  the 
arm,  or  leeching  him  behind  the  ear;  in  place  of  making  it  my  rule  to  ad- 
minister emetics,  and  give  purgatives  in  repeated  doses;  instead  of  placing 
the  patient  on  very  low  diet — I  remain  with  folded  arms  spectator  of  a 
contest,  from  which  I  know  nature  will  come  forth  victorious,  if  I  refrain 
from  disturbing  her  operations.  And  I  again  repeat,  that  of  the  great 
number  of  cases  of  erysipelas  which  I  have  attended,  three  only  have  had 
a  fatal  termination:  the  others  spontaneously  recovered.  That  is  a  fact 
which  I  ought  not  to  be  afraid  to  proclaim.  In  erysipelas,  as  in  a  certain 
number  of  other  diseases  which  pursue  a  natural  course,  we  physicians  re- 
quire to  beware  of  trying  to  direct  nature  when  we  see  the  pathological  phe- 
nomena proceeding  regularly,  for  our  ill-timed  intervention  will  only  dis- 
turb the  natural  course  of  the  disease,  and  injure  the  sick  man  who  has 
sought  our  succor. 

I  think  it  right  to  go  minutely  into  these  views,  because  you  are  entitled 
to  receive  from  me  an  explanation  of  the  manner  in  which  I  act,  or  rather 
abstain  from  acting,  in  respect  of  patients  suffering  from  erysipelas.  When 
you  have  seen  recoveries  take  place  in  the  practice  of  other  hospital  physi- 
cians in  cases  treated  on  the  heroic  plan,  by  bleeding,  purging,  administra- 
tion of  emetics,  application  of  blisters,  cauterization  of  the  affected  parts 
with  nitrate  of  silver — when  you  have  seen  recoveries  take  place  in  ^}>itc  of 
that  treatment,  you  may  have  been  apt  to  believe  that  they  were  due  to  it, 
and  that  the  remedies  employed  were  sovereign  and  necessary.  But  before 
forming  an  opinion  as  to  the  effects  of  medical  treatment  in  a  disease,  it  is 
necessary  to  be  acquainted  with  its  natural  history.  The  primary  knowl- 
edge, in  fact,  which  the  practitioner  ought  to  acquire  is  acquaintance  with 
the  natural  history  of  diseases.  In  my  practice,  you  observe,I  adopt  active 
measures  in  certain  circumstances) and  in  others  allow  matters  to  take  their 
own  course,  attentively  watching  the  symptoms,  however,  and  ready,  if  occa- 
sion reqire,  to  employ  the  therapeutic  resources  of  medicine.  To  know  when 
to  wait  is  in  our  art  great  knowledge;  and  prudent  waiting  explains  many 
successes,  particularly  those  which  arc  sometimes  obtained  by  the  sect  of 
Hahnemann. 

The  erysipelas  which  seizes  a  person  in  the  midst  of  health — not  that 
which  supervenes  in  the  course  of  another  disease — is  one  of  the  maladies 
which  spontaneously  terminate  in  recovery.  This  statement  of  curse  does 
not  apply  to  thai  erysipelas  which  is  only  the  expression  of  a  spec!;!!  influ- 
ence acting  on  the  whole  system.  For  example,  during  epidemics  of  puer- 
peral fever,  lying-in  women  often  sink  under  erysipelas,  but  they  sink  from 
erysipelas  under  the  same  influence  which  causes  other  patients  of  the  same 
class  lo  die  of  peril oiiit  i>  or  pleurisy — or,  to  express  the  idea  more  correctly, 
of  an  affection  which  is  merely  the  expression  of  a  general  pathological 
condition,  really  the  one  cause  of  death.  These  important  questions, 
gentlemen,  1  propose  to  discuss  in  my  clinical  course,  when  an  opportunity 

is  afforded  of  doing  so  in  connection  will)  puerperal  fever. 

Meanwhile,]  have  a  few  words  to  say  on  the  subject  of  erysipelas  in  new- 
born infants. 


ERYSIPELAS    OF    NEW-BORN    INFANTS.  205 


Erysipelas  of  New-Born  Infants. — Affrcfmn  <>/f<  u  Puerperal. — Differ* 
essentially  from  ordinary  Erysipelas. —  Generally  fatal. 

In  bed  No.  21  of  our  nursery  ward  there  is  an  infant,  three  months  old, 
the  subject  of  congenital  syphilis,  which,  very  recently,  has  been  attacked 
by  erysipelas.  After  spreading  over  the  superior  extremities,  it  reached 
the  base  of  the  chest.  In  this  case,  therefore,  two  diseases  were  combined, 
both  of  which  generally  prove  fatal  in  very  early  life.  But  the  erysipelas 
is  already  gone,  and  there  seems  every  prospect  of  the  syphilis  being  cured. 
Let  me  call  your  attention  to  the  special  condition  which  has  probably  been 
the  cause  of  this  doubly  fortunate  result — that  condition  I  believe  to  be  age. 

The  erysipelas  of  new-born  infants  is  justly  regarded  as  a  disease  almost 
as  certainly  fatal  as  cerebral  fever  at  a  more  advanced  age.  This  is  a  fact 
which  all  physicians  who  have  had  charge  of  a  children's  hospital  can  verify 
from  their  own  experience,  as  I  can,  after  having  been  twelve  years  attached 
to  the  Necker  Hospital.  I  have  found  that  infants  who  take  erysipelas  during 
the  first  fifteen  or  twenty  days  of  life  almost  invariably  die,  no  treatment 
being  of  the  least  use;  but  that  in  those  who  pass  that  age,  particularly 
when  they  get  beyond  the  first  month  of  extra-uterine  life,  and  are  thus 
more  removed  from  their  state  of  fcetal  existence — more  individualized — 
erysipelas  loses  much  of  its  formidable  character.  To  the  child  of  eighteen 
months  or  two  years  erysipelas  is  not  more  serious  than  to  the  adult. 

Upon  what  then  depends  the  gravity  of  the  disease  in  newly-born  infants? 
'Does  it  depend  solely  on  their  extreme  youth  and  deficiency  of  vital  power? 
No !  Its  formidable  character  in  these  subjects  arises  from  quite  different 
causes,  which  I  pointed  out  long  ago,  and  which  have  been  thoroughly 
explained  by  Dr.  P.  Lorain  in  one  of  the  most  remarkable  works  which 
have  been  published  on  the  subject.*  Twelve  or  fifteen  years  ago  I  was 
struck  by  observing  that,  during  epidemics  of  puerperal  fever  at  the  Ma- 
ternity Hospital,  a  great  many  children  were  admitted  to  my  nursery  wards 
at  the  Necker  Hospital  with  purulent  ophthalmia,  peritonitis,  and  erysipelas. 
I  at  that  time  applied  the  term  puerperal  to  all  these  affections,  and  in  my 
published  lectures  stated  that  all  the  children  in  question  had  the  same 
disease,  only  that  in  some  it  showed  itself  in  forms  different  from  those  it 
assumed  in  others.  I  was  then  of  opinion  that  epidemic  puerperal  fever 
presides  over  the  pathology  of  new-born  infants,  just  as  much  as  it  presides 
over  the  pathology  of  recently  delivered  women.  This  view  hardly  trans- 
pired beyond  the  class-room  of  the  Necker  Hospital :  it  did  slip  into  the 
columns  of  some  medical  journals,  but  it  did  not  at  that  time  obtain  general 
publicity.  To  Dr.  P.  Lorain  the  merit  is  due  of  having  given  it  full  pub- 
licity, and  of  having  demonstrated  categorically  the  truth  of  the  doctrine 
of  which  I  had  caught  a  glimpse.  To  him  science  owes  its  right  to  regard 
this  view  as  the  expression  of  well-observed  facts.  To  enable  you  to  under- 
stand this  question,  upon  some  parts  of  which  I  wish  to  touch,  I  require  to 
give  you  a  succinct  analysis  of  the  work  of  Dr.  P.  Lorain.  During  the 
epidemic  at  the  Maternity,  where  this  able  and  laborious  observer  was  a 
resident  pupil,  he  collected  the  information  of  which  the  following  is  a 
summary. 

Of  106  still-born  infants,  10  were  found  to  have  died  from  peritonitis,  and 
three  of  the  mothers  of  these  ten  infants  were  carried  off  by  puerperal  fever 
after  delivery.     Of  193  infants  born  alive,  50  died  of  the  very  same  affec- 

*  P.  Lorain:  These  Inaugurate  "  Sur  la  Fievre  Puerperale  chez  la  Ferame,  le 
Foetus,  et  le  Nouveau-ne."     Paris,  1855. 


206  ERYSIPELAS    OF    NEW-BORN    INFANTS. 

tions  which  proved  fatal  to  the  lying-in  women.  The  most  frequent  causes 
of  death  were  peritonitis,  numerous  abscesses,  purulent  infection,  phleg- 
monous swellings,  erysipelas,  gangrene  of  the  limbs,  putrid  infection,  or 
some  other  remarkable  septic  condition.  Mother  and  child  often  had  the 
same  disease,  but  sometimes  its  form  and  seat  were,  and  at  other  times  were 
not  the  same  in  both;  for  example,  a  child  sometimes  died  of  peritonitis  and 
its  mother  of  purulent  infection,  or  the  child  of  purulent  infection  and  the 
mother  of  peritonitis.  In  30  cases  in  which  recently  born  infants  died  of 
peritonitis  simple,  or  complicated  with  erysipelas,  meningitis,  or  numerous 
abscesses,  mother  and  child  were  in  ten  instances  carried  off  by  the  same 
affection.  The  infants  of  fifty  women  who  recovered  after  having  had  puer- 
peral symptoms  died  of  peritonitis. 

From  these  facts,  the  details  of  which  I  recommend  you  to  read  in  Dr. 
Lorain's  excellent  thesis,  the  author  proves  that  it  is  the  same  epidemic  in- 
fluence which  affects  mothers  and  their  offspring.  The  existence  of  this 
influence  cannot  be  disputed,  when  we  recollect  that  new-born  infants  very 
seldom  die  from  the  lesions  I  have  just  named,  except  during  epidemics  of 
puerperal  fever. 

We  cannot  denj7  that  there  is  a  bond  of  pathological  community  between 
mother  aud  infant,  similar  to  that  which  unites  the  tree's  trunk  with  the 
branch  which  proceeds  from  it.  This  is  admitted  in  respect  of  other  mala- 
dies, such  as  syphilis  and  small-pox.  Who  is  unacquainted  with  cases  of 
individuals  presenting  at  birth  the  scars  of  variolous  pustules?  There  is 
not  a  year,  I  may  say  there  is  hardly  a  month,  in  which  I  do  not  point  out 
to  you  in  our  wards  new-born  infants  suffering  with  syphilis  engendered  by* 
a  father  or  conceived  by  a  mother  affected  with  that  disease.  In  such  cases 
no  one  denies  the  existence  of  the  pathological  solidarity  to  which  I  have 
referred,  and  yet  it  is  denied  in  respect  of  puerperal  fever  !  In  districts 
where  iutermitteut  fevers  are  endemic,  as  in  Sologne,  Bresse,  and  some  pails 
of  Bourhonnais,  infants  are  born  with  symptoms  of  marsh  cachexia,  nothing 
being  wauting  to  mark  this  fact,  even  the  hypertrophy  of  the  spleen  being 
found.  Without  hesitation  we  admit  that  these  infants  when  still  within 
their  mother's  womb  have  been  subjected  to  the  influence  of  marsh  mias- 
mata. It  would  be  easy  to  multiply  similar  illustrations;  but  still  there  is 
a  disposition  to  make  puerperal  fever  an  exception  to  the  rule:  and  the 
opinion  so  ably  maintained  by  Dr.  Lorain  has  found  obstinate  opponents. 
The  day  will  come,  however,  when  the  truth  which  he  has  demonstrated 
with  so  much  precision  will  be  generally  accepted. 

Mother  and  child  then  are  both  subject  to  the  same  morbific  influence. 
Let  us  now  inquire,  whether  there  is  not  a  great  similarity  in  the  anatomi- 
cal ami  physiological  conditions  of  the  two  organisms  which  during  gesta- 
tion are  one,  and  which  continue  to  be  one,  so  to. -peak,  tor  some  days  after 
birth.  Acquaintance  with  the  physiological,  will  enable  us  to  understand 
tin'  pathological  analogy.  Bui  before  proceeding  farther,  it  is  indispensa- 
ble to  define  what  is  meant  by  a  Dew-born  child  [enfant  nouveau-ne]:  and 
this  I  do  by  quoting  Dr.  Lorain's  definition,  which  is  to  the  following 
effeel  : 

"The  infant  comes  into  the  world  possessed  of  organs  which  have  ceased 
to  perform,  and  of  other  organs  \\  bich  have  n<>t  a-  yet  performed,  their  func- 
tions.     It  at  once,  without  any  transition,  passes  from  one   to  another  kind 

of  life:  it  bas  not,  like  the  young  of  other  animals,  a  period  of  repose  and 
physical  recruiting,  during  which  the  changes  requisite  for  the  new  kind  of 
existence  are  accomplished.  It  has  been  forcibly  thrown  into  a  new  medium. 
The  very  firsl  efforts  of  the  organs  hitherto  in  reserve  arc  effective:  at  the 
very  first  moment  afterbirth  it  breathes,  and  each  succeeding  inspiration  is 


ERYSIPELAS    OF    NEW-BORN    INFANTS.  207 

performed  in  the  same  manner  as  the  first:  the  first  mouthful  of  liquid 
swallowed  brings  into  play  the  organs  of  digestion :  every  organ  in  fact 
responds  to  the  appeal  made  to  it  bythenew  life,  and  proves  faithful  to  the 
Power  which  created  it.  But  it  is  not  enough  for  the  new-born  infant  to 
come  into  possession  of  its  reserve  organs,  to  make  trial  of  them,  to  use  them 
for  all  their  purposes,  and  to  live  in  completeness  the  new  life:  it  also 
requires  to  get  rid  of  the  organs  by  which  alone  it  once  lived,  but  which 
have  now  ceased  to  be  of  any  use.  The  period  during  which  the  new  func- 
tions are  perfected  and  the  old  organs  disappear  is  the  period  of  transition 
or  metamorphosis:  during  it,  the  umbilical  cord  separates,  and  the  navel 
becomes  cicatrized  :  the  epidermis  cracks  and  falls  off:  the  hair  is  renewed  : 
the  meconium  is  expelled:  the  umbilical  artery  and  umbilical  vein  are  ob- 
literated; and  the  foramen  ovale  is  closed.  The  'new-born'  in  fact  is  the 
creature  in  whoui  this  progressive  work  of  separation  is  going  on,  and  the 
duration  of  the  period  in  which  it  is  accomplished  is  not  less  than  a  month." 

Let  us  now  return  to  the  consideration  of  the  anatomical  and  physiologi- 
cal conditions  of  mother  and  child.  In  the  mother,  after  the  birth  of  the 
foetus,  the  placenta  is  detached  from,  and  expelled  by,  the  uterus.  It  leaves 
the  surface  of  the  uterus  to  which  it  was  attached  denuded  of  mucous  mem- 
brane— the  protecting  membrane  by  which  it  was  previously  covered.  This 
denuded  surface  is  not  only  in  contact  with  the  external  air  reaching  it  by 
the  vaginal  orifice,  but  also  with  fluids  accumulated  within  the  uterine 
cavity — first  of  all  with  blood,  and  afterwards  with  pus  necessarily  formed 
while  the  reparative  process  is  being  accomplished  in  the  wound  caused  by 
the  separation  of  the  placenta.  This,  like  all  recent  wounds,  is  an  open 
door  for  the  reception  of  contagia.  It  undergoes  changes  analogous  to  those 
which  often  take  place  in  the  hospitals  of  large  towns  in  the  solutions  of 
continuity  made  by  the  surgeon's  knife,  and  which  are  liable  to  become  the 
starting-point  of  general  poisoning  of  the  system,  like  a  wound  made  by  a 
lancet  charged  with  virus. 

We  find  the  very  same  anatomical  conditions  in  the  child.  In  the  new- 
born infant,  at  the  moment  of  its  abrupt  separation  from  its  mother,  at  the 
moment  when  the  functions  of  foetal  existence  are  superseded  by  those  of 
the  new  life,  we  observe  that  changes  take  place  which  may  be  compared 
with  those  which  occur  in  the  organism  of  the  mother.  The  umbilical  cord 
falls  off:  having  ceased  to  be  of  any  use,  when  the  placenta  which  joined 
the  child  to  the  mother  was  detached  from  the  uterus,  it  withers  up  to  its 
point  of  attachment  to  that  sort  of  muff  formed  by  the  skin  of  the  abdomen, 
the  cutaneous  muff  which  will  afterwards  be  the  navel.  This  is  the  point 
at  which  separation  takes  place,  and  this  separation  is  the  result  of  a  neces- 
sary inflammatory  process.  Upon  the  fall  of  the  cord,  the  umbilicus  be- 
comes the  seat  of  a  reparatory  process  analogous  to  that  which  takes  place 
in  the  wound  of  the  uterus.  The  remains  of  the  cord  become  detached,  and 
as  a  necessary  consequence  of  this  elimination  there  is  slight  suppuration, 
to  which  Dr.  Lorain  has  very  happily  given  the  name  of  umbilical  lochia 
{locliie-H  omhilkales].  No  expression  could  have  been  better  chosen  to  ex- 
press the  truth.  In  the  infant,  exactly  as  in  the  mother,  there  is  a  wound  : 
and  with  Dr.  Lorain  I  say  that  the  umbilicus  in  the  iufaut  is  analogous  to 
the  uterus  in  the  mother. 

The  umbilicus  and  the  uterus  equally  present  an  open  way  for  the  en- 
trance of  infection  ;  so  that  if  both  mother  and  infant  are  placed  under  the 
same  epidemic  influence,  it  is  not  surprising  that  both  should  contract  the 
same  disease,  just  as  happens  to  hospital  patients  with  open  wounds  when 
similarly  exposed.  And  what  is  it  that  we  see  happen  to  these  persons  with 
wounds?     Phlebitis,  metastatic  abscesses,  suppurating  pleurisy,  and  ery- 


208  ERYSIPELAS    OF    NEW-BORN    INFANTS. 

sipelas  supervene.  Analogous  affections  occur  in  lying-in  women,  with  this 
difference,  that  peritonitis  is  the  most  common  lesion  in  them,  as  might  be 
expected  from  the  direct  effect  produced  by  parturition  upon  the  abdomi- 
nal serous  membrane  :  for  a  similar  though  stronger  reason,  the  uterus  and 
its  appendages  are  still  more  often  than  the  peritoneum  the  first  parts  in 
which  the  disease  declares  itself.  In  newly  delivered  women  it  is  the  wound 
of  the  uterus,  and  in  new-born  infants  it  is  the  wound  of  the  navel  which  is 
the  starting-point.  The  pathological  analogy  is  still  greater,  as  I  have  al- 
ready said,  from  the  circumstance  that  the  child  at  birth  represents  a  branch 
detached  from  the  piarent  stem,  which,  for  a  certain  time,  seems  to  live  by 
the  life  of  the  tree  which  produced  it:  the  new-born  infant  may  be  com- 
pared to  "a  layer"  which  cannot  grow  by  itself  till  it  has  taken  root.  The 
new-born  infant  like  the  layer  is  not  at  first  entirely  nourished  by  its  own 
sap — by  blood  which  till  some  time  has  elapsed  it  cannot  have  made :  it  is 
still  nourished  by  its  mother's  blood,  it  retains  all  the  aptitudes  of  the  ma- 
ternal organism,  from  which  it  is  hardly  yet  separated ;  and  the  diseases 
which  it  contracts  under  the  same  influences  as  the  mother,  will  assume  the 
same  expression  as  in  her. 

The  erysipelas  then  of  the  new-born  infant  will  not  be  ordinary  erysipelas ; 
it  will  be  puerperal  erysipelas,  and  possessed  therefore  of  the  exceedingly 
formidable  character  which  belongs  to  puerperal  affections.  This  formi- 
dable character  depends  less  upon  the  smallnessof  the  vital  power  of  resist- 
ance possessed  by  the  subject,  than  upon  the  essential  nature  of  the  disease. 
You  can  now,  gentlemen,  explain  to  yourselves  the  recovery  of  the  child 
of  bed  21  in  St.  Bernard's  Ward.  It  recovered  because  it  had  got  beyond 
the  first  days  of  extra-uterine  existence,  because  it  was  three  months  old, 
because  in  fact  it  had  ceased  to  be  a  "new-born"  infant.. 

Erysipelas  occurring  during  the  first  fifteen  or  twenty  days  of  life  is 
inevitably  fatal.  It  generally  begins  to  show  itself  at  the  pubes,  and  not 
at  the  umbilicus:  it  is  characterized  by  a  vivid  redness  of  skin,  and  a 
hard,  shining  appearance  of  the  subjacent  cellular  tissue.  The  infant  at 
the  same  time  falls  into  a  state  of  great  prostration:  it  suffers  pain,  and 
gives  expression  to  its  sufferings  by  cries  :  it  has  scarcely  any  fever.  If  the 
infant  be  vigorous,  and  at  the  time  of  its  seizure  in  apparently  good  health, 
you  will  probably  regard  the  affection  as  of  little  consequence.  What  risk 
is  there  in  an  erysipelas  extending  over  not  more  than  three  or  four  cen- 
timetres, accompanied  by  very  little  febrile  excitement  and  by  no  disturbance 
of  the  functions,  the  little  patient  being  quite  in  his  usual  state  of  health '! 
I  ii  spite  of  the  deceitfully  trifling  appearance  of  such  a  case,  you  must  lie  pre- 
pared lor  its  unfavorable  termination  ;  tor  to-morrow,  the  erysipelas  will  have 
extended  to  the  scrotum  or  vulva,  soon,  it  will  have  reached  the  thighs,  and 
invaded  the  legs,  spread  over  the  other  side,  ascended  to  the  abdomen  and 
trunk,  thus  advancing,  without  fading  on  the  parts  first  affected.  At  the 
end  of  two  or  three  days,  high  fever  will  be  set  up.  The  infant  will  become 
exceedingly  restless,  get  no  ,-leep,  and  Buffer  from  gastric  symptoms,  vomit- 
ing, and  diarrhoea.  He  will  cry  incessantly  from  pain.  A  state  of  rest- 
lessness will  lie  succeeded  by  collapse,  which  will  close  the  scene  on  the 
fifth,  sixth,  or  seventh  day.  <  >n  examining  the  body  after  death,  pus  will 
lie  found  in  the  cellular  tissue,  sometimes  suppurative  pleurisy,  more  fre- 
quently phlebitis  of  the  umbilical  v<  In  or  of  the  vena  porta,  or  peritonitis. 
Adopting  the  views  of  Dr.  Lorain  1  have  long  held  t  hat  these  lesions  ought 
to  he  looked  on  as  the  extension  of  erysipelatous  inflammation  from  the 
>kin  to  the  bloodvessels  and  internal  parts.  Krysipclas,  phlebitis,  peri- 
tonitis, eYc,  are  manifestations  of  one  sole  disease.  In  some  cases,  w . 
peritonitis   in    infants,  although  the  eiy-ipelas  was   on   the   face  and    not  on 


ERYSIPELAS    OF    NEW-BORN    INFANTS.  209 

the  abdomen:  and  sometimes,  on  examining  bodies  after  death,  we  only 
find  indications  of  the  cutaneous  inflammation,  all  the  other  lesions  to 
which  I  have  directed  your  attention  being  absent.  Thus  you  see  that  the 
erysipelas  of  new-born  children  is  an  insidious  malady.  Its  formidable 
character,  I  cannot  too  often  repeat,  depends  upon  the  nature  of  the  cause 
under  the  influence  of  which  it  is  produced,  and  not  on  the  importance  of 
the  local  lesion. 

I  cannot  sufficiently  impress  upon  you  how  easy  it  is  to  commit  serious 
errors  of  prognosis.  Some  of  you  may  recollect  a  child  of  twenty-three 
davs  old  which  took  erysipelas,  when  under  the  vaccine  influence,  but  in 
the  midst  of  an  epidemic  of  puerperal  fever.  This  infant  was  born  at  the 
Maternity  Hospital,  when  decimated  by  that  scourge:  it  was  removed  to 
the  Hote'l-Dieu  on  one  of  the  latter  days  of  March,  1861,  along  with  its 
mother,  who  was  suffering  from  abscess  of  the  mamma.  You  may  remem- 
ber what  I  said  to  those  who  attended  my  visit :  notwithstanding  the  ap- 
pearance of  vital  power  in  the  little  patient,  though  the  health  seemed 
excellent,  though  the  cry  was  vigorous,  and  the  fever  moderate,  I  announced 
that  death  would  take  place  within  three  or  four  days.  I  was  mistaken: 
that  very  night  the  child  died.  In  point  of  fact,  the  disease  generally  runs 
a  course  infinitely  more  rapid  than  the  strength  of  the  infant  and  the  char- 
acter of  the  symptoms  lead  one  to  expect. 

To  me  it  has  always  appeared  a  strange  fact — but  it  is  one  of  which  I 
have  seen  examples — that  recoveries  from  this  kind  of  erysipelas  some- 
times take  place  when  abscesses  form  in  the  invaded  parts.  Within  the 
last  two  years,  I  have  seen  three  cases  of  this  kind.  I  think  the  only  in- 
terpretation of  these  recoveries  is,  that  the  progress  of  the  disease  to  other 
parts  is  stopped  by  its  exhausting  its  violence  in  one  locality.  In  these 
cases,  the  affected  part  becomes  much  swollen,  and  the  red  color  of  the 
integuments  acquires  a  deeper  shade.  Lying-in  women  attacked  by  puer- 
peral symptoms  have  also  a  better  chance  of  recovery,  when  an  abscess 
forms  in  the  broad  ligament  or  iliac  fossa. 

In  the  beginning  of  1861,  you  saw  a  child,  twenty  days  old,  recover  from 
general  erysipelas,  after  the  formation  of  a  deep  abscess  on  the  back  of  the 
hand.  In  April  of  the  same  year,  when  an  epidemic  of  puerperal  fever, 
erysipelas,  and  boils  was  prevailing  in  our  hospitals,  I  received  into  my 
nursery  ward,  an  infant,  twenty-seven  days  old, 'suffering  from  erysipelas. 
The  erysipelas  ran  over  the  whole  body  from  head  to  foot,  and  even  re- 
invaded  the  parts  which  it  had  occupied  and  quitted  ;  and  yet  for  more 
than  twenty  days  the  infant  resisted  death.  It  had  more  than  ten  abscesses, 
situated  on  the  feet,  ankles,  elbows,  back,  and  other  parts.  It  died  from 
acute  peritonitis.  I  freely  admit  that  I  have  great  difficulty  in  explaining 
why  abscesses,  which  ought  a  priori  to  be  serious  complications,  should  on 
the  contrary  prove  to  be  a  sort  of  salutary  crisis :  but  the  facts  are  so  strik- 
ing, that  however  we  interpret  them,  we  must  at  least  admit  them. 

Gangrene  is  another  common  termination  of  erysipelas  in  new-born  chil- 
dren. It  arises  quickly.  Unlike  abscesses,  it  exercises  a  very  unfavorable 
influence  on  the  whole  economy,  and  in  no  form  of  the  disease  does  death 
take  place  so  quickly  as  that  in  which  there  is  gangrene.  This  gangrene 
is  dependent  upon  the  puerperal  state :  it  attacks  infants  under  conditions 
precisely  similar  to  those  in  which  it  attacks  women  with  sphacelus  of  the 
vulva,  vagina,  uterus,  and  in  fact  of  all  the  parts  to  which  parturition  im- 
parts a  traumatic  condition. 

Finally,  gentlemen,  erysipelas  in  place  of  running  its  usual  rapid  course, 
may  have  a  long  duration ;  and  in  lying-in  women  we  sometimes  see  the 
puerperal  symptoms  proceed  so  slowly  as  to  lead  to  hopes  which  are  too 
vol.  i. — 14 


210  MUMPS. 

often  blasted.  Sometimes,  also,  in  new-born  infants,  the  attack  is  prolonged 
beyond  its  usual  duration,  lasting  for  ten,  fifteen,  or  even  for  more  than 
twentv  days,  as  you  saw  in  one  of  our  little  patients  in  the  nursery,  who 
died  on  the  twenty-third  day. 

I  am  not  acquainted  with  any  treatment  of  use  in  the  erysipelas  of  new- 
born infants:  it  is  a  disease  which  resists  all  the  efforts  of  the  physician. 

It  is  otherwise,  however,  with  the  erysipelas  of  infants  who  have  passed 
the  first  month  of  life.  In  them,  in  all  respects,  it  resembles  the  disease  in 
adults,  and  all  that  we  have  to  take  into  account  is  the  organization  and 
vital  power  of  the  subject.  I  have  often  employed  a  method  of  treatment 
in  this  erysipelas  of  children,  which,  in  certain  cases,  has  seemed  to  stop  its 
advance:  I  refer  to  the  application  to  the  skin,  by  a  hair  pencil,  of  a  solu- 
tion  of  camphor  and  tannin  in  ether.  The  lotion  ought  to  be  applied  both 
to  the  parts  affected,  and  to  the  neighboring  unaffected  parts. 

You  recollect  the  case  of  a  child,  two  months  old,  admitted  with  it- 
mother  to  bed  14,  St.  Bernard's  'Ward.  A  day  or  two  after  birth,  this  infant 
had  had  a  small  abscess  behind  the  left  ear,  which  left  a  slight  wound.  ^In- 
attention was  called  to  an  erysipelatous  redness  occupying  the  angle  of  the 
left  eye,  and  invading  the  eyelid,  cheek,  and  nose.  Although  there  was  a 
little  fever,  the  general  condition  of  the  child  seemed  satisfactory.  It  took 
the  breast  as  usual,  and  digestion  was  accomplished  in  a  regular  manner. 
I  employed  the  ether  lotions  containing  camphor  and  tannin.  From  the 
first  day  on  which  they  were  used,  the  erysipelas  did  not  extend  beyond  the 
limits  it  then  occupied;  and  on  the  fifth  day  from  the  date  of  admis-ion, 
the  infant,  having  completely  recovered,  left  the  hospital  with  its  mother. 


LECTURE  XL 

MUMPS. 

A  Specific  and  Contagious  Disease. — M>:t<ist<isrs. —  Complications. 

You  have  seen  a  young  man  with  mumps  [preUlorui]  in  the  last  bed  in 
the  men's  ward.  I  eagerly  seize  the  opportunity  of  speaking  to  you  about 
a  disease,  of  which,  most  probably,  we  shall  not  see  another  case  here  for  a 
long  time  to  come. 

This  young  man,  six  days  before  his  admission  into  hospital,  felt  pain-  at 
the  angle  of  the  lower  jaw,  first  on  one  side  and  then  on  the  other.  He  at 
the  same  time  perceived  thai  the  cheek  and  neck  were  much  swollen.  He 
had  great  difficulty  in  swallowing,  and  Buffered  from  headache  ami  I 
However,  from  the  evening  of  the  day  on  which  the  patient  came  under  our 
observation  the  swelling  had  sensibly  diminished.  During  the  coure 
the  disease,  metastasis  to  the  testicles  occurred.  He  lefl  the  hospital  per- 
fectly recovered,  and  without  having  had  any  serious  symptoms. 

When  I  ask  Btudents  who  come  up  to  the  Medical  Faculty  for  examina- 
tion, to  tell  me  what  mumps  is,  many  reply  that  it  IS  an  affection  of  the 
parotid  glands  which  often  supervenes  during,  or  at  the  decline  of  severe 
fevers,  scarlatina,  measles,  Bmall-pox,  dothienteria,  or  puerperal  Wmv.  thus, 
confounding  the  disease  upon  which  I  am  now  going  to  address  you  with 
parotiditis.    That,. gentlemen,,  is  a  great  mistake:  parotiditis  and  mumps, 


MUMPS.  211 

even  looking  to  the  anatomical  lesion  only,  are  essentially  differenl  from 
one  another.  Parotiditis  is  an  inflammation  of  the  gland  and  of  its  cellular 
tissue:  it  supervenes  during  or  after  Bevere  fevers,  is  susceptible  of  passing, 

and  often  does  pass,  into  suppuration.  But  mumps  is,  properly  speaking, 
only  a  simple  engorgement  [simple  fluxion]  of  the  gland.  This  engorge- 
ment, as  was  correctly  pointed  out  by  our  predecessors,  is  much  more  an 
affection  of  the  interglandular  cellular  tissue  than  of  the  gland  itself,  and 
(unlike  parotiditis)  never  terminates  in  suppuration.  Moreover,  while 
parotiditis  occurs  generally  on  one  side  only,  both  sides  are  almost  invaria- 
bly affected  in  mumps,  though  one  is  often  more  affected  than  the  other. 

Mumps  is  a  specific  disease  which,  for  many  reasons,  may  be  classed  with 
eruptive  levers;  and  this  1  do,  in  point  of  fact,  following  the  example  of 
some  authors.  Like  the  eruptive  fevers,  it  is  a  specific  malady,  and  like 
them,  too,  it  is  very  contagious.  It  usually  attacks  young  persons.  Some- 
times, however,  it  is  met  with  in  adults,  and  even  in  old  people.  In  such 
cases,  the  disease  can  be  traced  to  contagion:  and  of  this  JBorsieri  gives  an 
illustrative  case.  Indeed  it  is  only  in  very  exceptional  cases,  that  it  is  prop- 
agated otherwise  than  by  contagion.  Mumps  does  not  attack  the  same 
individual  more  than  once — a  fact  which  is  an  additional  point  of  resem- 
blance between  it  and  the  eruptive  fevers. 

A  malady  not  severe,  and* of  short  duration — nee  diu,  nee  gravioribus,  aid 
saltern  non  periculosis  symptomatibus,  si  reete  curenlur,  stipantur,  brevique  et 
perfecte  resolvuntur — the  mumps,  "  les  ourles"  (for  so  it  is  still  called),  is 
never,  except  under  circumstances  which  I  will  point  out  to  you,  attended 
with  serious  nervous  symptoms;  and  even  in  these  exceptional  cases,  the 
life  of  the  patient  is  seldom  in  danger.  A  fact,  to  which  I  propose  forth- 
with to  call  your  attention  is,  that  the  older  the  person  attacked,  so  much 
the  more  painful  is  the  malady. 

Mumps,  then,  is  characterized  by  a  fluxionary  engorgement  [engorgement 
fluxionnaire]  of  the  parotid  glands,  and  of  the  salivary  glands  in  general, 
for  the  submaxillary  and  lingual  glands  are  often  affected.  The  malady 
first  makes  its  existence  known  by  a  painful  bruised  feeling  which  the  pa- 
tient complains  of  in  the  parotid  region,  and  a  difficulty  in  mastication, 
partly  caused  by  pain,  and  partly  dependent  upon  the  disturbance  of  the  sali- 
vary secretion,  which  is  sometimes  completely  in  abeyance.  Even  during  con- 
valescence, some  patients  are  obliged  constantly  to  drink  when  eating,  from 
there  being  no  insalivation  of  the  food.  There  is  more  or  less  swelling  of  the 
affected  parts:  sometimes  the  swelling  extends  to  the  face,  so  as  completely 
to  disfigure  the  patient:  occasionally,  it  spreads  to  the  tonsils  and  intra- 
guttural  cellular  tissue,  producing  difficulty  of  deglutition.  There  is  little 
change  in  the  color  of  the  integuments,  but  it  is  not  unusual  for  them  to  be 
slightly  red. 

Mumps  is  a  painful  disease,  and  is  often  at  its  commencement  accom- 
panied by  intense  fever,  but  it  subsides  rapidly ;  and  at  the  end  of  seven  or 
eight  days,  recovery  has  taken  place  spontaneously,  and  without  leaving 
any  traces  of  the  passage  of  the  disorder.  But  cases  occur  in  which  it  ter- 
minates by  metastasis,  the  parotid  swelling  disappearing  abruptly,  to  attack 
in  males  the  testicles,  epididymis,  and  tunica  vaginalis,  and  in  females,  the 
breasts  or  sometimes  the  labia.  As  a  general  rule,  when  this  metastasis 
takes  place,  there  is  only  slight  constitutional  disturbance  excited  by  the 
new  local  inflammation  resulting  from  the  morbid  poison;  but  it  sometimes 
happens  that  delitescence  of  the  parotid  engorgement  takes  place  without 
the  disease  becoming  completely  fixed  elsewhere,  when  general  symptoms 
of  very  unusual  character  show  themselves,  alarming  relations,  disconcert- 


212  MUMPS. 

ing  physicians,  and  causing  the  latter  to  adopt  treatment  which  may  prove 
very  perilous. 

Permit  me,  gentlemen,  to  relate  two  cases  in  point  which  I  have  seen. 
In  1832,  I  attended  a  man,  about  thirty-five  years  of  age,  suffering  from 
mumps.  The  symptoms  were  following  their  regular  course,  the  pain  had 
diminished,  and  the  swelling  in  the  parotid  region  was  beginning  to  de- 
crease. I  had  seen  the  patient  in  the  morning,  when  he  seemed  quite  as 
well  as  I  had  any  right  to  expect ;  but  in  the  evening  I  was  hurriedly  sent 
for.  I  found  him  with  a  countenance  of  inexpressible  anxiety;  with  face 
pale,  and  pinched  ;  with  pulse  small,  rapid,  and  unequal,  and  the  extrem- 
ities cold.  He  had  neither  vomiting  nor  diarrhoea,  nor  any  appreciable 
lesion  of  lungs  or  heart.  I  proceeded  in  accordance  with  the  indications, 
giving  ether  and  warm  aromatic  drinks,  and  moving  sinapisms  over  the 
surface  of  the  body.  Meanwhile,  I  anxiously  waited  for  the  issue  of  an 
attack  which  had  set  in  under  such  unfavorable  auspices.  Next  morning, 
to  my  agreeable  surprise,  the  patient  had  smart  fever,  a  full  pulse,  and  a 
moist  skin.  There  was  color  in  the  face,  and  a  lively  expression  of  coun- 
tenance. But  there  was  swelling  of  the  scrotum,  and  one  of  the  testicles, 
particularly  the  epididymis,  was  swollen  and  painful ;  in  fact,  there  were 
all  the  characteristic  symptoms  of  the  most  acute  form  of  swelled  testicle. 
I  recalled  to  my  recollection  cases  reported  by  Borsieri,  and  Morton's  febris 
testiculars:  I  felt  reassured.  I  respected  the  local  manifestation,  which 
had  been  the  means  of  relieving  the  economy  from  a  threatening  state.  A 
few  days  sufficed  to  accomplish  the  cure  of  the  metastatic  complication,  and 
to  restore  the  patient  to  perfect  health.  .  This  case  made  a  deep  impression 
upon  me,  for  it  occurred  when  I  was  young,  and  at  the  age  when  one  forgets 
nothing.  I  resolved  at  the  time,  in  the  event  of  a  similar  case  presenting 
itself  to  my  observation,  to  place  the  two  together.  Twenty  years  elapsed 
before  this  opportunity  was  afforded  me. 

In  1853, 1  was  summoned  by  my  honorable  friend,  Dr.  Moynier,  to  meet 
him  in  consultation  in  the  case  of  a  student,  seventeen  years  of  age,  about 
whom  there  Avas  very  great  anxiety.  This  young  man,  when  in  the  midst 
of  apparently  good  health  (according  to  the  statement,  at  least,  of  his 
parents  and  the  principal  of  his  educational  institution),  was  seized  with 
burning  fever,  extreme  frequency  of  pulse,  desponding  tendencies,  delirium, 
picking  of  the  bed-clothes,  vomiting,  and  the  involuntary  passing  of  serous 
stools  ;  the  symptoms  resembled  those  of  the  bad  days  of  the  third  week  of 
putrid  fever,  or  the  onset  of  those  attacks  of  malignant  scarlatina  which 
prove  fatal  in  a  few  hours. 

You  can  understand  the  dismay  of  the  family  and  of  the  physician  in 
presence  of  these  symptoms.  Dr.  Andral  had  seen  the  patient  from  the 
commencement  of  the  illness,  and  like  Ih\  Moynier  had  perceived  the 
danger  without  being  able  to  recognize  its  cause.  Both  were  of  opinion 
that  the  primary  indication  was  to  sustain  the  powers  of  life:  and,  con- 
sequently, opium  in  small  doses,  sulphate  of  quinine  in  pretty  lull  doses, 
and  slightly  cordial  drinks,  were  judiciously  prescribed.  On  the  following 
morning,  when  I  met  my  two  colleagues,  the  condition  of  the  patient  con- 
tinued very  much  the  same,  but  perhaps  was  not  quite  so  bad.  We  were 
told  of  a  slighl  complication  which  had  arisen  during  the  oighl  -swelling 
of  the  scrotum,  ami  a  swollen  painful  state  of  one  of  the  testicles.  This 
was  the  only  organic  lesion  in  any  respect   noteworthy,  and  it  certainly  was 

not  of  a  nature  to  explain  the  terrible  train  of  symptoms  before  us.  All  al 
once  the  history  of  my  lirst  patient  flashed  across  me,  and  1  related  it  to 
my  colleagues.  I  ventured  to  give  a  somewhat  less  unfavorable  prognosis, 
believing  the  affection    to   be   metastasis  of  mumps.      It  was,   however,  in- 


MUMPS.  213 

oumbent  on  me  to  yield  to  the  precise  statement  of  symptoms  laid  before 
me,  and  the  treatment  of  the  preceding  evening  was,  therefore,  continued. 
Next  day,  there  was  much  less  swelling  of  the  testicle  and  epididymis,  the 
delirium,  vomiting,  and  diarrhoea  had  ceased;  there  was  still  smart  fever, 
hut  the  pulse  had  more  volume,  and  the  skin  was  moist.  In  a  few  days, 
the  young  man  was  restored  to  his  family,  and  to  health. 

We  now  questioned  him  minutely.  He  told  us,  that  two  or  three  days 
prior  to  the  beginning  of  his  illness,  he  had  experienced  a  feeling  of  gen- 
eral discomfort,  with  pain  in  the  throat,  and  swelling  near  the  ear,  and  at 
the  angle  of  the  lower  jaw  ;  and  that  he  had  caught  cold  in  an  excursion 
to  the  forest  of  St.  Germain.  He  stated  that  the  swelling  diminished  next 
day,  and  that  it  was  on  the  following  day  that  the  alarming  symptoms 
appeared. 

About  the  date  at  which  this  case  occurred,  mumps  were  prevailing  in 
a  boys'  boarding-school  to  which  I  was  a  physician.  I  informed  the  prin- 
cipal that  the  malady  was  not  of  a  serious  character,  but  I  also  stated  that 
metastasis  to  the  testicle  was  a  possible  occurrence,  so  that  in  the  event  of 
any  of  the  elder  boys  being  affected  in  this  way,  he  might  not  suspect  the 
cause  to  be  gonorrhoea.  Some  days  afterwards,  on  visiting  the  infirmary 
of  this  school,  I  found  one  of  these  metastatic  cases.  • 

Mumps  was  also  at  that  time  prevailing  in  young  ladies'  boarding- 
schools,  and  I  met  with  cases  of  metastasis  in  those  institutions.  As  I  have 
already  said,  the  metastasis  in  women  is  generally  to  the  mamma?.  It  is  a 
remarkable  circumstance  that  no  case  of  metastasis  of  mumps  to  the  ovaries 
has  been  recorded.  As  these  organs  are  considered  the  analogues  of  the 
testicles,  it  might  be  supposed  that  they  were  specially  the  seat  of  the  metas- 
tatic engorgements  of  which  I  am  speaking. 

In  some  families,  there  is  a  peculiar  tendency  to  this  metastasis.  Dr. 
Poinset  told  me  that  he  and  his  two  brothers  had  violent  orchitis  after 
mumps. 

The  two  cases,  the  particulars  of  which  I  have  now  detailed,  are  exceed- 
ingly curious,  not  in  respect  of  the  mere  metastasis  itself,  for  that  is  a  fact 
pointed  out  by  all  authors,  but  on  account  of  the  symptoms  during  the 
accomplishment  of  the  metastasis,  before  it  was  established. 

Many  physicians,  especially  since  the  doctrine  of  the  localization  of  dis- 
ease has  taken  so  sadly  important  a  place  in  medical  education — a  place 
which,  thank  heaven  !  it  is  daily  tending  to  lose — many  physicians,  I  say, 
have  denied  metastasis,  to  the  extent  at  least  of  holding  that  the  sympto- 
matic phenomena  do  not  show  themselves  until  the  new  lesion  is  developed. 
The  Hippocratic  physicians  believe  that  the  morbid  poison  is  afloat  in  the 
economy-,  that  it  comes  in  contact  with  all  the  organic  elements,  producing 
a  variable  amount  of  general  disturbance  precisely  similar  to  what  is  seen 
during  the  period  of  invasion  in  eruptive  fevers,  when  terrible  symptoms 
occur  prior  to  the  existence  of  any  lesion  of  the  solids,  ceasing  or  decreas- 
ing as  the  local  lesions  show  themselves.  This  is  a  question  involving  im- 
portant clinical  facts  ;  and  as  it  is  only  from  such  facts  that  we  can  derive 
a  useful  acquaintance  with  it,  my  duty  is  to  bring  them  under  your  notice. 
The  kind  of  metastasis  now  being  considered  by  us  proves  the  existence 
of  a  sympathy  between  the  parotid  gland  and  the  genital  organs  :  the  ex- 
istence of  this  sympathy  is  matter  of  common  observation,  but  its  manifes- 
tation in  an  inverse  order — that  is  to  say  proceeding  from  the  genitals  to 
the  parotid — is  a  less  familiar  fact.  A  case  of  this  kind,  however,  was 
observed  by  Dr.  Peter  when  he  was  Professor  Gerdy's  interne.  On  May 
1st,  1855,  a  woman,  twenty-two  years  of  age,  was  admitted  to  La  Charite 
Hospital.     She  had  all  the  signs  of  violent  inflammatory  congestion  of  the 


214  MUMPS. 

right  parotid  region  :  there  was  swelling  and  pain,  but  neither  redness  nor 
fluctuation.  The  patient  had  anorexia  and  a  little  fever.  The  malady 
had  commenced,  four  days  previously,  with  great  difficulty  of  moving  the 
lower  jaw :  an  hour  after  this  symptom  was  experienced,  swelling  super- 
vened, and  this  was  followed  by  pain.  But  the  point  of  interest  in  this 
case  was  the  statement  of  the  patient,  that  many  times  before  she  had  had 
a  similar  affection,  always,  however,  at  the  menstrual  periods,  and  in  sub- 
stitution for  the  menstrual  discharge.  Her  menstruation  was  irregular, 
and  several  times,  for  months  in  succession,  she  had  been  without  her 
courses  :  she  then  suffered  from  headache,  and  swelling  in  the  parotid  re- 
gion (generally  on  the  left  side),  which  was  sometimes  attended  with  loss 
of  consciousness  for  an  hour.  On  each  occasion  recovery  took  place 
quickly,  after  the  application  of  leeches  and  cataplasms.  That  is  not  all : 
the  patient  stated  that  even  more  frequently  than  the  affection  of  the  paro- 
tid glands,  and  always  at  menstrual  periods,  when  the  discharge  was  scanty, 
she  had  had  a  sort  of  thrombus  of  the  left  nympha, 'accompanied  by  acute 
pain  and  inability  to  walk.  The  symptoms  continued  for  four  or  five  days, 
and  then  terminated  in  slight  hemorrhage  from  the  nympha.  The  patient 
left  the  hospital  on  the  5th  May,  and  was  readmitted  to  the  same  wards  on 
the  1st  .September,  at  a  date  which  exactly  corresponded  with  her  catame- 
nial  period.  On  this  occasion,  there  was  again  the  same  inflammatory 
engorgement  on  the  left  side.  She  stated  that  in  June  she  had  had  paro- 
tiditis ;  in  July,  a  thrombus  occupying  the  left  labium  and  nympha,  fol- 
lowed by  considerable  hemorrhage;  in  August,  parotiditis ;  and  in  Sep- 
tember, she  returned  to  the  hospital  with  a  repetition  of  the  latter  affection. 
Finally,  on  the  2d  November,  Dr.  Peter  saw  her  in  the  out-patient's  room, 
with  true  thrombus  of  the  left  labium  and  nympha.  She  did  not  then  wish 
to  come  in  to  the  hospital. 

Gentlemen,  it  is  difficult  not  to  see  in  this  case  the  reciprocity  of  classical 
facts.  Just  as  metastasis  to  the  genital  organs  may  take  place  in  mumps, 
so  was  there,  in  Dr.  Peter's  case,  a  metastasis  to  the  parotid  glands  of  an 
abortive  catamenial  congestion. 

Mark  well,  that  in  quoting  this  interesting  case,  I  have  not  been  discuss- 
ing mumps:  in  this  case  the  affection  was  parotiditis,  or  at  least  inflamma- 
tory congestion  of  the  parotid  gland.  But  mumps,  as  I  have  told  you,  is  a 
specific  affection,  analogous  to  the  eruptive  fevers,  like  them  contagious, 
and  like  them  not  attacking  the  same  subjects  more  than  once.  I  have 
therefore  quoted  Dr.  Peter's  case  only  as  an  additional  and  curious  example 
of  a  kind  of  sympathy  which  is  still  unexplained. 


/ 


URTICARIA.  ^15 


LECTURE  XII. 

URTICARIA." 

A  Distinct  Nosological  Species. — Sudoral  Nettlerash  [T  eruption  ortiee  sudorale~] 
is  no  more  Urticaria  than  Morbilliform  and  Scarlatiniform  Sudoral  Erup- 
tions are  Measles  and  Scarlatina. —  General  Precursory  Symptoms. — Ex- 
citing Causes. 

Gentlemen:  An  officer,  of  about  thirty  years  of  age,  of  good  constitu- 
tion, was  seized,  in  the  midst  of  perfect  health,  with  symptoms  which  at  first 
presented  an  alarming  character:  the  symptoms  to  which  I  refer  were  pre- 
cordial oppression,  intense  headache,  nausea,  and  high  fever.  They  had  set 
in  during  the  evening,  had  continued  all  night,  and  had  scarcely  moderated 
when  the  physician  arrived.  At  this  time  the  face  was  considerably  swollen, 
and  the  swelling  occasioned  a  very  disagreeable  feeling  of  tension  of  the 
skin ;  swelling  in  a  less  degree  was  observed  over  the  whole  surface  of  the 
body.  The  skin  was  covered  with  an  eruption  characterized  by  whitish 
blotches  [elevures]  surrounded  by  a  slightly  red  areola.  The  general  symp- 
toms rapidly  disappeared,  the  patient  complained  only  of  insupportable 
itching,  and  had  completely  recovered  within  thirty-six  hours  from  the 
commencement  of  the  illness.  Some  time  afterwards  he  had  a  return  of  the 
same  malady,  the  symptoms  being  similar  to  those  of  the  first  attack.  A 
similar  eruption  appeared  on  the  skin,  and  it  disappeared  with  similar 
rapidity,  possibly  under  the  influence  of  a  mild  laxative,  which  was  admin- 
istered on  both  occasions.  This  gentleman  could  not  attribute  either  attack 
to  any  food  he  had  taken.  He  only  recollected  that  he  had  eaten  a  bit  of 
sole  on  the  evening  before  the  first  seizure,  but  he  also  remembered  that  it 
was  perfectly  fresh ;  and  moreover,  till  then,  he  had  always  eaten  with  im- 
punity the  various  articles  which  often  in  others  occasion  urticaria,  such  as 
mussels,  various  other  descriptions  of  shell-fish,  and  crabs. 

Urticaria  was  the  affection  from  which  the  officer  suffered ;  and  in  the 
very  succinct  account  I  have  now  given  of  it,  you  have  recognized  the 
description  of  the  special  form  of  exanthem,  the  absolute  type  of  which  is 
the  eruption  caused  by  the  touch  of  the  stinging  nettle. 

I  pointed  out  to  you  the  other  day  nettlerash  \V  eruption-m*ti'ee~\  occurring 
as  a  sudoral  exanthem,  but  that  eruption  does  not  constitute  the  malady 
now  under  our  consideration  any  more  than  morbilliform  and  scarlatiniform 
sudaminal  exanthemata  constitute  measles  and  scarlatina. 

Urticaria,  the  febris  urticata,  is  a  well-defined  nosological  species,  although 
it  originates  under  the  influence  of  exceedingly  various  causes.  These 
causes,  however,  only  play  a  secondary  part.  They  are  the  exciting  causes 
[causes  occasionelles~]  waking  up  according  to  the  idiosyncrasies  of  individuals 
a  special  predisposition,  in  virtue  of  which  the  morbific  matter  is  formed, 
which  is  the  real,  or  as  the  old  writers  would  have  called  it,  the  immediate 
cause  of  the  disease. 

Urticaria  makes  its  presence  known,  like  the  eruptive  fevers,  by  precur- 

*  Fievre  Ortiee:  Febris  Urticata  of  Vogel. 


216  URTICARIA. 

sory  symptoms,  which  continue,  with  variable  degrees  of  intensity,  for  some 
hours,  a  day,  or  two  days.  These  symptoms  are  general  discomfort,  head- 
ache, horripilation,  rigors,  precordial  oppression,  lipothymia,  and  more  or 
less  difficulty  in  breathing,  which  is  sometimes  so  great  as  to  excite  the  fear 
that  the  patient  will  be  suffocated.  In  some  cases,  nausea  and  vomiting 
occur;  and  there  are  also  some  cases  in  which  there  are  colic,  diarrhoea, 
and  all  the  symptoms  of  iudigestion,  but  this  is  when  the  exciting  cause  is 
the  eating  some  particular  kind  of  food.  The  symptoms  are  always  accom- 
panied by  a  well-marked  febrile  condition.  It  seems  as  if  the  morbific 
matter  were  formed  in  such  quantity  that  the  different  emuuctories  are 
scarcely  sufficient  to  eliminate  it,  or  that  before  finding  its  natural  exit, 
which  is  by  the  skin,  it  goes  round — pardon  the  figure — knocking  at  every 
door,  thus  affectiug  the  nervous  system,  the  organs  of  respiration,  and  the 
organs  of  digestion. 

The  patient  soon  begins  to  feel  an  unusual  sensation  of  heat  and  itching 
at  particular  points  in  the  skin,  which  forthwith  become  swollen.  This 
swelling,  quite  appreciable  by  the  eye,  becomes  generalized  over  a  more  or 
less  extensive  surface,  occasions  a  feeling  of  tension  complained  of  by  the 
patient;  and  finally,  the  characteristic  eruption  appears. 

The  eruption  which  now  occupies  the  face,  and  by  and  by  other  parts  of 
the  body — particularly  the  shoulders,  loins,  inner  aspect  of  forearms,  thighs, 
circumference  of  the  knees — consists  of  blotches  which  are  of  a  rosy  or  bright- 
red,  and  sometimes  dull-white  color,  always  surrounded  by  a  red  areola, 
and  exactly  resembling  in  form,  extent,  and  general  appearance  the  erup- 
tion produced  by  the  stinging  of  nettles,  and  sometimes  by  the  stings  of  bees 
and  wasps:  "Forma,  magrdtudvne  et  specie  valde  similes  Mis  quas  urticarial! 
puuctura,  aid  vesparum  apumve  ictus  excitat." 

The  number  of  the  blotches  is  variable:  sometimes  they  are  very  few  and 
quite  distinct  from  each  other;  at  other  times  they  cover  nearly  the  whole 
body,  and  become  confluent.  There  is  nothing  determinate  in  their  shape, 
which  may  be  round,  oval,  or  irregular.  When  numerous  and  confluent, 
they  may  resemble  the  eruption  of  scarlatina ;  and  the  rapidity  with  which 
they  come  out,  combined  with  the  short  duration  of  the  precursory  symp- 
toms, increases  the  chance  of  a  mistake  in  diagnosis,  if  sufficient  elements 
for  arriving  at  a  correct  opinion  are  not  furnished  by  the  tumefaction  of 
the;  skin  (sometimes  great),  the  pruritus  and  tingling,  and  an  attentive 
examination  of  the  blotches.  The  pruritus  and  tingling,  which  give  great 
annoyance  to  the  patient,  are  increased  by  the  warmth  of  bed. 

I  have  still  to  call  your  attention  to  a  circumstance  connected  with  the 
eruption  which  was  pointed  out  by  Koch,  viz.,  that  it  may  become  devel- 
oped on  the  inside  of  the  mouth.  This  observation  leads  me  to  ask,  whether 
the  chest  symptoms  of  which  I  have  spoken,  are  not  occasioned  by  an  erup- 
tion or  congestive  state  of  the  mucous  membrane  of  the  bronchial  tidies 
analogous  to  the  eruption  and  congestion  seen  on  the  skin.  My  opinion  is 
that  bronchia]  eruption  may  occur  in  urticaria,  precisely  as  in  measles. 

In  the  pyrexia!  exanthemata,  the  cutaneous  manifestations  occur  in  regu- 
lar order,  and  follow  a  definite  course,  hut  in  urticarious  t'cwv  \  fit  vre  ortiee] 
this  is  not  the  case.  The  total  duration  of  the  disease,  including  the  pro- 
dromic  period,  is  very  variable,  ranging  between  two  and  seven  or  eight 
day- ;  bul  the  individual  Mot  dies  of  eruption  disappear  very  quickly,  their 
duration  being  from  four,  five,  or  six  minute-  to  one.  two,  or  three  hours. 

The  eruption,  then,  does  not  come  oul  all  at  once.  Inn  in  successive  Crops  J 
anl  the  precursory  symptoms  which  announced  the  lirsi  appearance  of  erup- 
tion may  recur  again  and  again.  Sometimes  scratching  causes  the  eruption 
to  reappear  in  the  places  scratched. 


URTICARIA.  217 

Urticaria  spares  neither  age  nor  sex :  it  attacks  old  men,  adults,  and  chil- 
dren;  and  women  as  well  as  men.  A  first  attack,  so  Car  from  being  pro- 
tection against  a  second,  is  a  reason  for  expecting  subsequenl  attacks, 
especially  in  those  in  whom  it  supervenes  under  the  influence  of  exciting 
causes.  In  fact,  some  individuals  cannot  eat  certain  descriptions  of  food 
without  bringing  on  symptoms  of  indigestion,  or  rather  of  true  poisoning, 
soon  accompanied  by  a  more  or  less  considerable  urticarious  eruption.  It 
is  impossible  to  state  in  general  terms  the  kinds  of  food  which  produce 
these  symptoms,  because  so  much  depends  upon  idiosyncrasy.  Shell-fish, 
particularly  muscles,  crab,  lobster,  the  ova  of  certain  fish,  and  some  kinds 
of  fish  (fresh  or  smoked)  seem  to  be  the  articles  of  diet  which  are  most 
powerful  in  exciting  urticaria  in  some  persons;  whereas  in  other  persons, 
similar  results  are  caused  by  dietetic  articles  of  a  totally  different  descrip- 
tion, such  as  pork,  edible  mushrooms,  almonds,  cucumbers,  strawberries, 
raspberries,  honey,  &c.  Lorry  gives  cases  in  which  eating  rice  produced 
urticarious  eruption. 

A  predisposition  to  urticaria  is  sometimes  hereditary.  In  October,  1861, 
I  saw  in  my  consulting-room,  a  lady  of  fifty,  who  was  very  subject  to  anoma- 
lous nervous  symptoms,  and  who  had  been  a  martyr  to  urticaria  during  the 
greater  part  of  her  life.  She  had  a  son  and  daughter  who  had  inherited 
from  her  this  distressing  infirmity,  which  was  as  inveterate  in  them,  as  it 
had  proved  in  their  mother. 

Although  urticaria  is  apparently  a  simple  affection,  it  assumes  in  some 
persons  an  extraordinarily  obstinate  character,  and  becomes  a  real  torment 
of  existence.  I  have  seen  it  last  for  years,  renewing  itself  daily,  and  defy- 
ing all  treatment. 

Sometimes,  also,  urticaria  has  a  terrible  influence  upon  the  nervous  system. 
I  knew  a  young  woman  of  twenty,  who  during  the  invasion-period  of  an 
urticarious  fever,  was  seized  with  nervous  symptoms  of  the  most  formidable 
character.  She  was  struck  down  by  profound  stupor,  paralysis  of  the  lower 
extremities,  and  anaesthesia.  In  some  cases,  fortunately  very  rare,  after  the 
eruption  has  entirely  disappeared,  nervous  symptoms,  anaesthesia  and 
amyosthenia,  particularly  of  the  lower  extremities,  continue  for  a  longer  or 
shorter  period. 

The  hot  weather  of  summer  is  often  an  exciting  cause  of  urticaria;  but, 
as  has  been  remarked  by  J.  Franc,  it  likewise  sometimes  appears  under 
the  influence  of  cold,  and  disappears  under  the  influence  of  heat. 

Finally,  it  is  also  sometimes  absolutely  impossible  to  assign  any  cause 
whatever  for  the  appearance  of  this  disease. 

I  will  not  speak  to  you,  gentlemen,  of  chronic  urticaria,  or  of  urticaria 
tuberosa.  They  are  forms  of  the  disease  which  I  have  never  had  an  oppor- 
tunity of  observing  in  the  clinical  wards ;  but  my  colleagues  of  St.  Louis 
Hospital  will  show  them  to  you,  and  make  you  acquainted  with  them. 

I  have  still  a  word  to  add  on  the  subject  of  treatment.  When  urticaria 
occurs  without  any  appreciable  exciting  cause,  it  is  seldom  necessary  for 
art  to  interfere,  as  the  malady  spontaneously  terminates  in  recovery.  How- 
ever, at  the  beginning  of  the  attack,  the  administration  of  mild  purgatives 
is  sometimes  indicated,  with  a  view  to  divert  a  tendency  to  congestion  from 
the  respiratory  organs  to  the  intestinal  canal.  To  moderate  the  symptoms, 
it  is  generally  sufficient  to  order  tepid  baths,  and  cooling  acidulated  drinks, 
such  as  orangeade  and  lemonade. 

But  when  urticaria  is  excited  by  the  ingestion  of  alimentary  substances, 
it  is  necessary,  without  loss  of  time,  to  induce  vomiting.  After  the  action 
of  the  emetic,  draughts  containing  ether  may  be  prescribed — for  example, 
a  quarter  of  a  tumbler  of  sugared  water,  containing  from  twenty  to  forty 


218  ZONA    OR    HERPES    ZOSTER. 

drops  of  sulphuric  ether,  may  be  taken  every  half  hour.  Ether  is  also  in- 
dicated, when  you  wish  to  subdue  spasmodic  action. 

When  urticaria  assumes  a  chronic  form,  it  sometimes  resists  the  best 
devised  modes  of  treatment.  Some  benefit,  however,  is  obtained  from  fre- 
quent emetics,  the  preparations  of  quinine  in  large  doses,  and  arsenical 
solutions. 

When  urticaria  appears  as  a  natural  crisis  of  a  chronic  affection  of  the 
mucous  membranes,  you  must  not  interfere  with  it.  Some  time  during  the 
year  1860,  I  saw,  in  consultation  with  my  honorable  colleague,  Alfred  Bec- 
querel,  a  lady  of  sixty,  who  had  been  attacked  in  the  spring  with  violent 
bronchitis.  Soon  after  her  seizure,  symptoms  of  extensive  vesicular  em- 
physema supervened,  accompanied  by  nocturnal  attacks  of  orthopncea,  and 
constant  dyspnoea.  It  would  be  tedious  to  tell  you  all  the  therapeutic  means 
I  had  recourse  to.  Suffice  it  to  say,  that  they  had  all  failed,  when,  about  the 
end  of  January,  1861,  a  violent  coryza  led  us  to  dread  an  exacerbation  of  her 
symptoms,  but  on  the  contrary,  a  profuse  urticarious  eruption  having  ap- 
peared over  the  whole  body,  they  all  at  once  ceased.  I  felt  that  under  the 
circumstances,  I  ought  not  to  interfere  with  an  eruption,  which  though  un- 
doubtedly very  inconvenient  and  very  obstinate  is  not  dangerous. 


LECTURE  XIII. 

ZONA  OR  HERPES  ZOSTER 

Characteristics. — Accompanying  Pains. — Inveterate  Consecutive  Neuralgic 

Affection*. 

Gentlemen  :  You  recollect  a  man  of  55  years  of  age,  who  occupied  bed 
No.  10  in  St.  Agnes's  Ward  in  April,  1859.  Three  days  prior  to  admission, 
this  individual  was  seized  with  acute  pain  behind  the  left  ear.  On  the  fol- 
lowing day.  there  was  a  temporary  cessation  of  pain  ;  but  on  that,  day  and 
the  following,  he  perceived  an  eruption  consisting  of  groups  of  blebs.  These 
groups  increased  in  number,  and  when  the  case  came  under  my  notice, 
occupied  the  situations  which  I  am  now  going  to  describe. 

The  eruption  extended  from  the  ear  to  the  front  of  the  chest:  it  was  mosl 
abundant  on  the  left  shoulder  and  arm,  within  the  triangle  formed  by  the 
sterno-cleido-mastoid  muscle,  the  trapezius  and  clavicle.  Over  the  pectoralis 
major  muscles,  about  two  centimetres  below  the  clavicle,  there  was  a  group 

extending  marly  live  cent i metre-.  Behind  t lie  car, over  the  mastoid  process, 
we  found  the  firsl  which  appeared;  ami  between  it  and  the  other  large 
group,  in  the  space  which  I  have  described,  there  were  other  smaller  groups. 
Some  were  also  situated  on  the  external  aspeel  of  the  shoulder,  ami  three 
mi  it-  posterior  aspect.  These  groups  were  formed  by  blebs  not  yet  com- 
pletely developed,  and  the  patient,  who  complained  01  their  being  painful, 
traced  with  his  finger  the  course  of  differenl  branches  of  the  cervical  plexus. 

lie  had  a  good  appetite,  no  fever,  ami.  as  he  expressed  it.  was  in  QO  wav 
out  of  BOrtS. 

<  >n  the  second  day  after  admission,  the  eruption  was  perfectly  bullous. 
The  blebs  desiccated  in  succession  forty-eighl  hours  afterward-,  and  the 
desiccation  was  complete  on  the  sixth  day,  consequently,  on  the  ninth  day 


ZONA    OR    HERPES    ZOSTER.  219 

from  the  beginning  of  the  disease.  The  neuralgic  pains  became  less  severe; 
and  on  the  twenty-second  day  the  patient  was  quite  well,  and  left  the  hos- 
pital.     There  were  only  visible  some  red  spots  where  the  blebs  had  been. 

Some  months  afterwards,  another  ease  of  herpes  zoster  came  under  our 
observation. 

The  patient  was  a  man,  thirty-eight  years  of  age,  employed  as  a  servant 
in  the  wards.  He  had  been  aware  of  the  existence -of  the  affection  for  two 
days  ;  but  it  occasioned  no  pain,  and  only  some  itching.  Till  the  third  day, 
which  was  the  first  day  on  which  he  had  pain,  he  did  not  mention  his 
ailments  to  me.  The  eruption  began  to  the  right  of  the  tenth  vertebra  and 
extended  from  the  vertebral  column  to  the  sternum:  it  consisted  of  four 
groups  of  vesicles  of  about  the  diameter  of  a  small  walnut,  resting  on  a  red 
surface.  The  pains  were  sufficiently  acute  to  prevent  the  patient  sleeping; 
but  he  had  neither  fever  nor  rigors,  and  complained  of  only  a  little  general 
discomfort.  On  inquiring  into  the  seat  of  the  pain,  Ave  were  struck  by  find- 
ing that  it  did  not  exist  in  the  course  of  the  zona,  and  was  not  excited  even 
by  pressure  on  the  affected  parts,  though  felt  above  and  below  them.  The 
pain  was  acute,  and  was  aggravated  by  the  slightest  pressure.  On  the 
eighth  day,  the  patches  of  herpes  zoster  changed  into  very  painful  furuncu- 
lar  tumors;  and  soon  afterwards,  we  found  an  engorged  lymphatic  gland  in 
the  intercostal  space  below  them,  and  also,  red  lines  leading  from  the  erup- 
tion to  the  axilla,  indicating. inflammation  of  the  lymphatics  with  its  start- 
ing-point iu  the  furuncular  tumors.  These  circumstances  explained  why 
the  patient  experienced  pain  beyond  the  seat  of  the  eruption. 

At  the  beginning  of  the  year  1863,  another  man,  acting  as  servant  in  the 
wards,  was  attacked  with  herpes  zoster  of  the  face,  which  I  showed  to  Dr. 
Cusco,  my  honorable  colleague  in  the  hospitals.  It  was  situated  on  the  left 
side  of  the  forehead.  The  eruption  followed  with  remarkable  anatomical 
regularity  all  the  cutaneous  ramifications  of  the  ophthalmic  branch  of  the 
fifth  pair.  It  was  most  confluent  in  the  parts  where  the  external  frontal 
branch  spreads  out  into  ascending  ramifications ;  it  likewise  extended  to 
the.  eyelids,  where  the  divisions  of  the  descending  branches  are  distributed, 
and  became  more  violent  at  the  point  of  emergence  of  the  branch  of  the 
nasal  nerve  which  is  distributed  to  the  integuments  of  the  lobe  of  the  nose. 
The  neuralgic  pains  were  very  acute,  and  continued  long  after  the  disap- 
pearance of  the  exanthem.  There  was  also  ophthalmia,  accompanied  by 
pain  and  photophobia. 

In  1862,  I  had  previously  seen,  along  with  my  honorable  colleague,  Dr. 
Delpech,  a  man  aged  sixty  with  herpes  zoster  exactly  similar  to  that  now 
described.  The  photophobia  continued  for  more  than  three  months,  and 
was  associated  with  iritis. 

The  very  remarkable  tendency  which  herpes  zoster  sometimes  has  to 
follow  the  course  of  the  nerves  is  fully  established  by  the  cases  which  I 
have  now  related  to  you.  You  must  not  suppose,  however,  that  the  erup- 
tion always  assumes  the  form  which  I  have  described.  If  you  attentively 
look  at  its  distribution  on  the  chest  in  relation  to  the  direction  of  the  ribs, 
you  will  be  convinced  that  it  does  not  follow  the  course  of  the  intercostal 
nerves.  Generally,  on  the  chest,  the  half  girdle  formed  by  the  eruption  is 
almost  exactly  perpendicular  to  the  axis  of  the  body,  beginning,  for  exam- 
ple, at  the  seventh  dorsal  vertebra,  and  terminating  directly  opposite,  at 
the  sternum ;  but  the  ribs  and  intercostal  nerves  are  very  far  from  follow- 
ing a  line  perpendicular  to  the  axis  of  the  body.  Portions  of  the  vertebral 
column,  and  the  ribs  below  the  fifth  rib,  slope  very  much  downwards,  and 
form  an  angle  of  more  than  twenty-five  degrees  with  the  spine:  theoreti- 
cally, the  zona  ought  to  follow  the  same  direction,  but  it  does  not  do  so,  as 


220  ZONA    OR    HERPES    ZOSTER. 

you  know  from  cases  you  have  seen  in  the  wards.  It  is  evident,  therefore, 
that  it  is  not  an  absolute,  though  a  general,  rule  that  the  bullous  eruption 
of  herpes  zoster  follows  the  course  of  the  nerves. 

When  the  eruption  appears  on  the  legs,  it  does  not  encircle  them  like  a 
bracelet  or  garter,  but  extends  in  the  length  of  the  limb.  You  recollect  a 
man  who  occupied  bed  No.  8  of  our  St.  Agnes's  Ward,  in  whom  it  was 
situated  on  the  thighs  and  extended  from  the  groin  to  the  knee.  In  August, 
1862,  I  saw  in  my  consulting-room  a  patient  in  whom  the  eruption  ex- 
tended from  the  hollow  of  the  axilla  down  to  the  hand,  keeping  rather  to 
the  palmar  aspect  of  the  forearm.  In  the  patient  of  St.  Agnes's  Ward,  the 
herpetic  patches  were  distributed  exactly  in  the  course  of  the  principal 
divisions  of  the  crural  nerve,  while  in  the  other  patient,  it  was  very  difficult 
to  find  any  relation  between  their  distribution  and  the  course  of  the  branches 
of  the  brachial  plexus :  in  both  patients,  however,  there  were  acute  neuralgic 
pains  in  the  part  of  the  limb  occupied  by  the  eruption. 

Here  then,  gentlemen,  is  a  singular  disease,  the  specific  nature  of  which 
no  one  can  tell.  The  eruption  by  which  it  is  characterized  consists  of 
patches,  individually  variable  in  size,  of  a  bright  red  erythematous  color, 
and  having  vesicles  grouped  upon  them — or,  more  correctly,  bullae,  form- 
ing sometimes  real  blisters,  more  or  less  numerous  and  more  or  less  large. 
These  patches,  separated  from  one  another  by  healthy  skin,  form,  when 
taken  collectively,  a  sort  of  half  girdle,  a  sort  of  zone,  which  has  given  the 
name  of  zona  to  the  disease,  and  which  is  nearly  always  limited  to  half  of 
the  body,  whether  the  eruption  occupy  the  trunk  or  the  face.  On  the 
thorax,  its  usual  seat,  the  zone  never  passes  beyond  the  middle  of  the 
sternum  :  on  the  abdomen,  it  stops  at  the  linea  alba,  and  behind,  it  never 
crosses  the  vertebral  column.  "  Perpetua  lege,"  said  De  Haen,  "  ab  antcriore 
parte  abdominis  nunquam  lineam  albam,  nunqutm,  aposlica  spinam  |  macuke) 
transcendunt."  The  chest  is  the  most  usual  situation  of  the  eruption,  but 
it  is  also  seen  on  the  abdomen,  where  it  encircles  the  lumbar  or  iliac  region, 
proceeding  thence  to  the  groin,  and  terminating  on  the  anterior  surface  of 
the  thigh,  sometimes  also  invading  the  genital  organs.  When  the  zone 
occupies  the  thorax,  it  generally  also  invades  the  arm  of  the  same  side,  pre- 
senting patches  in  continuation  of  the  line  of  the  girdle,  either  inside  or 
outside  of  it,  or  both.  In  the  first  of  our  patients,  the  eruption  was  situated 
mi  the  Deck,  shoulder,  and  upper  part  of  the  chest  and  back.  Sometimes, 
it  remains  limited  to  the  first  of  these  regions:  sometimes  also,  it  is  con- 
fined to  the  face;  and  in  exceptional  cases,  it  appears  on  the  hairy  scalp. 
It  has  been  seen  to  extend  within  the  mouth.  Finally,  in  a  still  smaller 
number  of  cases,  the  limbs  only  are  invaded.  In  all  cases,  however,  there 
is  only  one  side  of  the  body  affected.  It  is  also  important  to  recollect,  that 
when  herpes  zoster  affects  the  extremities,  the  groups  of  eruption,  whether 
they  follow  or  not  the  course  of  the  superficial  nerves,  are  always,  as  I  have 
already  said,  disposed  Longitudinally,  and  not  round  the  limb. 

The  hall'  girdle  is  sharply  defined  at  both  ends,  and  lias  a  breadth  of 
several  fingers.  The  groups  which  compose  it  are  sometimes  rather  close 
to  each  other,  and  at  other  times  rather  distant.  The  eruption  begins  by 
the  appearance  of  the  red  irregular  spots  of  which  1  have  spoken,  and  which 
come  out  the  one  after  the  other,  showing  themselves  in  such  a  way  in  some 

cases,  at    the  two  extremities  of  tie'  line,  as    to  indicate  that    the  succession 

of  eruptions  is  just  about  to  he  completed.     The  patches  at  the  extremities 

of  the  line  are  larger  than  those  which  intervene.      (  'a/.enave,  from  whom  I 

have  taken  m  y  de-en  pi  ic f  the  disease,  says  thai  "if  its  progress  he  atten- 
tively observed,  small  elevations  will  he  seen  which  have  from  the  first  the 
hie-  of  the  patch,  and  which  increase  in  size  and    rapidly  bi  Come  true  vesi- 


ZONA    OR    HERPES    ZOSTER.  221 

cles,  quite  distinct  from  one  another,  very  transparent  and  resembling  little 
pearls  in  color.  The  development  of  the  eruption  is  completed  in  three  or 
four  days.  The  largest  vesicles  are  seldom  larger  than  a  large  pea.  Winn 
the  eruption  has  attained  its  maximum  intensity,  the  patch  which  constituted 
its  base  presents  great  redness,  which  generally  extends  one  or  two  centime- 
tres beyond  the  limits  of  the  vesicular  group.  Each  patch,  therefore,  has 
its  phases  of  increase,  and  patches  are  developed  one  after  another  in  the 
same  way,  till  all  constituting  the  demizone  have  been  formed." 

Cazenave  continues:  "  At  the  end  of  five  or  six  days  the  vesicles  begin 
to  diminish  in  size,  and  the  liquid  which  they  contain  becomes  muddy, 
opaque,  and  sometimes  blackish,  as  if  it  were  sanguinolent:  the  vesicles 
become  wrinkled,  withered,  collapsed,  and  are  soon  covered  with  small, 
thin,  brown  crusts,  which  fall  off  in  a  few  days.  Every  group  undergoes 
similar  changes,  and  about  the  tenth  or  twelfth  day  from  the  beginning  of 
the  disease,  the  eruption  has  run  its  course.  Nothing  then  remains  except 
a  few  red  stains,  which  gradually  disappear.  Nevertheless  it  sometimes 
happens,  even  in  the  simplest  cases,  that  in  scratching  the  parts  the  patient 
tears  the  vesicles,  causing  them  to  be  succeeded  by  excoriations,  and  some- 
times by  small  ulerations,  which  often  greatly  prolong  the  duration  of  the 
malady.     This  complication  generally  occurs  at  the  base  of  the  chest." 

The  mode  of  succession  described  by  Cazenave  is  more  apparent  than  real. 
I  concur  with  the  statement  that  the  herpetic  groups  do  not  all  appear  on 
the  same  day;  but,  in  general,  by  the  third,  or  at  most  by  the  fourth  day 
the  eruption  is  complete.  After  that  period  the  vesicles  enlarge,  and  unite 
to  form  large  bullae,  which  forthwith  become  filled  with  transparent  serosity 
around  which  the  skin  has  a  violet-red  color,  and  seems  to  yield  a  slightly 
slate-colored  exudation.  Between  the  eighth  and  eleventh  days  the  bulla? 
become  filled  with  pus,  and  go  on  bursting  in  succession  till  the  fourteenth 
day,  dating  from  the  commencement  of  the  malady.  A  great  many  vesicles, 
however,  remain  on  the  road,  if  I  may  be  allowed  the  expression,  and  dis- 
appear prematurely,  or  at  least  without  having  become  filled  with  pus. 
Those  which  have  reached  the  stage  of  suppuration  burst,  as  I  have  stated, 
and  the  denuded  dermis  becomes  covered  with  a  blackish  crust,  which  comes 
off  between  the  fifteenth  and  twentieth  days,  when  the  dermis,  at  first  of  a 
purple-red  hue,  by  degrees  loses  its  deep  color,  until  at  the  end  of  two,  three, 
or  four  months,  there  is  nothing  visible  excepting  a  white  cicatrix  similar 
to  that  left  by  a  very  superficial  burn. 

It  is  a  remarkable  fact  to  which,  gentlemen,  I  bespeak  your  special  at- 
tention, that  generally  ''though  not  always,  as  some  have  alleged;  the 
eruption  is  developed  in  the  track  of  the  nervous  filaments  of  which  it  de- 
lineates the  course :  thus,  on  the  thorax,  it  may  follow  the  course  of  the  in- 
tercostal nerves,  and  in  our  first  case,  you  saw  how  it  delineated,  so  to  speak, 
the  ascending  and  descending  branches  of  the  cervical  plexus.  This  cir- 
cumstance is  more  than  a  mere  descriptive  detail :  this  disposition  of  the 
eruption  is  related  to  another  phenomenon,  which,  independent  of  the  form 
of  the  disease,  is  a  precise  and  definite  characteristic  of  herpes  zoster.  This 
characteristic  is  the  local  pain,  which  almost  always  precedes  and  accom- 
panies the  eruption,  and  often  continues  long  after  its  disappearance.  I  am 
not  at  present  speaking  of  the  prodromic  symptoms,  the  slight  discomfort 
and  feverishness  which,  either  nearly  or  altogether,  cease  when  the  eruption 
has  completely  come  out :  I  refer  to  the  neuralgic  pain  in  the  future  seat  of 
the  zona,  the  true,  acute,  pungent  neuralgic  pain — a  sensation  of  roasting, 
of  burning  heat,  a  symptom  from  which  the  disease  derived  its  old  names 
ignis  sacer,feu  sacre,  and  feu  de  Sain&Antoine.  These  pains  accompany  the 
eruption,  and  I  pointed  out  to  you  in  our  first  patient,  that  they  exactly 


222  ZONA    OR    HERPES    ZOSTER. 

followed  the  course  of  the  articular  and  subacromial  branches  of  the  cervi- 
cal plexus,  and  were  increased  by  pressure  on  these  parts  just  as  pressure 
increases  the  pain  of  ordinary  neuralgia.  There  are  exceptions,  gentlemen, 
to  this  rule,  and  the  case  of  our  second  patient  is  one  of  these  exceptions. 
This  individual  had  no  prodromic  phenomena,  and  none  of  the  usual  neu- 
ralgic pains.  The  pains  which  he  did  complain  of  on  the  third  day  of  the 
eruption  were  situated  beyond,  that  is  to  say  above  and  below  the  eruption 
which  it  circumscribed,  and  were  not  neuralgic,  but  dependent  upon  inflam- 
mation of  the  lymphatic  vessels. 

At  the  beginning  of  March,  1861, 1  was  sent  for  in  haste  to  a  lady  of  sixty- 
three,  who,  with  the  exception  of  some  attacks  of  gout,  had  generally  en- 
joyed good  health.  She  had  excruciating  pain  in  the  left  lumbar  region, 
which  caused  her  to  utter  piercing  cries,  and  although  she  had  no  vomiting, 
her  gouty  constitution  led  me  to  suppose  that  she  was  suffering  from  the 
passing  of  renal  calculi.  Xext  morning,  when  the  pains  were  a  little  sub- 
dued, I  observed  an  herpetic  eruption  occupying  the  surface  over  the  place 
which  had  been  the  seat  of  such  exquisite  suffering,  and  I  was  therebv  im- 
mediately  enlightened  as  to  the  nature  of  the  malady.  In  forty  hours  from 
the  onset  of  the  attack,  the  eruption  was  complete,  extending  from  the  spine 
to  the  linea  alba. 

The  persistence  of  the  neuralgic  pain  after  the  disappearance  of  the  erup- 
tion is,  particularly  in  old  people,  one  of  the  most  remarkable  character- 
istics of  herpes  zoster.  The  pain,  which  always  possesses  the  same  acute 
character,  which  always  produces  the  same  intolerable  sufferings,  often  con- 
tinues, not  merely  for  months,  when  the  marks  of  the  bulla?  are  still  on  the 
skin,  but  may  even  continue  for  several  years.  I  knew  an  old  lady  who 
had  herpes  zoster  when  seventy  years  of  age,  and  who  after  the  lapse 
of  fourteen  years  still  experienced  most  excruciating  pains,  particularly 
during  the  night.  I  have  at  present  under  treatment  a  lady  of  sixty  who 
for  the  last  five  years  has  been  horribly  tormented  by  the  pains  which 
belong  to  this  disease.  There  is  a  curious  circumstance  in  the  case  of  this 
lady,  which  I  have  observed  in  several  other  cases:  the  mere  contact  of 
her  clothes  sometimes  produces  indescribable  suffering,  although  superfi- 
cially there  is  a  sort  of  cutaneous  insensibility,  which  continues  long  after 
the  pains  leave  her. 

I  am  not  quite  sure  that  herpes  zoster  is  not  sometimes  contagious  like 
erysipelas  of  the  face.  On  the  20th  August,  1862,  I  was  sent  for  by  Dr. 
Brossard  to  see  with  him  an  old  Jewish  lady  living  in  Rue  Montmorency. 
She  was  suffering  from  softening  of  the  brain.  Six  weeks  before  our  vi.-it 
she  had  had  very  painful  zona  on  one  side  of  the  chest.  Her  son,  aged 
thirty,  who  waited  on  her,  took  the  disease  at  the  commencement  of  his 
mother's  convah  scenct  , 

Although  the  prognosis  of  this  disease  is  not  unfavorable,  seeing  that  it 
does  not  endanger  life,  it  is  unfavorable  in  one  sense,  for  it  leaves  many 
persons,  old  people  at  least,  martyrs  to  those  intolerable  pains  which  make 
both  patients  and  physicians  de-pair  of  a  cure. 

The  pain,  and  its  persistence  after  the  disappearance  of  the  eruption, 
long  ago  engaged   the  attention  of  observers.     Lorry  in   his  treatise  "  I>< 
morbis  cutaneis,"  and,  aboul  the  same  time,  Geofiroy  and  Borsieri  pointed 
out  and  insisted  upon  this  circumstance.     It  did  aol  escape  the  notice  of 
AJibert,  Haver,    and  man y  others ;  and  more  recently  Dr.  J.  Patrol  has 


*  Raykr:   Traitfe  Theorifjue  et    Pratimx-  <lcs    Maladi.-s  dr  la  P<-au.      Pari.-.:    ls:;5, 
T.  i,  p.  880. 


ZONA    OR    HERPES    ZOSTER.  223 

ably  discussed  the  subject  of  zona  and  of  the  pain,  one  of  its  predominating 
symptoms,  which  pain  he  classes,  as  I  do,  along  with  neuralgic  affections. 

Dr.  Bazin,  my  distinguished  colleague  of  the  St.  Louis  Hospital,  lias 
found  it  necessary  to  distinguish  two  kinds  of  zona — one  arthritic  and  of 
the  nature  of  rheumatism,  and  the  other  herpetic.  Arthritic  zona  may  often 
originate  in  moist  cold,  and  in  changes  of  temperature.  It  occurs  most  fre- 
quently in  adults,  and  almost  never  in  old  people.  The  disease  when  met 
with  in  infancy  is  arthritic  in  the  vast  majority  of  cases.  Herpetic  zona,  on 
the  other  hand,  is  most  common  in  old  age.  It  is  often  brought  on  by  men- 
tal emotions,  and  is  accompanied  by  jaundice  in  a  certain  number  of  cases. 
Its  vesicles  are  pretty  equal  in  size,  and  grouped  in  a  regular  manner.  The 
bulke  which  I  have  described  to  you  are,  on  the  contrary,  must  frequently 
met  with  in  the  arthritic  form.  Herpetic  zona  is  often  preceded,  and  is 
generally  accompanied  by,  neuralgic  pains.  These  pains  sometimes  de- 
crease in  severity  during  the  eruption,  to  return  as  before  with  the  erup- 
tion :  they  are  then  only  a  secondary  symptom.  Dr.  Bazin  says  that  the 
neuralgic  pains  have  been  known  to  continue  for  months  and  years,  to  fol- 
low an  intermittent  course,  and  at  last  to  be  replaced  by  other  neuralgic 
pains  in  situations  different  from  those  which  wrere  in  the  first  instance  the 
seat  of  the  neuralgia.  Finally,  herpetic  zona  generally  has  as  antecedents, 
hemicrania,  dyspepsia,  and  other  herpetic  affections.  In  relation  to  these 
doctrines,  recollect  the  persistence  of  pains  following  zona  in  the  aged  pa- 
tients of  whose  cases  I  have  just  been  speaking. 

To  prevent  the  vesicles  from  being  torn,  the  only  means  which  require  to 
be  employed  during  the  acute  stage  are  powdering  the  affected  parts  with 
starch,  and  during  the  latter  days,  bathing  them.  Some  have  recommended 
cauterization  with  the  nitrate  of  silver,  but  the  expected  beneficial  results 
have  never  been  obtained  from  this  treatment.  For  the  pains  subsequent 
to  the  eruption,  it  is  useful  to  employ  frictions  with  the  mixture  of  bella- 
donna, or  a  solution  of  atropine  or  of  morphia :  subcutaneous  injections 
with  the  same  solutions  may  also  be  advantageously  resorted  to.  Flying 
blisters  and  vapor  douches  have  also  been  employed.  Often,  however,  every 
kind  of  treatment  fails ;  and  I  know  patients,  chiefly  women,  who  have  for 
years  been  tortured  by  these  neuralgic  pains.  Acquaintance  with  the  na- 
ture of  herpetic  zona  led  Dr.  Bazin  to  adopt  a  rational  method  of  treat- 
ment. He  gave  arsenical  preparations  with  success  in  the  obstinate  neu- 
ralgia consecutive  to  zoster ;  and  so  accomplished  cures  in  cases  which  had 
resisted  narcotics,  narcotico-acrids,  and  cauterization.  His  method  of  treat- 
ment ought  to  be  imitated. 


*  J.  Parrot:  Union  Medicate,  ilars,  1856. 


224  SUDORAL    EXANTHEMATA. 


LECTURE  XIV. 

SUDORAL  EXANTHEMATA. 

Multiplicity  of  Forms. —  Cutaneous  and  Mucous  Exanthemata. — Physiological 
Causes. — Antagonism  of  the  Secretions  with  the  Skin  anal  the  Intestinal, 
Respiratory,  and  Urinary  Mucous  Membranes. — Exanthemata  produced 
by  Medicinal  Agents. — Sudoral  Exanthemata  becoming  Purulent  in  Ly- 
ing-in Women  and  others. — Analogies  behveen  Sudoral  Exanthemata,  and 
Exanthemata  Produced  by  a  Viru%,  or  Dependent  on  Diathesis. 

Gentlemen  :  During  the  hot  season,  you  have  often  observed  the  spon- 
taneous development  of  cutaneous  eruptions  in  a  great  many  patients. 
These  eruptions  are  concurrent  with  profuse  perspirations,  and  are  most 
abundant  in  those  parts  of  the  body  which  are  most  constantly  bathed  in 
sweat.  You  have  observed  them  most,  frequently  in  the  children  of  our 
nursery  ward,  that  is  to  say,  in  children  under  two  years  of  age.  The 
greater  frequency  of  these  affections  in  very  young  children  arises  from 
the  manner  in  which  they  are  clad — on  the  swaddles  and  flannel  binders 
in  which  they  are  always  enveloped,  and  by  which  they  are  kept  in  a  state 
of  continual  sweating.  You  have  been  struck  by  the  multiplicity  of  forms 
which  these  efflorescences  assume — you  have  seen  them  as  erythematous, 
searlatiniform,  and  morbilliform  patches,  as  urticaria,  or  as  vesicular,  pus- 
tular, and  papular  eruptions.  You  could  not  fail  to  be  struck  with  the 
rapidity  of  their  development,  and  the  generality  of  their  localization; 
nor  could  )rou  but  be  surprised  at  their  short  duration,  sonic  disappearing 
with  marvellous  ease,  either  spontaneously,  or  under  the  influence  of  very 
mild  treatment.  Finally,  gentlemen,  you  have  had  an  opportunity  of 
watching  their  transformations:  you  have  seen  patches  quickly  succeeded 
by  vesicles,  pustules,  or  papules,  and  have  often  observed  a  combination 
of  these  different  forms  of  eruption  in  the  same  patient. 

Although  the  study  of  these  affections  is  apparently  of  small  importance, 
it  really  possesses  a  much  higher  practical  interest  than  is  generally  sup- 
posed. I  hope  to  he  able  to  prove  this  to  you  when  I  come  to  speak  of 
symptoms  met  with  in  the  great  pulmonary  and  digestive  organs,  and 
which  are  somewhat  analogous  to  the  appearance  of  those  cutaneous  efflor- 
escences upon  the  internal  skin — the  mucous  membrane.  We  will,  there- 
fore, study  the  relations  which  mayexisl  between  the  sudoral  eruption- and 
the  affections  of  the  mucous  membranes  to  which  I  alluded. 

Tin'  number  and  variety  of  sudoral  eruptions  associated  together  in  the 
same  individual,  and  their  transmutations,  even  when  produced  by  the 
same  cause,  is  an  important  fact.     My  friend   Dr.  Duclos,  of  Tours,  in  Ins 

excellent  work  on  sudoral  eruptions  -  published  when  he  was  my  interne  at 
the  Neckcr  Hospital  .  shows  wosl  conclusively,  though  in  opposition  to  the 
views  of  many  dermatologists,  thai  it  is  impossible  to  establish  distinction 
of  species  upon  anatomical  characters  alone,  as  these  characters  differ 
according  to  the  epoch  at  which  they  are  studied,  merge  into  one  another, 
and  do  not  retain  specilic  characteristics  throughout  their  duration. 

To  enable  you  to  understand  the  subject  now  under  discussion,  it  will  be 


SUDORAL    EXANTHEMATA.  225 

indispensable,  as  we  proceed,  thai  T  recall  to  your  recollection  some  points 
connected  with  the  physiology  of  the  skin.  The  cutaneous  system  is  en- 
dowed with  excreting  and  secreting  functions.  It  excretes  a  certain  amount 
of  gaseous  matter — carbonic  acid  gas,  hydrogen,  and  nitrogen:  it  excretes 
liquids  which  it  has  secreted,  the  sweat  containing  solid  matter,  partly  in  a 
state  of  solution,  and  partly  undissolved  :  finally,  by  its  sebaceous  glands, 
it  secretes  and  excretes  fatty  products.  When  these  different  secretions  and 
excretions  take  place  in  a  normal  manner;  when  on  the  one  hand,  in  rela- 
tion to  quantity,  evaporation,  which  is  constantly  going  on,  and  secretion 
balance  one  another ;  when,  on  the  other  hand,  in  relation  to  quality,  no 
alteration  takes  place  in  the  composition  of  the  products,  there  is  no  unusual 
cutaneous  manifestation.  But  if  under  the  influence  of  a  high  tempera- 
ture, or  of  any  other  exciting  cause,  the  excretions  become  more  abundant, 
though  unchanged  in  quality,  symptoms  of  irritation  are  soon  seen.  This 
irritation  is  partly  produced  by  a  precursory  increased  determination  to  the 
cutaneous  organs ;  and  also  partly  by  the  deposition  of  an  abnormal  quan- 
tity of  solid  matter  on  the  surface  of  the  skin.  These  phenomena  of  irri- 
tation account  for  the  exanthemata  of  which  I  am  now  speaking. 

If  an  individual  sweat  profusely,  even  though  he  is  in  the  plenitude  of 
health,  these  special  sudoral  efflorescences  will  be  observed ;  they  will  at 
times  be  very  painful,  and  may  bear  the  aspect  of  measles,  roseola,  urticaria, 
&c.  I  say  the  aspect  only,  and  not  the  real  characters.  However  great  a 
similitude  they  may  bear  to  the  eruption  of  measles,  they  essentially  differ 
from  it  in  respect  of  the  rapidity  of  development,  absence  of  general  pre- 
cursory synrptorns,  shortness  of  duration,  and  absence  of  the  symptoms 
which  belong  to  measles.  There  are  cases,  however,  in  which  the  diagnosis 
presents  some  difficulty,  as  for  example,  when  the  "eruption  supervenes  in 
children  attacked  with  feverish  catarrh,  the  result  of  a  chill.  In  such  a 
case,  it  is  often  impossible  to  establish  the  differential  diagnosis  on  the  first 
day :  it  is  necessary  to  wait,  for  the  surest  way  to  avoid  error  is  to  observe 
attentively  the  progress  and  consecutive  characteristics  of  the  malady. 

So  is  it  also  with  sudoral  scarlatiniform  eruptions.  During  an  epidemic 
of  scarlatina,  which  prevailed  at  Paris,  I  was  called  in  to  a  young  girl 
supposed  to  have  the  current  malady.  After  a  paroxysm  of  fever,  accom- 
panied by  very  profuse  sweating,  induced  by  the  great  heat  of  the  weather 
and  confinement  to  bed,  an  eruption  identical  in  appearance  with  that  of 
scarlatina  came  out  over  a  great  extent  of  the  skin.  The  absence  of  the 
specific  sore  throat,  the  natural  color  of  the  tongue,  and  the  character  of 
the  general  symptoms,  led  me  to  conclude  that  the  exanthem  was  sudoral. 
Next  day,  it  had  disappeared ;  and  none  of  the  symptoms  which  so  often 
complicate  scarlatina  supervened. 

These  facts,  gentlemen,  are  very  sufficient  to  explain  certain  alleged 
second  attacks  of  measles  and  scarlatina,  and  also  the  mildness  of  some 
supposed  anomalous  cases  of  these  eruptive  fevers. 

Excessive  perspiration,  then,  is  in  itself  a  cause  of  sudoral  exanthemata. 
And  precisely  analogous  consequences  result  from  the  excess  of  other  secre- 
tions than  those  of  the  skin.  Does  not  a  too  copious  secretion  of  tears, 
which  are  perfectly  inoffensive  so  long  as  they  are  secreted  in  not  more 
than  sufficient  quantity  to  lubricate  the  surface  of  the  eye,  irritate  the  con- 
junctiva, and  produce  bright  redness  of  the  eyelids  and  even  of  the  cheeks? 

Hence  you  observe,  that  an  exaggeration  of  the  normal  secretion  may 
lead  to  symptoms  of  irritation  and  inflammation  in  the  mucous,  as  well  as 
in  the  cutaneous  membrane.  Many  cases  of  diarrhoea  originate  in  causes 
analogous  to  those  which  produce  sudoral  exanthemata  on  the  skin.  Gen- 
tlemen, you  are  acquainted  with  that  sort  of  reciprocity  which  exists 
vol.  i. — 15 


226  SUDORAL    EXANTHEMATA. 

between  the  cutaneous,  intestinal,  and  urinary  secretions.  You  are  aware, 
that  inasmuch  as  they  all  act  on  the  composition  of  the  blood,  from  which 
they  ought  to  remove  certain  matters  useless  for  the  maintenance  of  life, 
none  of  them  can  undergo  any  change  without  disturbing  the  equilibrium 
which  existed  between  the  secretions  in  relation  to  their  influence  on  the 
blood.  Hence  it  arises,  that  the  diminution  or  augmentation  of  oue  secre- 
tion necessitates  the  augmentation  or  diminution  of  another:  this  is  termed 
the  antagonism  of  the  secretions.  Sometimes  individual  peculiarities,  idio- 
svncrasies,  exist,  in  virtue  of  which  the  elimination  of  products  which  ought 
to  be  excreted  is  accomplished  by  one  emunctory  rather  than  by  another. 
Thus,  in  one  person  the  skin  will  be,  so  to  speak,  more  open  than  in  another, 
and  the  least  increase  of  the  temperature  of  the  atmosphere,  the  slightest 
exertion,  or  a  little  febrile  excitement,  will  cause  profuse  perspiration ; 
while  another  will  nut  be  made  to  perspire  by  the  greatest  heat  of  summer. 
But  in  compensation  for  deficient  elimination  by  the  skin,  the  latter  will 
probably  pass  large  quantities  of  urine,  and  have  frequent  stools ;  for  it  is 
essential  that  elimination  take  place  by  some  channel.  Some  individuals 
are  at  once  seized  with  diarrhoea  on  exposure  to  a  rather  warm  temperature, 
or  on  sleeping  with  an  excess  of  bedclothes.  They  call  in  their  physician 
to  set  them  to  rights,  and  he  calls  the  attack  acute  enteritis:  he  is  right, 
for  the  affection  really  is  enteritis,  just  as  the  cutaneous  exanthem  caused 
by  excess  of  heat  is  an  inflammation  of  the  skin.  Both  are  the  results 
of  secretion,  and  consequently  of  increased  determination  to  the  parts;  but 
the  fact  is  not  sufficiently  recognized  that  both  are  phenomena  of  the  same 
class.  "When,  therefore,  with  a  view  to  check  excessive  perspiration,  we 
recommend  the  patient  to  diminish  his  covering,  we  augment  in  place  of 
diminishing  the  intestinal  flow.  This  effect  is  equally  brought  about, 
whether  wTe  give  medicines  which  increase  the  determination  to  the  intes- 
tine, or  supplement  the  precautions  against  cold  already  taken  by  the 
patient. 

There  is  also  an  antagonism  between  the  secretions  of  the  skin  and  those 
of  the  pulmonary  mucous  membrane;  for  as  you  know,  gentlemen,  abrupt 
suppression  of  the  normal  cutaneous  exhalation  caused  by  a  chill  excites 
a  mucous  flux  from  the  lungs,  just  in  the  same  way  that  it  excites  a  diar- 
rhoea. These  considerations  will  enable  you  to  understand  how  it  is  that 
certain  bronchial  catarrhs  are  of  the  same  nature  as  the  cutaneous  and  in- 
testinal affections  of  which  I  have  been  speaking,  whether  the  determin- 
ation to  the  mucous  membrane  of  the  respiratory  passages  be  primary 
from  individual  predisposition,  or  whether  that  determination,  after  man- 
ifesting itself  in  the  skin,  and  ceasing  there,  from  some  particular  influence, 
had  declared  itself  in  the  pulmonary  organs. 

Certain  therapeutic  indications  obviously  arise  out  of  the  considers 
now  stated.  The  production  of  diaphoresis  by  the  action  of  appropriate 
drinks  on  the  interior  i>  sometimes  a  successful  means  of  treating  bronchial 
and  intestinal  catarrh,  and  of  removing  alarming  and  unexplainable  symp- 
toms. But  even  when  perspiration  is  excited  for  a  therapeutic  purpose,  we 
may  meet  with  sudoral  eruptions.  From  among  the  cases  which  1  could 
adduce  in  support  of  this  proposition,  I  select  the  following  communicated 
to  me  by  1  >r.  Dumontpallier. 

A  child,  of  four  and  a  half  years  old,  of  a  nervous  temperament,  bul  who 
generally  enjoyed  good  health, was  seized  during  the  month  of  August, with- 
out any  appreciable  cause,  with  irregular  intermittent  diarrhoea.  The  child 
did  not  lose  his  appetite;  but,  nevertheless,  he  grew  pale,  and  went  on  losing 
strength, when,  two  days  after  a  fit  of  greal  excitement,  the  diarrhoea  became 
so  severe,  that  within  twenty  minutes  he  had  several  stools:  they  were  first 


SUDORAL    EXANTHEMATA.  227 

yellowish,  then  serous,  and  at  last  eholeriform.  Neither  vomiting  nor  cramps 
supenrened,  but  the  patient  fell  into  a  state  of  profound  prostration,  and,  ;it 
the  same  time,  the  extremities  became  cold.  The  eyes  were  sunken,  and 
the  nose  pinched:  the  pulse  was  small,  thready,  and  very  rapid:  death  was 
supposed  to  be  impending.  Proceeding  to  the  most  urgent  indication,  which 
was  to  restore  the  threatened  powers  of  life,  the  child  was  made  to  take  a 
dessertspoonful  of  brandy  mixed  with  an  equal  quantity  of  infusion  of  tea. 
The  little  patient  was  restless  for  a  minute  or  two,  and  then  fell  into  a  calm 
sleep.  During  this  sleep  his  face  was  bathed  with  a  profuse  warm  sweat, 
and  the  pulse  rose.  During  the  night  a  little  restlessness  was  observed,  and 
the  child  directed  his  hands  to  various  parts  of  the  body,  as  if  for  the  pur- 
pose of  scratching  himself.  About  six  o'clock  in  the  morning  his  mother 
perceived  that  he  was  red  from  head  to  foot,  and  the  physician,  who  had 
not  left  him,  found  that  the  whole  surface  of  the  skin  was  covered  with  a 
sheet  of  strawberry  redness,  which  was  more  conspicuous  on  the  hands  and 
feet  than  on  any  other  situation.  Rejecting  the  idea  of  an  eruptive  fever, 
of  which  the  child  had  had  no  precursory  symptoms,  the  diagnosis  was  re- 
served. The  pulse  was  full,  and  less  rapid.  His  sleep  was  tranquil,  inter- 
rupted only  by  the  itching.  From  the  time  at  which  the  cutaneous  reaction 
began,  he  had  had  no  more  stools.  By  noon  the  danger  was  averted,  and 
the  scarlatiniform  eruption  had  become  pale,  as  well  as  less  general.  In  its 
place,  on  different  parts  of  the  body,  there  were  patches  of  urticaria,  two  of 
which,  however,  only  remained  till  evening.  The  natural  color  of  the  skin 
was  restored,  and  the  diarrhoea  was  at  an  end,  for  he  had  not  had  a  stool 
for  forty-eight  hours.  The  intestinal  functions,  however,  remained  somewhat 
sluggish  for  a  time,  the  child  being  only  able  to  digest  meat  nearly  raw. 
But  in  the  course  of  a  few  days,  under  the  influence  of  tonics  and  bitters, 
health  wras  completely  re-established. 

It  happens  sometimes,  though  very  seldom,  that  the  symptoms  to  which 
I  have  been  directing  your  attention  show  themselves  simultaneously  in  the 
skin  and  the  mucous  membranes:  thus,  in  some  individuals,  violent  exer- 
cise always  brings  on  both  sweating  and  purging.  All  the  emunctories 
seem  in  such  persons  to  be  scarcely  adequate  for  the  depuration  of  the  blood 
from  its  superfluity  of  excrementitious  matter.  Here  we  see  occurring 
physiologically  the  same  thing  which  we  have  already  studied  as  a  patho- 
logical occurrence  in  measles.  I  pointed  out  to  jou.  that  the  exanthematous 
determination  takes  place  in  measles  simultaneously,  and  from  the  begin- 
ning of  the  attack,  in  the  skin,  intestinal  canal,  and  air-passages,  as  is  mani- 
fested by  the  cutaneous  eruption,  the  diarrhoea,  and  the  bronchial  catarrh. 

Hitherto,  gentlemen,  I  have  spoken  only  of  the  effects  produced  by  a 
change  in  the  quantity  of  the  elimination :  I  have  now  to  consider  the  con- 
sequences of  a  change  in  its  quality,  of  the  formation  of  new  bodies,  various 
in  their  nature  and  origin,  as  manifested  by  different  affections  of  the  cuta- 
neous and  mucous  organs. 

Although  modifications  in  the  quality  of  the  matter  eliminated  are  not 
always  physically  and  chemically  appreciable,  they  are,  even  when  not  thus 
appreciable,  indisputable,  as  can  be  analogically  shown.  In  a  great  number 
of  cases  chemical  analysis  demonstrates  in  the  sweat  substances  which  have 
been  absorbed  internally:  sometimes  their  presence  is  made  known  by 
physical  signs,  as  is  the  case  when  the  sweat  exhales  the  special  odor  of 
copaiva  in  persons  who  have  taken  that  drug.  Now,  as  in  certain  cases, 
these  alterations  manifestly  coincide  with  the  existence  of  cutaneous  affec- 
tions, are  we  not  entitled  to  conclude  that  they  also  occur  in  the  other  cases 
in  which  these  cutaneous  affections  occur,  although  we  cannot  physically 
or  chemically  prove  that  alterations  on  which  they  depend  have  taken  place 


228  SUDORAL    EXANTHEMATA. 

in  the  sweat?  In  the  absence  of  physical  characters,  and  chemical  tests, 
the  point  is  established  by  what  I  may  call  pathological  tests. 

A  person,  for  example,  lives  on  exciting  diet,  arid  under  its  influence, 
different  exauthematous  affections  supervene,  such  as  urticarious  eruptions, 
which  appear  on  some  individuals  after  eating  some  kinds  of  shell-fish,  mus- 
sels, for  instance,  and  crabs;  in  others,  the  same  effect  is  produced  by  eating 
pork;  and  in  others,  again,  by  taking  a  variety  of  articles  of  food,  the  na- 
ture of  which  it  would  be  difficult  to  specify.  In  point  of  fact,  it  is  impos- 
sible to  state  in  general  terms,  the  conditions  under  which  these  eruptions 
take  place,  idiosyncrasy  having  beyond  doubt  the  largest  share  in  their 
production.  Although  we  cannot  in  these  cases  demonstrate  physically  or 
chemically  the  modification  which  the  sweat  has  undergone,  it  is  evident 
that  a  modification  has  taken  place,  from  the  fact,  that  the  affections  of  the 
skin  determined  thereby  take  place,  although  there  is  not  the  slightest  in- 
crease in  the  quantity  of  the  perspiration. 

This  fact  will  be  made  much  more  palpable  by  what  I  am  now  going  to 
say  regarding  exanthemata  produced  by  certain  therapeutic  agents;  for  in 
these  cases  no  one  will  deny  that  an  alteration  has  taken  place  in  the  sweat, 
although  in  numerous  instances  that  alteration  is  appreciable  only  in  its 
effects. 

A  patient,  for  example,  takes  opium  to  the  extent  of  producing  stupefac- 
tion. We  know  that  under  such  conditions  opium  generally  produces  pro- 
fuse sweating;  and  we  also  know  that  it  is  the  most  powerful  and  most 
energetic  of  all  sudorifics.  When,  carried  by  the  torrent  of  the  circulation, 
it  presents  itself  to  the  different  emunctories,  and  particularly  to  the  cuta- 
neous emunctor3r,  which  is  specially  charged  with  its  elimination,  it  there 
causes  an  irritation,  and  an  eruption  is  observed  on  the  skin,  which  may 
consist  of  red  erythematous  patches,  pseudo-morbillous  spots,  vesicles,  or 
true  papules,  if  the  action  of  the  medicine  have  been  long  continued.  Here 
then  is  a  substance  which  imparts  a  peculiar  quality  to  the  excreted  sweat, 
and  determines  a  state  of  inflammation  or  irritation  of  the  skin,  a  transient 
state,  it  is  true,  but  nevertheless  a  state  very  different  from  that  produced 
by  a  mere  superabundance  of  natural  sweat.  This  difference  is  not  shown 
in  the  form,  but  in  the  intensity  of  the  exanthem.  So  much  is  this  par- 
ticular inflammatory  state  dependent  upon  the  special  modification  which 
the  sweat  has  undergone  in  its  composition,  that  in  some  cases  we  see  the 
opium-exanthemata  supervene  when  there  has  been  no  increased  perspira- 
tion. 

Belladonna  given  in  certain  doses  also  produces  eruptions.  In  the  case 
of  this  drug,  the  exanthem  is  generally  scarlatiniform,  as  it  also  is  when 
produced  by  datura  stramonium,  mandragora,  and  most  of  the  poisonous 
solanese. 

The  effects  which  turpentine,  and  still  more  the  effects  which  copaiba 
produces  on  the  skin,  are  known  to  everybody.  After  continued  use,  and 
sometimes  from  the  first  day  of  taking  them,  the  employment  of  these  medi- 
cines is  followed  by  sweats,  the  odor  of  which  distinctly  proclaims  the  agent 
which  has  produced  them.  Papular  exanthemata  result  from  their  employ- 
ment, and    when    their   use    is  long   continued,  vesicular   eruptions   appear. 

Similar  results  sometimes  follow  the  use  of  cubebs  pepper.  The  eruptions 
are  exceedingly  fugitive,  and  do  ool  in  general  continue  longer  than  the 
period  during  which  the  perspiration  retains  the  characteristic  odor  im- 
parted to  them  by  the  drugs,     'these  medicinal  exanthemata  have  been, 

and  arc  sometimes  still,  confounded  with  Ryphilitic  roseola.  From  a  scien- 
tific point  of  view,  this  is  a  deplorable  mistake;  and  from  a  practical  point 
of  view,  the  error  is  even  more  deplorable,  because  it  leads  to  the  institu- 


SUDORAL    EXANTHEMATA.  229 

tion  of  antisyphilitic  treatment,  when  our  therapeutic  measures  ought  to 
be  limited  to  those  required  in  simple  gonorrhoea,  devoid  of  all  specific 

character. 

This  remark  applies  to  the  exanthemata  which  appear  after  the  admin- 
istration of  iodide  of  potassium — an. eruption  which  assumes  an  eczematous 
and  then  a  pustular  form,  generally  consisting  of  pustules  of  acne  situated 
chiefly  on  the  shoulders  and  face.  There  are  persons,  as  you  know,  who 
cannot  take  even  the  most  moderate  doses  of  this  medicine  without  having 
these  eruptions,  and  suffering  from  pains  in  the  throat,  coryza,  and  intol- 
erable laehrymation.  When  these  pustules  occur  in  the  course  of  anti- 
syphilitic  treatment,  they  may  be  supposed  to  be  of  a  syphilitic  character, 
unless  they  are  very  carefully  examined.  A  mistake  of  this  kind  at  the 
beginning  of  the  treatment  would  matter  little,  but  at  a  later  period,  it 
might  be  serious,  by  leading  to  the  prolonged  use  of  a  medicine  which 
ought  to  be  discontinued. 

The  resemblance  which  I  maintain  exists  between  sudoral  cutaneous  ex- 
anthemata and  some  affections  of  the  mucous  membranes  is  peculiarly  well 
marked  in  the  class  of  cases  I  am  now  speaking  of.  The  coryza,  lachry- 
mation, sore  throat,  and  pustular  affections  produced  by  the  iodide  of  po- 
tassium are  all  symptoms  of  the  same  class.  Being  all  essentially  depen- 
dent upon  the  action  of  this  medicine,  they  all  rapidly  disappear  upon  its 
use  being  discontinued,  and  they  all  equally  resist  every  kind  of  topical 
treatment  so  long  as  it  is  being  taken. 

These  remarks  are  applicable  to  the  eruptions  produced  by  copaiva. 
When  they  supervene,  there  is  an  action  on  the  skin  of  a  nature  similar  to 
that  which  the  medicine  usually  excites  in  the  mucous  membranes.  Co- 
paiva, turpentine,  and  all  the  oleo-resinous  bodies,  cause  a  congestive  deter- 
mination to  the  mucous  membranes,  which  explains  their  beneficial  in- 
fluence in  gonorrhoea,  urethritis  and  bronchial  catarrh:  the  balsams  act  by 
inducing  a  substitution,  by  exciting  a  therapeutic  congestion  which  modi- 
fies the  morbid  or  inflammatory  state  which  we  wish  to  subdue.  When  this 
fluxionary  condition  proceeds  too  far  in  the  intestinal  canal,  the  result  is  a 
kind  of  diarrhoea  which  may  be  regarded  as  analogous  to  sweating. 

Many  other  substances  produce  similar  effects  on  the  skin  and  mucous 
membranes.  The  substances  I  have  mentioned  are  those  which  are  most 
employed  in  medical  practice,  and  they  are  also  those  which  most  frequently 
produce  sudoral  exanthemata.  I  must  not,  however,  omit  to  mention  a  con- 
cluding illustration.  A  patient,  for  example,  takes  mercury  in  large  doses, 
and  so  brings  on  violent  inflammation  of  the  mouth  and  salivation.  These 
symptoms  become  so  violent  that  fever  is  excited,  and  with  it  profuse  sweat- 
ing sets  in.  The  blood,  changed  in  its  character  by  the  mercury,  upon  pre- 
senting itself  to  the  cutaneous  emunctories,  there  produces  mercurial  eczema, 
that  serious  vesicular  affection  which  Alley  has  described  under  the  name 
of  "hydrargyria." 

Sudoral  exanthemata  are  observed  during  the  course  of  a  great  many  dis- 
eases. The  sweat,  altered  in  its  composition,  acts  as  an  irritant,  and  the 
eruptions  of  which  we  have  been  speaking  supervene,  whether  or  not  there 
be  an  increase  in  the  quantity  of  perspiration. 

A  patient  has  a  large  suppurating  sore  in  some  part  of  the  body.  Ab- 
sorption of  pus  takes  place — not  purulent  absorption,  nor  absorption  of  pu- 
trid matter — but  that  kind  of  absorption  always  going  on  of  the  fluid  part 
of  pus,  and  of  the  materials  dissolved  in  it.  This  exchange  of  materials 
between  pus  and  the  economy  does  not  seem  to  exercise  any  injurious  in- 
fluence upon  the  system,  provided  the  pus  has  not  undergone  any  altera- 
tion.    However,  in  persons  with  purulent  collections,  we  sometimes  observe 


230  SUDORAL    EXANTHEMATA. 

a  slight  febrile  excitement  recurring  at  intervals,  and  followed  by  a  critical 
sweat,  as  if  the  economy  was  getting  rid  of  some  of  the  matter  imbibed  from 
the  abscess.  It  is  under  these  circumstances  that  we  see  exanthematous 
affections,  very  various  in  form,  but  chiefly  vesicular,  and  when  the  perspi- 
ration is  profuse  and  long-continued,  the  eruption  consists  of  pemphigoid 
bullae.  The  squamous  form  is  also  sometimes  observed.  Indeed,  it  is  un- 
usual for  a  person  to  be  laid  up  with  protracted  suppuration,  without  the 
skin  becoming  the  seat  of  more  or  less  extensive  furfuraceous  desquamation. 

Thei'e  are  some  people,  whose  blood,  to  use  the  common  expression,  is 
poisonous  [venimeux].  Under  the  dominion  of  a  true  suppurative  diathesis, 
the  smallest  wound,  the  slightest  excoriation  becomes  the  starting-point  of 
interminable  suppuration  in  some  people,  an  ophthalmia  or  coryza  resisting 
every  kind  of  treatment.  In  patients  of  this  diathesis — chiefly  children — 
you  will  often  see  eruptions,  vesicular  and  pustular  generally,  supervene 
even  after  perspirations  which  are  not  very  profuse. 

The  miliary  fever  of  lying-in  women  is  nothing  more  than  a  sudoral  exan- 
thern.  The  solution  of  continuity  in  the  surface  of  the  uterus  caused  by  the 
detachment  of  the  placenta  necessarily  suppurates  during  the  reparative 
process,  and  thus  places  the  woman  in  the  condition  of  a  wounded  person, 
in  point  of  fact,  in  the  condition  of  the  person  in  whom  we  were  supposing 
that  there  was  absorption  of  the  constituents  of  pus.  Both  in  one  and 
the  other,  when  profuse  perspiration  is  induced,  when  that  deplorable 
custom  is  adopted  of  covering  the  patient  with  an  excess  of  bedclothes,  we 
see  erythematous  patches  and  measly  spots  in  addition  to  the  vesicular 
eruption  which  constitutes  the  miliary  affection. 

Beware,  gentlemen,  of  supposing  that  these  cutaneous  eruptions  are 
never  serious.  As  I  have  just  mentioned,  Alley  has  shown  that  a  general 
eczematous  eruption  may  result  from  the  excessive  absorption  of  mercury, 
causing  a  terrible  fever,  and  nervous  symptoms  which  are  often  followed  by 
speedy  death. 

A  similar  result  too  frequently  occurs  in  the  miliary  fever  of  lying-in 
women.  Miliary  fever  is  not,  as  I  have  already  remarked,  a  specific  affec- 
tion: it  is  merely  a  sudoral  exanthem.  It  supervenes,  when  the  woman 
has  been  shut  up  in  a  hot  room,  smothered  with  bedding,  and  neglected  in 
those  matters  of  cleanliness,  more  necessary  to  her  after  parturition  than 
when  in  health.  The  perspiration  secreted  in  unusual  quantity,  and  im- 
pregnated with  morbid  elements  imbibed  from  the  surface  of  the  intestine 
and  from  the  manimie,  produces  an  irritation  of  the  skin  which  assumes 
serious  proportions. 

Very  recently  I  was  sent  lor  by  my  honorable  friend  Dr.  Patouillet  to  see 
a  young  recently  confined  lady.  Her  nurse  was  an  old  woman  imbued  with 
the  prejudices  of  last  century.  The  lady  had  been  kept  without  change  of 
linen,  soaking  in  the  lochia!  discharge,  and  smothered  with  a  mass  of 
blankets  for  the  alleged  purpose  of  promoting  the  secretion  of  milk.  From 
the  sixth  day  of  her  illness,  she  had  a  searlatinil'onn  eruption;  and  four 
davs  later,  she  had,  over  the  whole  hody,  n  confluenl  and  frightfully  violent 

eczema.     Fever  kindled  in  her  countenance,  delirium  supervened ;  and  this 

poor  young  lady  died  a  victim  to  prejudices  equally  disgusting  and  dan- 
gerous. 

These  eruptions  are.  most  frequently  met  with  in  the  disease  called  puer- 
peral liver,  and  in  purulent  infection,  to  one  of  I  he  forms  of  which  | rperal 

fever  has  a  great  resemblance.  Diarrhoea  and  bronchial  catarrh,  so  com- 
mon in  puerperal  fever  and  purulent  infection,  are  produced  by  the  same 
mechanism  as  sudoral  exanthemata,  that  is  to  say,  by  the  irritation  carried 
to  the  external  and  internal  tegumentary  Burface  through  the  medium  of 


SUDORAL    EXANTHEMATA.  231 

the  serosity  of  the  pus  in  process  of  elimination  by  the  natural  emunctories. 
These  symptoms  Bupervene  when,  from  the  suspension  of  the  cutaneous 
secretion,  emunction  has  to  be  accomplished  solely  by  the  mucous  mem- 
branes, or  when  the  congestion  arises  simultaneously  in  the  skin,  respiratory 
passages,  and  intestinal  canal. 

The  miliary  eruption  of  dothinenteria  has  perhaps  no  other  origin  than 
sweat  altered  in  composition  by  the  absorption  of  putrid  elements. 

Let  me  remind  you  that  vaccinal  eruptions  [eruptions  vaccinates]  are  like- 
wise sudoral  exanthemata.  I  refer  to  eruptions  essentially  fugitive  and 
very  varied  in  form,  and  not  to  the  eruptions  of  accidental  vaccinal  pus- 
tules to  which  I  formerly  directed  your  attention. 

Sudoral  exanthemata  are  also  met  with  in  small-pox  during  the  period 
of  desiccation.  They  generally  assume  the  pustular  form,  but  it  is  impossi- 
ble to  inoculate  small-pox  by  using  the  pus  contained  in  these  pustules. 
Perhaps  these  exanthemata  consecutive  to  small-pox  are  due  to  the  presence 
of  the  elements  of  pus  in  the  sweat;  for  variolous  patients  may  be  compared 
to  persons  under  the  dominion  of  the  great  suppurations  to  which  I  formerly 
referred. 

The  intensity  of  the  fever,  the  smartness  of  the  reaction  in  the  skin,  and 
the  alteration  and  modification  of  its  secretions  explain  the  production  of 
the  miliary  eruption  in  scarlatina. 

T1  j  mechanism  by  which  the  eruptive  fevers  accomplish  their  manifesta- 
tions on  the  skin  and  mucous  membranes  has  the  greatest  possible  similarity 
to  that  which  is  in  operation  in  the  sudoral  exanthemata.  In  both  cases, 
there  is  a  morbific  matter  in  contact  with  the  blood,  which  matter  journey- 
ing with  the  blood  presents  itself  to  the  different  emunctories,  and  produces 
an  irritation  in  them,  the  result  being  an  eruption.  The  pathological  lesion 
is  equally  produced  by  morbific  principles  traversing  the  emunctories, 
whether  the  agent  be  medicinal,  such  as  opium,  belladonna,  copaiva,  and 
mercury,  or  pathological,  such  as  the  elements  of  pus,  the  putrid  elements 
of  dothinenteria,  the  virus  of  small-pox,  measles,  or  scarlatina.  But  in  the 
eruptive  fevers,  the  manifestations  are  always  uniform,  spots  and  patches 
being  always  produced  by  the  same  cause,  whereas  in  the  sudoral  exanthem- 
ata very  varied  effects  proceed  from  the  same  cause.  In  the  latter,  they 
are  transient,  like  the  cause  which  produces  them :  in  the  former,  they  are 
more  persistent,  for  it  is  essential  that,  in  accordance  with  a  law  almost 
invariable,  the  elimination  of  the  morbid  matter  should  follow  a  natural 
course. 

The  facts  are  similar  in  respect  of  chronic  exanthematous  affections  re- 
lated to  acquired  diatheses  such  as  the  syphilitic,  or  to  original  diatheses 
such  as  the  herpetic  and  the  scrofulous.  But  just  as  in  acute  diseases,  the 
exanthematous  manifestations  take  place  in  hours,  days,  or  at  most  in 
w7eeks,  so  in  diathetic  diseases  they  are  accomplished  more  slowly,  and  con- 
tinue for  a  longer  time.  In  syphilis,  the  cutaneous  eruptions  appear  a 
month,  two  months,  or  even  a  year  and  more  after  the  system  has  been 
infected.  In  the  herpetic  and  scrofulous  diatheses,  they  may  even  not 
appear  till  after  a  lapse  of  five,  ten,  twenty,  or  forty  years.  So  true  is  this 
that  sometimes  it  may  not  be  till  a  late  period  of  life  that  a  person  descended 
from  herpetic  or  scrofulous  parents,  and  bearing  a  constitutional  resem- 
blance to  their  organism,  as  well  as  to  their  external  forms,  shows  signs  of 
a  diathesis  till  then  silent. 

The  manifestations,  according  to  the  diathesis,  are  always  of  the  same 
class,  whether  the  action  of  the  morbific  principle  be  on  the  skin  or  on  the 
mucous  membrane.     In  respect  of  syphilis,  all  admit  that  this  is  the  case: 


232  SUDORAL    EXANTHEMATA. 

in  the  attacks  of  coryza,  sore  throat,  and  laryngitis  which  so  frequently 
supervene  in  the  second  period  of  that  disease,  no  one  fails  to  recognize  the 
influence  of  the  venereal  virus.  It  is  visible  in  morbid  vascularity,  erup- 
tions, and  ulcerations :  there  are  other  cases  in  which  if  these  lesious  exist, 
they  escape  our  means  of  investigation  in  the  living  subject,  but  the  effects 
which  we  do  see  are  not,  on  that  account,  the  less  dependent  on  the  same 
cause.  For  example,  diarrhoea,  as  I  will  tell  you  when  I  come  to  speak  of 
certain  anomalous  effects  of  constitutional  syphilis,  sometimes  supervenes  as 
one  of  the  earliest  symptoms  of  the  disease,  being  connected  with  the  intes- 
tinal determination  produced  by  the  action  of  the  morbid  poison  on  the 
mucous  membrane  of  the  digestive  canal. 

In  respect  of  the  herpetic  diathesis,  do  we  not  every  day  see  its  manifes- 
tations in  the  mucous  membranes  ?  And,  in  relation  to  the  transition  of 
the  affection  from  the  external  to  the  internal  integument,  do  we  not  con- 
stantly see  persons  under  the  influence  of  the  herpetic  diathesis  take  in  suc- 
cession eczema  of  the  upper  lip  or  inferior  orifice  of  the  nasal  fossse,  or 
chronic  coryza,  leading  sooner  or  later  to  ozsena?  Here,  the  affection  of  the 
Schneiderian  membrane  is  merely  a  propagation  of  the  eczema,  by  con- 
tinuity of  tissue,  from  the  external  to  the  internal  integument.  In  other 
individuals,  granular  sore  throat  will  supervene,  an  affection  of  the  nature 
and  possessed  of  all  the  inveteracy  of  herpes,  and  which,  like  an  herpetic 
affection,  will  give  way  when  the  diathesis  manifests  itself  elsewhere  in  the 
economy.  In  other  cases,  the  result  will  be  deafness,  caused  by  the  exten- 
sion of  the  lesion  to  the  Eustachian  tube.  In  coryza  and  sore  throat  you 
can  follow,  so  to  speak,  step  by  step  the  march  of  the  malady:  you  can  see 
it  approach  nearer  and  nearer  to  the  deepseated  parts :  you  can,  for  in- 
stance, see  an  eczema  of  the  labia  majora  invade  the  vagina,  attack  the 
uterus,  and  so  become  the  cause  of  obstinate  leucorrhoeal  discharges.  Her- 
petic affections  of  the  mucous  membranes  are  sometimes,  also,  the  first  mani- 
festations of  the  diathesis.  At  other  times,  they  are  consecutive  to  the 
disappearance,  spontaneous  or  from  treatment,  of  other  affections  of  a  sim- 
ilar kind  occupying  a  larger  or  smaller  surface  of  the  skin.  Manifestations 
of  the  herpetic  diathesis  are  not  confined  to  the  mucous  surfaces  of  which 
I  have  spoken,  but  are  also  met  with  in  those  of  deeper  seat,  such  as  the 
bronchial  tubes  aud  digestive  canal.  How  often  do  we  see  a  herpetic  sub- 
ject, when  suddenly  cured  of  a  cutaneous  affection,  become  a  sufferer  in 
the  organs  of  respiration  or  digestion — a  sufferer  from  bronchitis,  dyspepsia, 
or  intractable  diarrhoea!  Examples  of  this  throwing  inwards  of  herpes 
[repercussion  des  dartres']  as  our  predecessors  called  it,  cannot  seriously  be 
called  in  question.  Let  me  quote  a  case  in  point  published  by  my  colleague, 
Dr.  Noel  Gueneau  do  Mussy: 

"Some  time  ago,"  says  my  scientific  friend,  "I  attended  a  lady  of  about 
sixty  years  of  age,  who  for  a  long  time  had  had  chronic  eczema  of  the  right 
temple  and  cheek:  she  stated  that  the  malady  was  extending,  and  she 
wished  at  all  hazards  to  1>"  freed  from  it.  For  sonic  time,  I  opposed  her 
entreaties;  but  at  last,  yielding,  I  prescribed  depurative  drinks,  mild  pur- 
gatives once  a  fortnight,  and  the  application  of  a  mercurial  pomade  i"  the 
seat  of  the  alieelion.  The  eczema  disappeared:  but  this  was  followed  by 
an  obstinate  diarrhoea  setting  in,  which  did  not  yield  till  after  two  or  three 
months  of  treatment,  and  then  the  eczema  resinned  possession  of  the  parts 

which  it  had  so  long  occupied." 

"It  is  difficult,"  adds  Dr.  (iiienean  do  Mnssy,  "not  to  admit  that  there 
was  something  else  here  than  the  mere  efFecl  01  derivation,  and  difficult  to 

avoid  explaining  by  the  diathetic  condition,  the  intestinal  catarrh  which 


SUDORAL    EXANTHEMATA.  233 

continued  with  such  obstinacy  in  spite  of  a  regulated  diet  and  rational 
treatment."* 

Do  yon  not  find,  gentlemen,  that  there  is  a  great  resemblance  between 
Dr.  Gueneau  de  Mussy's  case  and  that  which  takes  place  in  sudoral  diar- 
rhoea? Do  you  not  find  in  it  an  example  of  that  law  of  compensation  and 
supplement,  which  I  pointed  out  as  existing  for  the  two  great  emunctories, 
the  skin  and  the  mucous  membrane  of  the  digestive  organs?  Other  cases 
might  be  mentioned,  in  which  dyspepsia,  bronchial  catarrh,  and  inflamma- 
tion of  the  cervical  glands  have  followed  herpetic  affections  of  the  skin.  I 
have  likewise  seen  sudoral  symptoms  occur  simultaneously  in  the  skin  and 
mucous  membranes:  and  the  diathetic  manifestations  of  syphilis,  herpes,  and 
scrofula  may  occur  simultaneously  in  both  integuments. 

The  possibility  of  these  diathetic  symptoms  affecting  internal  organs  is  a 
fact  of  the  highest  importance,  as  it  leads  to  therapeutic  measures  of  daily 
application.  Sulphurous  mineral  waters  are  remarkably  efficacious  in  the 
treatment  of  certain  bronchial,  intestinal,  uterine,  and  vesical  catarrhs,  de- 
pending upon  the  herpetic  diathesis,  because  they  exercise  a  remedial  influ- 
ence upon  it.  You  are  going,  perhaps,  to  send  your  catarrhal  patients  to 
Cauterots,  Bagneres-de-Luchon,  Aix,  and  Enghien;  but  before  doing  so, 
ascertain  whether  they  ever. had  herpetic  manifestations  in  their  youth,  or 
at  any  time  in  the  course  of  their  lives.  You  will  then  know  what  you  are 
about. 

Gentlemen,  thoroughly  realize  the  fact,  that  some  catarrrhal  affections 
are  simply  exanthemata  of  the  mucous  membranes.  A  chronic  bronchitis, 
for  example,  has  come  on  under  the  influence  of  a  chill,  but  the  chill  was 
only  the  exciting  cause  which  determined  the  direction  of  a  fluxion,  in 
virtue  of  which  the  herpetic  principle  was  carried  to  the  mucous  membrane 
of  the  resph'atory  passages,  just  as  it  is  carried  in  other  cases  to  the  vagina 
and  uterus,  or,  still  more  frequently,  to  the  skin. 

All  the  considerations  into  which  I  have  now  entered  lead  to  practical 
conclusions.  It  is  important  to  know  whether  cutaneous  exanthemata  pro- 
ceed from  mere  excess,  or  from  vitiation  of  the  natural  secretion  of  the  skin. 
How  often  has  the  most  simple  hygienic  advice  given  in  virtue  of  such 
knowledge  enabled  a  patient  to  get  rid  of  an  affection  which  must  other- 
wise have  become  a  very  obstinate  disease.  You  may  thus  have  it  in  your 
power  to  snatch  from  death  patients  suffering  from  the  general  eczema  so 
formidable  in  hydrargyria,  or  you  may  save  lying-in  women  by  having  the 
courage  to  remove  their  superfluous  bedclothes,  to  have  them  washed 
several  times  a  day,  or  even  plunged  in  a  bath.  Under  the  influence  of 
these  simple  means,  they  will  almost  immediately  lose  their  sleeplessness, 
burning  heat  of  skin,  and  unbearable  itching.  I  cannot  sufficiently  impress 
on  you  the  magnitude  of  the  services  you  may  be  able  to  render  to  your 
patients,  if  you  thoroughly  realize  the  importance  and  frecpuency  of  sudoral 
exanthemata ;  and  if  with  a  view  to  cure  them,  you  have  the  courage  to 
fight  against  the  deplorable  prejudices  propagated  by  physicians  of  a  former 
century,  and  which  it  is  your  duty  to  endeavor  to  eradicate. 


*  Gcjeneatj  de  Mussy  :  Traite  de  l'Angine  Glanduleuse. 


234  DOTHINENTERIA. 


LECTURE  XV. 

DOTHINENTERIA,  OR  TYPHOID  FEVER. 

Specific  Lesion. — Furuncular  Eruption  of  the  Intestine. — Intestinal 
Perforation. — Peritonitis  without  Perforation. 

Gentlemen  :  A  young  man  of  eighteen,  who  had  lived  in  Paris  only 
for  the  two  previous  years,  was  admitted  to  St.  Agnes's  Ward  on  the  19th 
February,  1859.  He  had  been  ill  for  eight  days.  His  illness  commenced 
with  debility,  lassitude,  pains  in  the  limbs,  repeated  rigors,  headache,  and 
distressing  insomnia.  At  first,  he  struggled  against  these  symptoms,  but 
at  the  end  of  four  days,  he  was  obliged  to  keep  his  bed.  I  found  him  lying 
on  his  back,  and  feverish,  with  a  rapid  pulse,  and  dry  hot  skin.  The 
tongue  was  dry,  red  at  the  point,  and  covered  with  a  slight  whitish  fur. 
There  was  gurgling  in  the  right  iliac  fossa,  but  no  abdominal  tympanites. 

On  the  22d  February,  there  was  tympanites,  and  diarrhoea.  The  fever 
was  great,  and  accompanied  by  delirium.  Next  day,  the  abdomen  was 
covered  with  an  eruption  of  rosy  lenticular  spots.  On  the  26th  and  28th, 
there  was  an  increase  of  severity  in  the  symptoms.  On  the  last-mentioned 
day,  the  tongue  and  teeth  were  fuliginous,  the  diarrhoea  continued,  and  the 
stools  were  passed  involuntarily.  As  there  was  retention  of  urine,  it  became 
necessary  to  use  the  catheter.  On  the  29th,  the  delirium  was  less  violent, 
the  fever  had  subsided,  and  the  tongue  was  not  so  dry.  On  the  30th,  the 
improvement  was  still  more  visible  :  the  abdomen  felt  soft :  he  was  able  to 
pass  his  water  naturally:  the  skin  looked  healthy,  the  pulse  had  fallen  to 
92  from  108,  which  it  was  in  the  early  days  of  his  attack  :  and  his  intellec- 
tual faculties  were  clear.  Recovery  proceeded  continuously  till  the  18th 
March,  when,  it  being  complete,  he  left  the  hospital. 

The  entire  treatment  in  this  case  consisted  of  lavements  of  infusion  of 
chamomile,  administered  twice  in  the  twenty-four  hours,  on  the  28th  and 
29th  February,  and  on  each  of  these  days  a  draught  composed  of  twenty 
grammes  of  balm-water,  one  gramme  of  ammonia,  and  forty  grammes  of 
syrup  of  orange-peel.  In  accordance  with  my  usual  practice  in  similar 
cases,  I  ordered  the  patient  to  have  every  day  some  spoonfuls  of  meat  soup 
and  beef  tea. 

In  the  history  of  this  case,  gentlemen,  you  have  recognized  the  disease 
generally  known  by  the  name  of  typhoid  j 'ever,  a  disease  (if  which  it  is  very 
unusual  for  us  mil  to  have  some  eases  in  our  wards.  It  is  one  of  the  mala- 
dies most  commonly  met  with  in  practice,  and  is  found  in  all  temperate 
climates.  It  is  endemic  in  some  places,  specially  so  in  (he  great  centres  of 
population,  and  this  is  perhaps   more   particularly  the  case  in   Paris,  where 

every  family  pays  a  heavy  tribute  to  it,  where  foreigners,  on  coming  to 

reside,  are  soon  attacked  liy  it,  and  where,  as  an  epidemic,  it  periodically 
spreads  very  cruel  desolation.  As  probably  there  is  not  one  of  yOU  who 
is  not  brought  into  contact  with  this  disease  at  the  very  threshold  of  his 
medical  career,  I  am  desirous,  without  attempting  to  discuss  the  whole 
subject,   to   enter   upon    some    considerat  ions   in    connection  with    the   cases 

which  yon  have  seen,  calling  your  attention  to  certain  peculiarities  which 

they  presented,  and  instructing   you  in  what  my  experience  has  taught  me. 


DOTHINENTERIA.  235 

You  are  aware  that,  at  present,  under  the  name  typhoid  fev.er,  are  included 
all  the  varieties  <>f  the  nosological  species  formerly  known  as  the  synochus 
putris  of  Cullen,  the  putrid  fever  of  Stoll,  the  malignant  nervous  fevei  of 
Huxham,  the  mucous  fever  of  Roederer,  the  bilious  lever  of  Tissot,  and  the 
adynamic  or  ataxo-adynamic  fever  of  others.  It  is  the  same  disease  which 
MM.  Petit  and  Serres*  have  called  entero-mesenteric  fever,  and  which 
Bretonneau  has  described  under  the  name  of  dothinenteria  [dothienentirie], 
to  indicate  the  special  nature  of  the  intestinal  affection  which  characterizes 
it — a  furuncular  eruption  on  the  intestine — from  dodiip,  a  pimple,  pustule, 
or  furuncle,  and  evtepou,  the  intestine. 

This  name — dothinenteria — is  now  the  prevailing  name  of  typhoid  fever. 
Names  are  not  of  much  consequence  if  there  is  an  exact  understanding  as 
to  the  meaning  attached  to  them,  for  then  they  cannot  give  a  false  notion 
of  the  thing  named.  The  term  "  typhoid  "  has  been  substituted  for  "  putrid," 
"malignant,"  and  "adynamic,"  but  it  is  a  term  quite  as  faulty  as  they  are. 
Conveying  as  they  all  do  the  idea  of  an  essential  character,  of  a  special 
symptom,  that  particular  symptom  ought — according  to  the  laws  of  good 
nomenclature — to  be  always  found  in  the  disease,  and  never  found  in  any 
other  disease.  But  this  is  very  far  from  being  the  case  in  respect  of  the 
malady  now  before  us.  On  the  one  hand,  typhoid  phenomena,  even  the 
phenomena  of  putridity,  malignity  and  adynamia  are  often  wanting  in  the 
fever  called  "  typhoid,"  "  putrid,"  "  malignant,"  aud  "  adynamic  ;"  and  on 
the  other  hand,  they  are  often  met  with  in  diseases  essentially  different  from 
it.  The  preferable  name  then  is  dothinenteria,  because  the  furuncular 
eruption  on  the  intestine  is  as  constant  and  special  in  this  disease  as  the 
pustular  eruption  on  the  skin  in  small-pox.  It  is  the  name  I  prefer, 
though  I  still  employ  those  of  "typhoid  fever,"  and  "putrid  fever,"  in 
conformity  with  universal  usage. 

Dothinenteria  is  an  acute,  febrile,  and  general  disease,  bearing  more  than 
one  striking  point  of  resemblance  to  the  eruptive  fevers^  Chiefly  attack- 
ing young  persons,  not  occurring  in  general  more  than  once  in  the  same 
subject,  and  being  undoubtedly  contagious,  it  has  three  characteristics 
common  to  it  and  the  eruptive  fevers ;  and  like  them,  it  also  has,  as  a 
special  character,  anatomical  lesions,  consisting  in  it  of  an  eruption  on  the 
skin,  and  an  eruption  on  the  intestine.  The  former,  called  the  rosy  lentic- 
ular spots  [taches  rosees  lenticulaires],  is  much  less  characteristic  than  the 
latter,  although  some  have  wished  to  make  the  cutaneous  eruption  the 
stamp  of  the  disease,  and  to  look  on  the  intestinal  lesion  as  only  a  second- 
ary and  consecutive  sign.  The  rosy  spots  are  often  wanting ;  and,  to  quote 
from  statistics,  I  may  mention  that  Chomel,  in  seventy  cases,  could  not 
find  any  trace  of  eruption  in  more  than  sixteen,  though  it  was  searched  for 
at  all  stages  of  the  disease.  If  it  be  argued,  that  the  absence  in  some  cases 
of  the  eruption  on  the  skin,  no  more  disproves  the  exanthematous  nature 
of  dothinenteria,  than  variolce  sine  variolis  disproves  the  exanthematous 
character  of  small-pox,  I  reply,  that  cases  of  variolce  sine  variolis  are 
infinitely  more  exceptional  than  cases  of  typhoid  fever  without  rosy  spots. 
In  some  localities,  as  at  Paris,  the  spots  are  found  with  sufficient  constancy 
to  justify  our  looking  out  for  them  as  the  most  obvious  pathognomonic 
sign,  but  there  are  other  places  in  which  attentive  observers  have  never 
been  able  to  see  them.  They  were  entirely  wanting  in  different  epidemics 
in  Touraine.  Far  be  it  from  me,  however,  to  dispute  the  symptomatic  value 
of  this  eruption  in  the  cases  in  which  it  is  present.     What  I  say,  gentle- 

#  Petit  et  Serres  :  Traite  de  la  Fievre  Entero-Mesenterique.     Paris,  1813. 


236  DOTHINENTERIA. 

men,  is,  that  the  cutaneous  eruption  of  cloth inenteria  cannot  be  regarded  as 
the  essential  character  of  the  disease — that  essential,  specific  character  is 
the  intestinal  lesion. 

On  the  21st  of  June  last  you  had  an  opportunity  of  seeing  the  nature  of 
this  lesion  in  the  body  of  a  patient  examined  in  your  presence.  On  our 
opening  the  intestines  you  saw  the  mucous  membrane  covered  with  a  copious 
eruption,  formed  by  the  glandules  agminatce  of  Peyer,  in  a  very  turgid,  but 
not  in  an  ulcerated  state,  some  of  them  being  in  relief,  to  the  extent  of  the 
thickness  of  a  silver  five  franc  piece  :  some  of  the  solitary  glands  were  equally 
turgid,  and  the  mesenteric  glands  were  enlarged.  The  patient  was  admitted 
tn  the  clinical  wards  on  the  14th  of  June,  and  died  four  days  afterwards. 
We  could  obtain  no  information  as  to  the  date  at  which  the  dothinenteria 
commenced.  Still,  the  nature  of  the  intestinal  lesions,  the  glands  of  Peyer 
being  turgid  but  not  ulcerated,  informed  me  that  the  disease  had  not  lasted 
more  than  twelve  or  fourteen  days. 

The  anatomical  researches  undertaken  for  the  elucidation  of  this  subject 
by  Bretonneau  in  1818,  and  subsequently  when  I  was  his  pupil  at  the  hos- 
pital of  Tours,  have  enabled  me  to  study  the  progress  of  the  changes  which 
take  place  in  the  glands  of  the  intestine,  and  to  describe  from  day  to  day 
the  changes  which  they  present.  I  have  published  the  results  of  my  labors, 
and  you  will  find  them  in  the  Archives  Generales  de  Medeciae  for  January, 
1826. 

The  characteristic  dothinenteric  eruption,  formed  at  the  expense  of  the 
aggregate  and  solitary  glands  of  Peyer,  does  not  begin  to  appear  till  the 
fourth  or  fifth  day,  and  sometimes,  according  to  Professors  Chomel  and 
Louis  (from  whose  opinion  I  differ),  not  till  the  seventh  or  eighth  day.  It 
is  progressively  accomplished  in  two  days,  all  the  glands  destined  to  be 
implicated  not  becoming  simultaneously  affected  ;  but  the  eruption  is  com- 
plete, at  the  latest,  by  the  seventh  day  of  the  disease.  The  aggregate  glands 
become  turgid,  and  increased  both  in  length  and  breadth  :  the  solitary  glands 
project  into  the  intestine:  at  the  same  time  the  mesenteric  glands,  commu- 
nicating with  the  aggregate  and  solitary  glands,  share  with  them  the  patho- 
logical changes  which  are  going  on,  and  become  enlarged. 

The  turgescence  of  the  glands  goes  on  increasing  up  to  the  ninth  day. 
On  the  tenth  day  one  of  two  things  occurs, — resolution  begins,  or  the  affec- 
tion continues  and  proceeds  through  all  its  stages.  In  the  first  case  the 
iiirgi'.-i-i-nce  of  the  aggregate  and  solitary  glands  of  Peyer  and  of  the  mes- 
enteric glands  begins  to  decrease, and  goes  on  gradually  subsiding  up  to  the 
fourteenth  day,  at  which  date  the  affected  glands  are  still  a  little  swollen  ; 
hut  by  the  end  of  the  third  week  resolution  is  complete,  excepting  that  the 
mesenteric  glands  do  not  quite  regain  their  norma]  condition  till  a  short 
time  later.  In  the  second  case  .-oine  patches  of  the  aggregate  glands  of 
I  towards  resolution,  whilst  other  patches  go  on  increasing  in 
size :  tli"  ame  may  he  -aid  of  the  solitary  glands,  some  of  which  proceed  to 
resolution, and  others  become  more  and  more  affected  by  the  disease.  The 
mesenteric  glands,  however,  have  always  decreased  in  Bize. 

On  the  twelfth  day  the  intestinal  affection,  till  then  pimply  [boutonneuse], 
becomes  to  some  extent  furuncular  [furonculeuse].  The  diseased  glands 
become  prominent,  presenting  the  appearance  of  red  conical  granulations 
[fongosites],  with  slighl  erosions  on  their  summits,  which  increase  in  Bize, 
till  they  form  on  the  fourteenth  or  fifteenth  day  a  core  [»//  bourbiUori]  of 
reddish  tissue,  deeply  stained  with  an  ochre  hue  by  the  bile,  which  at  this 
period  of  the  disease  is  abundant,  and  bas  a  special  tint:  the  sphacelated 
tissue  i-  adherent  at  its  base,  and  is  implanted  in  the  centre  of  an  extensive 
ulceration.     On  the  following  day  the  core   18  entirely  detached,  and   in  its 


DOTHINENTEIUA.  237 

place  there  is  a  deep  ulceration,  at  the  bottom  of  which,  generally,  is  the 
muscular  coat  of  the  intestine.  Sometimes  five  or  six  ulcerations  of  this 
description  may  be  seen  on  one  patch  of  the  aggregate  glands  of  Peyer, 
giving  it  an  irregular  fungous  appearance,  so  as  to  render  it  difficult  to 
recognize  the  existence  of  the  gland  which  is  the  seat  of  this  disorganization. 
All  around  isolated  ulcers  occupy  the  place  of  the  solitary  glands,  which 
have  been  destroyed  by  the  same  inflammatory  action.  The  mesenteric 
glands,  in  color  resembling  the  lees  of  wine,  are  for  the  most  part  so  sofl 
that  when  cut  into,  or  jn-essed  between  the  fingers,  they  become  almost  a 
pulp. 

After  the  seventeenth  and  eighteenth  days  the  edges  of  the  ulcerations 
are  less  prominent,  the  depth  of  the  ulcers  has  diminished,  and  the  intumes- 
cence by  which  they  were  circumscribed  has  begun  to  disappear.  By  the 
nineteenth,  twentieth,  and  twenty-first  days,  the  ulcerations  have  become 
superficial,  and  have  a  tendency  to  cicatrize.  About  the  twenty-fifth  day 
cicatrization  is  complete  ;  but,  generally,  the  cicatrices  are  not  consolidated 
till  the  thirtieth  day.  Some  ulcerations,  however,  remain  for  fifteen,  twenty, 
or  thirty  days  longer,  particularly  in  the  glands  situated  at  the  extremity 
of  the  small  intestine. 

Such  is  the  intestinal  eruption  of  cloth  inenteria,  and  such  are  the  differ- 
ent phases  through  which  it  passes.  The  lower  portion  of  the  ileum  is  the 
situation  for  which  it  has  a  preference;  and  when  the  eruption  only  occu- 
pies from  three  to  ten  inches  of  the  small  intestine,  the  portion  occupied  is 
the  lower  end  of  the  ileum  :  the  nearer  the  eruption  is  to  the  ileo-csecal 
valve,  the  more  confluent  is  it.  I  have  never  found  spots  beyond  the 
second  portion  of  the  jejunum,  ascending  towards  the  duodenum  and  stom- 
ach :  they  become  more  numerous  in  the  large  intestine,  the  nearer  they  are 
to  the  coecum. 

Gentlemen,  you  will  always  find  these  intestinal  lesions  on  examining 
the  bodies  of  persons  who  have  died  of  typhoid  fever,  whatever  form  it  may 
have  assumed,  whatever  may  have  been  the  variety  or  intensity  of  the 
symptoms,  provided  death  has  taken  place  after  the  fifth  day,  the  period  at 
which  these  lesions  begin  to  appear. 

In  connection  with  the  intestinal  lesion,  I  ought  to  mention  a  theory  of 
Virchow.  According  to  this  celebrated  anatomist,  and  according  to  con- 
temporary histologists,  the  follicular  crypts  of  the  intestine,  the  Peyerian 
patches  on  the  one  hand  and  the  Malpighian  tufts  of  the  spleen  on  the 
other,  have  the  same  structure  and  functions  as  the  lymphatic  glands :  they 
are  formed  of  a  gland-tissue.  And  as  it  is  looked  on  as  proved  that  the 
lymphatic  glands  produce  the  white  corpuscles,  it  follows  that  hypertrophy 
of  the  follicular  crypts,  Peyerian  patches,  and  Malpighian  tufts  in  typhoid 
fever  lead  to  the  superabundant  production  of  white  corpuscles,  or  in  other 
words,  to  leucocythamiia,  at  least  in  the  first  stage  of  the  disease.*  At  a 
later  period,  the  excessive  formation  of  the  constitutional  elements  of  lymph 
and  nuclei  distend  and  ultimately  destroy  the  reticulated  texture  of  the 
glandular  tissue.     This  of  course  terminates  the  leucocythremia. 

This  description  is  substantially  nothing  more  than  a  statement  of  facts 
disclosed  by  microscopic  observation.  The  solution  of  the  question  is  not 
advanced  one  step.  In  cholera  and  other  diseases,  there  is  a  similar  super- 
abundant production  by  the  Peyerian  glands,  while  the  progress  of  the 
symptoms  and  of  the  anatomical  lesions  is  very  different  from  those  of 
typhoid  fever.  In  this  difference  resides  the  essential  character  of  the 
disease.    The  symptoms  and  the  lesions  are  different,  because  the  morbid 

*  Virchow:   La  Pathologie  Cellulaire.   [Traduction  de  Paul  Picard.] 


238  DOTHIXEXTERIA. 

impetus — or  whatever  else  you  like  to  call  it — is  different.  We  are  obliged, 
therefore,  notwithstanding  the  microscopical  investigations,  and  even  in 
consequence  of  them,  to  inquire  into  the  causes  which  produce  the  disease, 
into  the  contagion,  the  epidemic  influence,  the  nature  of  the  symptoms,  and 
the  specific  characters  of  dothinenteria,  of  which  the  intestinal  lesions,  as 
well  as  the  lesions  in  other  parts  of  the  body,  are  the  effects  and  not  the 
cause. 

Gentlemen,  you  perceive  by  the  description  which  I  have  given  you,  that 
the  intestinal  eruption  proceeds  with  an  order  aud  precision,  which  can  only 
be  compared  to  what  we  see  in  distinct  small-pox.  As  I  do  not  wish  to 
leave  an  erroneous  impression  on  your  minds,  it  is  necessary,  however,  to 
state  that  while  the  description  which  I  have  given  applies  to  the  majority 
of  cases,  there  not  unfrequently  occur  modifications  in  the  form  and  prog- 
ress of  the  intestinal  exanthem,  which  it  would  be  useless  to  point  out 
here,  but  which  impress  on  it  characters  somewhat  different  from  those  I 
have  as.-igned  to  it. 

Cases  have  been  adduced  in  which  there  was  no  appreciable  alteration 
of  Peyer's  glands,  but  they  are  as  exceptional  as  cases  of  small-pox  without 
eruption,  and  possibly  they  were  cases  of  the  "typhus  fever"  of  the  English, 
or  the  "typhus  exanthematicus"  of  the  Germans.  Let  me  add  that  there 
are  some  formidable  diseases  which  for  the  first  few  days  by  simulating 
dothinenteria,  throw  off  their  guard  unobservant  and  inexperienced  physi- 
cians. You  have  seen  a  considerable  number  of  cases  in  which  the  general 
symptoms  at  first  consisted  only  of  a  feeling  of  discomfort,  lassitude,  pains 
in  the  limbs,  and  a  certain  amount  of  uneasiness  in  the  bowels — the  tongue, 
slightly  red  at  the  point  and  edges,  covered  with  a  thin  whitish  fur,  was  a 
little  swollen,  so  as  to  show  the  marks  of  the  teeth — there  was  anorexia, 
with  little  or  no  fever,  and  the  pulse  sometimes  even  below  the  normal  fre- 
quency— the  skin  was  somewhat  dry — and  there  either  were  no  stools,  or  the 
bowels  were  as  regular  as  usual.  We  sometimes  see  our  patients  continue 
in  this  condition  for  from  twelve  to  thirty  days,  without  the  symptoms  being 
.sufficiently  urgent  to  oblige  them  to  take  to  bed;  but  at  other  times,  after 
this  stage  has  gone  on  from  twelve  or  fourteen  days,  formidable  symptoms 
all  at  once  set  in,  it  may  be  without  appreciable  cause,  or  it  may  be  from 
indigestion  caused  perhaps  by  eating  quite  moderately,  and  then  the  dis- 
ease declares  itself  by  more  characteristic  symptoms,  and  witli  more  or  less 
severity.  WeH,  in  these  cases  of  mild  dothinenteria,  to  which  the  term 
•■latent'"  has  been  applied,  you  will  have  been  able  to  verify  the  existence 
of  the  intestinal  eruption  quite  as  will  a-  in  cases  attended  by  the  most 
dangerous  symptoms. 

Nevertheless,  it  must  not  he  supposed  that  the  furuncular  eruption  is 
the  entire  disease,  that  the  disease  is  nothing  more  than  an  inflammatory 
affection,  an  enteritis,  as  is  alleged  by  those  who  have  given  it  the  name  of 
" follicular  enteritis  :"  uor  musl  we  suppose  that  the  general  are  more  under 
the  influence  of  the  local  symptoms,  when  the  intestinal  lesions  a. 
and  most  extensive.  The  enteritis  which  characterizes  typhoid  fever  has 
at  the  autopsy  a  special  character,  hut  it  is  only  one  of  the  elements  of  the 
disease.  A-  Laennec  remarked,  the  alterations  in  the  intestinal  canal 
which  occur  m  typhoid  lever  are  no  more  the  cause  of  its  general  symp- 
toms, than  the  variolous,  morbillous,  and  scarlatinous  eruption-  arc  the 
-  respectively  of  small-pox,  measles,  ami  scarlatina.  So  far,  however, 
from  the  eruptions  being  the  causes  of  these  diseases,  there  arc  some  cases 
(very  exceptional  I  admit)  in  which  they  are  wanting,  and  they  are  al- 
ways developed  after  the  symptomatic  manifestations  of  the  fever,  finally, 
if  in  the  mild  cases,  the  dothinenteric  eruption  may  consist  only  of  very 


D0TI1INENTERIA.  239 

distinct  spots,  cases  have  been  adduced  in  which  (from  death  occurring 
suddenly  in  consequence  of  a  perforation  of  the  bowel)  then'  has  been  seen 
an  eruption  very  confluent  in  character  and  presenting  numerous  ulcera- 
tions; while,  in  contrast,  there  have  been  found  affected  only  one  or  two 
Peyerian  patches  in  other  cases  in  which  death  occurred  about  the  fifteenth 
day  of  very  violent  attacks  of  typhoid  fever.  My  opinion  may  he  summed 
up  in  a  few  words :  as  a  general  rule,  in  dothinenteria,  contrary  to  the 
general  rule  in  other  eruptive  fevers  I  particularly  in  small-pox  and  scarla- 
tina t,  the  severity  of  the  general  symptoms  bears  no  relation  to  the  intensity  of 
the  eruption. 

The  eruption,  though  it  be  a  local  symptom,  is  not  the  less  deserving  of 
our  serious  consideration,  for  it  explains  the  consecutive  abdominal  pains 
which  continue  for  weeks  and  months,  after  recovery  from  typhoid  fever ; 
and  also,  because  it  is  very  frequently,  during  the  attack,  the  starting-point 
of  a  mortal  complication.  About  the  fifteenth  or  sixteenth  day,  at  the  time 
when  the  fleshy  core  separates,  an  ulceration  forms,  which,  destroying  more 
or  less  deeply  the  coats  of  the  intestine,  may  proceed  in  a  few  days  to  per- 
foration. During  the  period  of  the  cicatrization  of  the  ulcers,  we  must 
bear  in  mind  the  risk  of  intestinal  perforation,  which,  by  producing  very 
acute  peritonitis,  carries  off  the  patient  with  frightful  rapidity.  You  will  I 
see  such  occurrences  not  only  in  severe  typhoid  fever,  but  even  in  those 
cases  which  are  so  mild  as  to  be  difficult  of  diagnosis. 

You  are  acquainted  with  the  symptoms  of  peritonitis  resulting  from  per- 
foration. Whether  it  occur  during  the  progress  of  the  disease,  or  during 
convalescence,  the  individual  is  suddenly  seized  with  violent  pain  in  the 
bowels  :  this  pain  is  increased  on  pressure,  and  rapidly  extends  to  the 
whole  abdomen.  At  the  same  time,  hiccup,  nausea,  and  intractable  vomit- 
ing of  green  and  leek-green  matter  set  in  :  a  pale,  collapsed  countenance 
tells  of  the  pain  and  anxiety  which  is  being  endured  :  there  is  considerable 
fever,  and  the  pulse  is  small  and  rapid  :  there  is  suppression  of  urine  :  the 
skin  is  covered  with  a  viscid  sweat ;  and  the  patient  sinks  within  a  period 
more  or  less  brief.  On  examination  after  death,  we  find  the  lesions  met 
with  in  cases  of  very  acute  peritonitis ;  and  on  examining  the  intestinal 
canal,  we  soon  find  the  perforation,  which  has  been  the  starting-point  of 
the  mischief,  and  which  is  always  situated  in  one  of  the  ulcerated  Peyerian 
patches.  Sometimes  there  are  several  perforations  ;  but  there  are  cases  in 
which  we  cannot  discover  any,  howTever  attentively  we  look  for  them  : 
moreover,  there  are  cases  in  which  it  is  difficult  to  see  the  slightly  promi- 
nent patches  of  Peyer,  which  present  no  traces  of  inflammation  or  ulcera- 
tion. 

These  are  the  cases  in  which  we  have  to  do  with  spontaneously  developed 
peritonitis,  a  subject  on  which  my  friend  Dr.  Thirial  has  communicated  an 
interesting  work  to  the  Hospitals'  Medical  Society.*  Here  is  one  of  the 
cases  which  he  gives. 

A  girl  of  twenty-one  had  typhoid  fever  in  a  mild  form.  After  the 
malady  had  gone  on  for  about  twenty  days,  she  was  entering  upon  con- 
valescence, and  beginning  to  take  food,  when,  after  strong  mental  emotion, 
she  was  suddenly  seized  with  very  alarming  symptoms,  pains  in  the  bow- 
els, bilious  vomiting,  great  change  in  the  countenance,  depression  of  pulse, 
and  general  prostration.  From  these  symptoms,  exceedingly  well-informed 
physicians  without  hesitation  diagnosed  peritonitis,  the  result  of  intestinal 
perforation.  Twenty  leeches  were  immediately  applied  to  the  abdomen. 
On  the  following  day,  there  was  no  improvement  in  the  state  of  the  patient. 

*  Thirial  :  Numbers  83,  84,  and  85,  of  Union  Medicalo  for  1853. 


240  DOTHINENTERIA. 

It  was  then  resolved  to  have  recourse  to  narcotics  in  large  doses,  thus 
adopting  the  practice  from  which  Stokes  of  Dublin  had  in  similar  cases 
obtained  beneficial  results.  Twenty-five  centigrammes  of  the  thebaic  ex- 
tract were  prescribed  to  be  taken  within  twenty-four  hours.  Complete 
abstinence  from  fluids,  and  absolute  immobility  were  also  enjoined.  ISot- 
withstanding  this  treatment,  the  vomiting  continued  :  the  tongue  became 
dry ;  and  there  was  no  improvement  in  the  other  symptoms,  with  the  ex- 
ception of  the  abdominal  pain.  From  the  first  day,  it  was  tolerably  bear- 
able, and  had  nearly  ceased  by  the  third  day,  the  patient  not  feeling  it, 
unless  pretty  strong  pressure  was  made  on  the  abdomen.  The  treatment 
was  continued ;  but  in  the  evening  the  patient  died,  that  is  to  say,  in  sev- 
enty-two hours  from  the  onset  of  the  alarming  symptoms. 

The  autopsy  established  the  existence  of  peritonitis.  The  intestines^ 
throughout  the  greater  part  of  their  extent,  were  covered  with  a  layer  of 
coagulable  lymph,  which  was  soft  and  recent.  The  cavity  of  the  pelvis 
contained  four  or  five  ounces  of  a  milky  fluid  of  purulent  character.  The 
mesentery  was  in  particular  covered  with  pseudo-membranous  deposits  of 
very  slight  consistence,  and  of  variable  thickness.  Notwithstanding  the 
most  diligent  search,  not  the  slightest  intestinal  perforation  could  be  de- 
tected. The  intestinal  canal  was  found  to  be  perfectly  healthy,  excepting 
that  towards  the  end  of  the  ileum,  particularly  at  the  ileo-csecal  valve, 
there  were  four  or  five  patches,  not  prominent,  but  presenting  a  blackish 
color:  these  were  Peyerian  glands  which  had  been  diseased,  but  had  reached 
the  period  of  resolution.  In  no  situation  in  the  intestinal  canal  could  ulcera- 
tion or  erosion  be  discovered.  The  other  abdominal  organs  were  healthy  : 
the  spleen  was  small  and  firm :  the  liver  was  normal :  the  posterior  part  of 
the  lungs  was  a  little  gorged. 

Two  similar  cases  are  described  in  the  work  of  Professor  Jenner,  of 
London. 

Possibly  some  of  the  cases  of  alleged  recovery  from  intestinal  perforation 
are  nothing  more  than  cases  of  this  class ;  but  still,  gentlemen,  the  case  1 
am  about  to  narrate,  and  which  you  have  had  an  opportunity  of  observing 
in  the  clinical  wards,  explains  the  possibility  of  recovery,  and  the  mechan- 
ism by  which  it  is  accomplished:  it  also  shows  how  peritonitis  without  per- 
foration is  produced  by  what  may  be  called  propagation. 

You  recollect  a  woman  who  lay  in  bed  No.  31  of  St.  Bernard's  Ward. 
Three  days  before  admission,  she  had  left  the  St.  Louis  Hospital,  where  she 
had  had  asevere  attack  of  dothinenteria, which  had  lasted  six  weeks.  She 
was  thin  and  pale,  and  had  a  great  deal  of  fever.  She  complained  of  pains 
in  the  lower  pari  of  the  abdomen,  which  were  increased  on  pressure.  She 
had  diarrhoea,  and  was  vomiting  yellowish  bilious  mailer.  There  was  con- 
siderable enlargement  of  the  liver  and  spleen.  My  diagnosis  was — perito- 
nitis consecutive  to  typhoid  fever;  and  1  though  I  that  she  had  had  a  relapse 
of  the  fever,  from  observing  some  recent  rosy  spots  on  the  abdomen. 

Six  davs  after  her  admission,  the  symptoms  of  peritonitis  seemed  to  be 
subdued,  after  the  administration  of  minute  doses  of  calomel— five  centi- 
grammes, divided  into  ten  doses,  having  been  given  daily.  The  pains  were 
less  severe,  and  the  abdomen  had  regained  its  natural  softness.  Hut  there 
were  very  alarming  chesl  symptoms.  Respiration  was  difficull  and  hurried. 
( )n  auscultation,  we  heard,  before  and  behind,  on  both  Bides,  numerous  mu- 
cous and  sibilanl  rales:  they  were  mosl  abundant  in  the  lower  and  posterior 
region  of  the  righl  side,  where  they  were  likewise  finer  and  subcrepitant : 
in  the  same  situation,  there  was  dulness  on  percussion.     She  -poke  in  a 

brief  ami    panting   manner.      There  was   more  fever   than   on    the   previous 

davs. 


D0TII1NENTEMA.  241 

On  the  following  day,  there  was  a  profuse  mucous  expectoration  which 
adhered  to  the  vessel,  aud  some  of  which  had  a  slight  ochreous  tint,  show- 
ing that  bronchitis  had  penetrated  to  the  extreme  ramifications  of  the  tubes, 
and  was  gaining  the  pulmonary  parenchyma  itself.  The  cough — the  stetho- 
scopic  signs — that  is  to  say,  the  fine  mucous  and  subcrepitant  rales — and 
the  dulness  at  the  base,  confirmed  this  diagnosis.  Still,  as  there  was  neither 
blowing  sound  nor  crepitant  rales,  I  could  not  pronounce  the  word  "  pneu- 
monia." In  five  days,  all  these  symptoms  had  yielded..  Notwithstanding 
the  diarrhoea,  I  had  given  the  precipitated  sulphuret  of  antimony  in  daily 
doses  of  50  centigrammes,  administered  in  pills,  each  containing  10  centi- 
grammes. A  drop  of  laudanum  was  ordered  to  be  taken  with  each  pill. 
The  cough  and  expectoration  were  less.  The  normal  sound  returned  to  the 
part  in  which  dulness  on  percussion  had  been  observed:  only  the  sibilant 
and  coarse  mucous  rales  were  audible;  and  the  breathing  was  easier.  The 
abdominal  symptoms  however  continued  without  change ;  and  there  was 
only  a  little  diarrhoea,  which  at  last  yielded  to  the  subnitrate  of  bismuth 
combined  with  chalk,  to  the  extent  of  4  grammes  of  each  given  daily,  divided 
into  eight  doses,  till  the  twelfth  day,  when  continuous  delirium  set  in,  along 
with  general  puffiness  unaccompanied  by  albuminuria,  and  an  aphthous 
condition  of  the  mucous  membrane  of  the  tongue  and  mouth.  In  conse- 
quence  of  these  new  symptoms,  I  prescribed  cinchona,  to  the  extent  of  a 
gramme  a  day,  in  coffee  without  milk.  The  symptoms  continued  without 
intermission  for  four  days;  and  then  the  patient  died,  on  the  fifteenth  day 
from  the  date  of  her  admission  into  the  Hotel-Dieu. 

At  the  autopsy,  we  found  the  usual  lesions  of  peritonitis.  All  the  in- 
testines were  glued  together  by  false  membranes,  which  were  easily  torn. 
The  adhesions  formed  pouches  filled  with  pus ;  and  there  was  no  trace  of 
any  effusion  into  the  abdominal  cavity  of  the  contents  of  the  intestine. 
On  the  concave  surface  of  the  diaphragm,  in  the  small  hollow,  the  parietal 
peritoneum  was  red,  presenting  vascular  arborizations  aud  purulent  striae. 

On  exposing  the  intestine,  the  serous  surface  of  which  was  covered  by 
purulent  matter  and  vascular  arborizations  forming  red  patches,  we  saw, 
toward  the  lower  portion  of  the  ileum,  spots  of  a  blackish-brown  color, 
around  which  there  irradiated  vascular  arborizations  more  conspicuous  than 
elsewhere.  The  corresponding  portion  of  the  peritoneum  was  thickened,  and 
puckered  like  the  edges  of  that  kind  of  purse  which  is  shut  by  pulling 
running  cords  ;  all  the  folds  of  the  serous  membrane  converged  towards  the 
black  spots  of  which  I  have  spoken.  On  opening  the  intestine,  we  found 
that  these  spots  corresponded  to  the  ulcerations  which  had  destroyed  the 
mucous  and  muscular  coats  of  the  bowel,  and  had  reached  the  peritoneal 
coat,  which  formed  their  floor.  These  ulcerations  of  Peyer's  glands,  char- 
acteristic of  dothinenteria,  were  from  eighteen  to  twenty  in  number,  and 
were  situated  in  the  lowest  metre  of  the  small  intestine,  and  the  nearer  they 
were  to  the  ileo-csecal  valve,  the  more  confluent  were  they.  In  that  situ- 
ation, the  whole  surface  was  one  vast  ulcer,  deeply  excavated,  and  jagged 
at  the  edges.  In  the  last  foot  of  the  ileum,  in  the  centre  of  two  large 
ulcerations,  there  were- perforations  with  thin  blackish  edges,  and  of  the 
size  of  a  twenty  centime  piece.  In  the  ulceration  nearest  to  the  coecum, 
blackish  filaments  were  floating,  the  remains  of  the  furuncular  core,  in  the 
seat  of  which  the  perforation  had  taken  place. 

The  explanation  of  the  absence  of  intestinal  matter  in  the  peritoneum  is 
the  stopping  up  of  the  perforations  by  the  intestinal  adhesions,  and  the 
manner  in  which  the  convolutions  were  glued  together. 

The  whole  of  the  lower  portion  of  the  intestinal  canal  was  arborized : 

vol.  i. — 16 


242  DOTHINENTERIA. 

the  arborizations  were  placed  closest  together  where  they  were  nearest  to 
the  ulcerated  parts. 

The  mesenteric  glands  were  swollen,  softened,  and  reduced  to  a  reddish 
pulp.  The  tissue  of  the  spleen  and  liver,  both  of  which  were  considerably 
enlarged,  was  soft,  and  broke  down  under  pressure.  The  lungs  were  con- 
gested, but  not  hepatized.    The  encephalon  presented  no  appreciable  lesion. 

This  case,  gentlemeu,  as  I  have  already  said,  explains  how  the  reparation 
of  intestinal  perforations,  as  reported  by  Stokes  and  Graves,  of  Dublin,  as 
well  as  by  other  physicians,  may  take  place  ;  and  it  also  points  out  to  us  the 
pathogeny  of  peritonitis  occurring  in  dothinenteria  without  perforation. 

The  peritonitis  may  be  the  consequence,  as  in  our  patient,  of  ulceration 
reaching  the  pei'itoneal  coat  of  the  intestine,  which  it  does  not  destroy,  but 
in  which  it  excites  inflammation.  Supposing  the  ulcerations  to  be  very  few 
in  number,  and  very  far  apart  from  one  another,  the  inflammation  devel- 
oped in  the  corresponding  portion  of  peritoneum  may  remain  within  a  very 
limited  space,  and  be  devoid  of  danger ;  but  supposing,  either  that  the 
ulcerations  are  numerous  and  confluent,  or  that  the  inflammation  of  the 
peritoneum  steadily  creeps  on,. as  in  erysipelas,  the  peritonitis,  becoming 
general,  may  destroy  the  patient. 

These  cases  of  partial  peritonitis,  then,  explain  the  possibility  of  recovery 
when  perforation  of  the  intestine  has  taken  place.  Perforation  does  not 
occasion  death,  except  by  the  violent  and  general  peritonitis  set  up  by  the 
passage  of  the  contents  of  the  bowels  through  the  perforation  into  the  cavity 
of  the  peritoneum.  Now,  when  adhesions  have  been  formed  between  the 
intestinal  convolutions  consecutively  to  the  inflammation  of  their  serous 
covering,  the  passage  of  the  contents  of  the  bowels  is  prevented,  because 
the  ulcerated  openings  are  shut  up  by  the  gluing  together  of  the  intestines; 
and  we  can  understand  these  adhesions  continuing  sufficiently  long  to  allow 
cicatrization  of  the  solution  of  continuity  to  be  accomplished,  and  the 
patient  to  recover. 

It  was  by  the  operation  of  the  mechanical  cause  which  I  have  now  ex- 
plained that  the  woman  in  the  case  under  consideration  did  not  succumb 
in  consequence  of  the  perforation.  She  died  from  general  peritonitis,  pro- 
duced by  the  extensive  ulceration  of  the  intestine  reaching  the  serous 
membrane,  and  not  from  sudden  general  peritonitis  consecutive  to  perfor- 
ation and  escape  of  fecal  matter;  for,  as  I  pointed  out  to  you  at  the  autopsy, 
the  convolutions  of  intestine  were  glued  together  in  such  a  manner  as  to 
prevent  that  escape. 

In  respect  of  diagnosis,  the  symptoms  are  the  same  whether  the  peritonitis 
be  or  be  not  the  consequence  of  perforation.  It  has  certainly  been  alleged 
that  peritonitis  consecutive  to  perforation  may  be  recognized  by  the  spon- 
taneousness  and  excessive  acuteness  of  the  pain  declaring  itself  first  in  the 
region  of  the  caecum  and  second  portion  of  the  ileum,  the  situation  in  which 
perforations  arc  mosl  common,  soon  extending  to  the  whole  abdomen,  and 
being  aggravated  by  pressure;  and  it  has  also  been  alleged  that  in  peri- 
tonitis consecutive  to  perforation,  there  is  always  suppression  of  urine. 
These  signs,  however,  arc  of  very  little  use  as  guides  to  a  differentia]  diag- 
nosis, which  can  only  be  established  by  an  examination  of  the  body  after 
death. 

Were  such  a  differential  diagnosis  possible,  il  would  have  some  impor- 
tance in  respect  of  prognosis,  because  peritonitis  without  perforation  b  not 
so  serious  as   peritonitis  from    perforation,  which  ie   almost  inevitably  fatal. 

The  impossibility  of  ascertaining  during  life  the  nature  of  this  abdominal 

Complication  justifies  our   worst   fear-   as    to  the    issue  of  a  ease  in  which    it 

exists.    Finally,  gentlemen,  you  can  understand  from  what  I   have  said. 


DOTHINENTERIA.  243 

that,  considering  the  alterations  to  which  the  intestinal  canal  is  liable  in 
dothinenteria,  you  ought  to  be  reserved  in  your  prognosis  in  this  disease, 
recollecting  that  even  in  cases  in  which  the  appreciable  signs  are  indicative 
of  a  mild  attack,  at  the  very  time  when  your  patient  seems  to  be  out  of  dan- 
ger, and  you  are  going  to  announce  his  recovery,  you  may  witness  the 
symptoms  of  that  terrible  complication,  intestinal  perforation,  or  of  peri- 
tonitis without  perforation,  a  complication  which  though  less  formidable, 
is  very  dangerous. 

Intestinal  Hemorrhage. — Hemorrhagic  Putrid  Fever. 

A  woman,  aged  64,  was  admitted  to  the  Hotel-Dieu  on  the  7th  March, 
1859,  where  you  saw  her  lying  in  bed  No.  31  of  St.  Bernard's  Ward.  I 
call  your  attention  to  her  age,  because,  as  a  general  rule,  dothinenteria 
only  attacks  young  subjects.  This  woman  died  on  the  seventh  day  after 
admission,  having  been  carried  off  by  a  complication  regarding  which  I 
now  wish  to  speak. 

When  she  came  into  our  wards,  she  was  delirious,  and  in  a  state  of  great 
prostration.  The  bowels  were  in  a  sluggish  condition:  pressure  over  the 
iliac  fossa  did  not  occasion  gurgling,  and  there  was  no  diarrhoea.  The 
pulse  was  108:  there  was  a  little  dyspnoea,  with  some  subcrepitant  rales  at 
the  base  of  the  right  lung.  The  spleen  was  not  enlarged.  We  learned 
that  the  illness  began  with  headache  and  shivering. 

Next  day,  I  observed  spots  on  the  abdomen,  possessing  some  of  the  char- 
acters of  typhoid  spots.  Three  days  latter,  their  typhoid  character  was 
undoubted.  On  that  day,  there  was  marked  amelioration  of  the  symptoms. 
In  the  evening,  my  chef  de  clinique,  M.  Moynier,  saw  the  patient  taking 
some  meat  soup  with  appetite,  and  complaining  that  it  was  insufficient  in 
quantity:  three  hours  later,  abdominal  hemorrhage  set  in  so  profusely  that 
the  blood  inundated  the  bed,  and  flowed  over  on  the  floor  of  the  ward.  In 
less  than  an  hour  the  patient  was  dead. 

At  the  autopsy,  the  upper  portions  of  the  small  intestines  were  found  to 
be  healthy;  but  in  the  lower  portions,  the  following  lesions  were  seen. 
The  Peyerian  patches  were  very  much  affected.  At  about  six  or  eight  cen- 
timetres from  the  ileo-csecal  valve,  one  of  the  patches  was  ulcerated  in  such 
a  way  as  to  expose  the  bare  peritoneum :  its  edges  were  turgid,  and  its  sur- 
face was  covered  with  detritus  exhaling  a  fetid  odor.  A  little  higher  up, 
there  were  other  patches  of  about  one  or  two  centimetres  ulcerated,  so  as  to 
lay  bare  the  muscular  coat  of  the  intestine.  The  patches  were  hypertro- 
phied,  and  softened.  The  solitary  glands  were  also  in  a  very  diseased  con- 
dition. The  intestine  contained  a  large  quantity  of  blood,  which  had  im- 
parted a  reddish-black  color  to  the  mucous  membrane.  There  was  no  fecal 
matter  in  the  intestinal  canal.  The  mesenteric  glands  were  blended  together 
in  an  enormous  mass  of  fat.  From  the  lesions  now  described,  it  is  evident 
that  the  disease  had  reached  its  fourteenth  or  fifteenth  day.  In  size,  the 
spleen  was  natural,  but  it  was  of  a  very  soft  consistence.  The  liver  had 
lost  its  natural  consistence,  and  was  hypertrophied.  Both  lungs  were  con- 
gested. The  heart  was  distended  with  black  clots.  There  was  no  lesion  of 
the  brain. 

This  is  the  third  case  which  I  have  seen  within  seven  years  of  a  person 
dying  of  intestinal  hemorrhage  in  the  course  of  an  attack  of  dothinenteria. 
In  the  two  other  cases,  the  patients  did  not  die  from  the  immediate  conse- 
quences of  the  loss  of  a  large  quantity  of  blood,  as  in  the  woman  whose  case 
I  have  detailed.  One  of  them  was  seized  on  the  twenty-third  or  twenty- 
fourth  day  with  intestinal  hemorrhage,  which  recurred  at  intervals  during 


244  DOTHINENTERIA. 

three  or  four  consecutive  days.  Death  took  place  in  consequence  of  these 
successive  hemorrhages,  the  patient  having  been  reduced  to  a  state  of  aniemia 
and  profound  debility-  The  other  patient,  on  the  nineteenth  day  of  the 
typhoid  fever,  had  ataxic  nervous  symptoms,  when  a  moderate  attack  of 
hemorrhage  supervened,  after  which  a  great  improvement  was  observed  in 
the  condition  of  the  patient,  which  continued  for  eight  days.  Then,  how- 
ever, the  nervous  symptoms  returned,  and  she  had  a  second  and  a  third 
attack  of  hemorrhage.  The  nervous  symptoms,  in  place  of  becoming  calmer, 
as  after  the  first  loss  of  blood,  increased  in  severity  and  carried  off  the 
patient. 

Intestinal  hemorrhage  is  a  frequent  complication  of  dothinenteria:  it  is 
perhaps  even  more  common  than  is  generally  believed,  judging  from  the 
fact,  that  it  is  often  not  till  the  autopsy  that  its  existence  is  revealed:  in 
such  cases,  on  opening  the  intestinal  tube,  we  may  find  a  greater  or  less 
quantity  of  blood,  none  of  which  has  passed  below  the  ileo-csecal  valve. 
While  a  somewhat  profuse  hemorrhage  into  the  bowel  might  be  suspected 
during  life  from  the  general  symptoms,  such  as  increased  debility  and  a 
sudden  paleness  of  the  skin,  a  more  moderate  loss  of  blood  might  escape 
notice.  Generally,  the  hemorrhage  shows  itself  externally;  and,  according 
to  the  nature  of  the  case,  the  blood  is  passed  almost  pure,  in  a  state  which 
though  not  pure  admits  of  easy  recognition,  or  in  a  very  altered  state:  when 
it  has  remained  long  in  the  intestine,  it  is  a  blackish  matter  resembling  tar 
in  appearance. 

You  will  read,  and  you  will  hear  said  by  everybody,  that  these  hemor- 
rhages are  formidable  complications,  and  increase  the  danger  of  the  disease. 
This  is  the  opinion  of  the  most  reliable  physicians;  but  nevertheless,  when 
thus  expressed,  it  is  far  too  absolute;  and  as  for  myself,  I  confess,  that 
after  holding  that  opinion  for  a  long  time  I  now  profess  the  opposite  doc- 
trine, believing  that  hemorrhages  in  typhoid  fever,  so  far  from  possessing 
the  character  of  danger  imputed  to  them,  are  usually  of  favorable  augury. 
Such  is  also  the  opinion  of  Graves.  When  I  read  this  proposition  for  the 
first  time  in  the  clinical  lectures  of  the  Dublin  professor,  being  still  under 
the  dominion  of  opposite  views  in  which  I  had  been  educated,  I  was  amazed 
that  a  man  of  such  sterling  merit  and  high  repute  should  disagree  with  me 
in  a  matter  which  I  believed  I  understood.  However,  the  opinion  of  so 
great  an  authority  caused  me  to  reflect,  and  reviewing  the  cases  which  I 
had  seen,  I  recollected  recoveries  in  cases  in  which  hemorrhages  had  oc- 
curred. I,  therefore,  from  that  time  directed  my  attention  more  diligently 
to  the  point:  audi  now  say,  that  while  the  three  cases  of  which  I  have 
just  spoken  seem  to  confirm  the  prevailing  idea  as  to  the  gravity  of  intes- 
tinal hemorrhages  in  typhoid  lever,  I  can  cite  as  a  set-oil'  to  them  a  much 
greater  number  in  support  of  the  doctrine  of  Graves. 

Without  going  beyond  our  wards  in  search  of  examples,  I  will  recall  two 
cases  which  occurred  under  your  own  observation. 

A  girl  aged  20,  of  good  constitution,  was  admitted  to  bed  No.  5,  St.  Ber- 
nard's Ward,  on  the  14-th  October,  L857.     She  had  been  ill  for  eight  days, 

but  had  not  been  obliged  to  take  to  her  bed  till  the  fourth  day.  The  doth- 
inenteria followed  its  regular  course,  without  presenting  any  other  symp- 
toms than  considerable  weakness  aocompanied  by  very  moderate  level-  and 

diarrhoea,  till  the  L8th  October,  the  twelfth  day  of  the  attack,  when  profuse 
intestinal  hemorrhage  occurred:  Bhe  nearly  tilled  a  chamber-pol  with  blood, 
which  was  black,  Quid,  and  wry  fetid.  The  hemorrhage  recurred  next 
day.  when  the  discharged  blood  was  similar  to  that  passed  on  the  firsl  occa- 
sion;  and  on  the  following  day  I  he  stools  were  still  I > lack  and  fetid. 

The  general  symptoms  were  not  such  as  to  occasion  much  alarm:   and 


DOTIIINENTERIA.  245 

from  that  time  they  became  sensibly  less  severe  ;  from  day  to  day  the  fever 
abated,  and  on  the  17th  November,  the  patient,  having  entirely  recovered, 
left  the  hospital,  a  month  after  admission.  It  was  a  remarkable  circum- 
stance in  this  ease,  that  notwithstanding  the  enormous  quantity  of  blood 
lost  on  two  occasions,  the  patient,  who  naturally  had  color  in  her  face,  did 
not  lose  it,  and  did  not  seem  to  be  weakened. 

Last  year,  a  man,  aged  27,  tall,  of  good  constitution,  but  having  a  pale 
complexion  and  fair  hair,  was  admitted  on  the  10th  of  June,  to  bed  No.  16, 
St.  Agnes's  Ward.  He  had  been  ill  for  eleven  days  with  putrid  fever,  the 
symptoms  of  which  were  well  marked  and  severe.  He  had  lately  come  to 
reside  at  Paris,  where  he  was  employed  as  a  day  laborer.  For  a  week  he 
had  been  feeling  languid,  and  complaining  of  violent  headache,  when,  on 
the  7th  June,  he  was  obliged  to  keep  his  bed.  The  abdominal  symptoms 
preponderated,  and  were  characterized  by  considerable  tympanitic  disten- 
sion, and  by  profuse  and  frequent  stools.  There  was  high  fever,  delirium, 
and  a  very  dry  state  of  the  tongue. 

On  the  23d  June — the  24th  day  of  the  dothinenteria — the  patient  had 
during  the  day  three  copious  motions,  consisting  of  liquid  black  blood  mixed 
with  some  clots.  Immediately  after  this  hemorrhage  I  observed  a  marked 
improvement.  In  the  evening  it  was  noted  that  the  fever  was  moderate; 
that  there  was  no  abnormal  heat  of  skin  ;  that  there  was  an  appearance  of 
greater  comfort,  and  a  desire  for  food.  The  tongue,  however,  continued 
foul  and  sticky,  with  its  centre  red  and  dry. 

Next  day  I  found  that  the  patient  had  had  three  ordinary  diarrhceal 
stools  since  the  hemorrhage  of  the  previous  evening.  The  tongue  was  moist, 
without  being  reel,  and  at  its  base  there  was  a  thin  yellowish-white  fur.  The 
pulse,  till  then  above  120,  had  come  down  to  80. 

The  patient,  however,  was  suffering  from  an  ecthymatous  eruption,  which 
from  the  first  wreek  of  the  fever  had  been  out  on  the  hips,  back,  and  thighs. 
Over  the  sacrum  the  pustules  had  become  converted  into  large  superficial 
sloughs,  not  involving  the  entire  thickness  of  the  dermis :  their  base  was  of 
a  grayish  hue.  With  a  view  to  get  rid  of  the  complications  occasioned  by 
the  contact  of  the  affected  parts  with  the  urine  and  excrementitious  matters, 
and  from  the  pressure  of  the  dorsal  decubitus,  which  the  patient  constantly 
maintained,  it  occurred  to  me  to  make  him  lie  on  straw,  covered  only  by  a 
sheet,  a  practice  adopted  at  the  Salpetriere  with  the  gdteuses  to  prevent 
excoriations  of  the  seat.  In  accordance  with  my  usual  plan,  the  patient 
had  taken  nourishing  diet  throughout  his  attack :  and  now  the  quantity  of 
broth  was  increased.  The  sloughs  cicatrized,  such  of  the  pustules  of  ecthyma 
as  had  not  ulcerated  dried  up,  and  the  general  condition  of  the  patient  was 
satisfactory,  when,  on  the  26th,  a  new  intestinal  hemorrhage  supervened, 
complicated  with  epistaxis  and  an  efflux  of  venous  blood  through  the  mouth 
from  the  nasal  fossse.  Notwithstanding  this  new  complication,  convales- 
cence was  speedily  and  satisfactorily  completed,  the  patient  being  soon  able 
to  leave  the  hospital. 

These  cases  are  conclusive.  I  could  add  others,  likewise  derived  from 
my  owm  practice,  as  well  as  others  observed  by  physicians  of  recognized 
eminence.  Thus  Dr.  Ragaine,  of  Mortagne,  states  that  in  four  hundred 
cases  which  he  saw,  eleven  had  intestinal  hemorrhage,  and  all  the  eleven 
recovered.*  Very  recently  Dr.  Juteau  of  Chartres  read,  before  the  Medical 
Society  of  Eure-et-Loir,  a  very  interesting  paper  on  an  epidemic  of  dothin- 

*  Ragaine  :  Mdmoire  sur  une  Epidemic  de  Fievre  Typhoide  qui  regna  a  Moulins- 
la-Marche  pendant  les  ann6es  1855,  1856. 


246  DOTHINENTERIA. 

enteric  fever,  in  which  he  stated  that  five  of  his  patients  had  had  intestinal 
hemorrhage,  and  that  all  of  them  recovered. 

I  would  not  wish,  however,  to  be  represented  as  saying  that  these  hemor- 
rhagic complications,  hitherto  looked  on  as  always  serious,  are  really  quite 
free  from  dauger.  They  are  in  too  many  cases  exceedingly  serious.  The 
hemorrhage  may  by  its  profusion  destroy  the  patient,  just  like  any  other 
loss  of  blood;  and  you  have  heard  of  death  resulting  from  intractable  epis- 
taxis.  Intestinal  hemorrhages  are  also  formidable  when,  by  recurring,  they 
exhaust  the  patient  and  cause  him  to  fall  into  a  state  of  anaemia  and  debility, 
leading  to  extinction  of  vital  power  and  ataxic  nervous  symptoms,  such  as 
occurred  in  one  of  the  three  cases  I  mentioned.  Finally,  intestinal  hemor- 
rhages really  are  serious  complications  of  typhoid  fever,  when,  occurring 
along  with  bleeding  from  the  nose,  gums,  lungs,  urethra,  or  along  with  sub- 
cutaneous hemorrhage,  they  are  symptomatic  of  a  dyscrasia  against  which 
the  resources  of  art  are  powerless.  I  am  now  speaking  of  the  hemorrhages 
which  constitute  one  of  the  characteristics  of  the  disease  to  which  our  pre- 
decessors gave  the  name  of  ''putrid  fever"  as  a  distinctive  term,  and  which 
at  present  we  call  "hemorrhagic  putrid  fever,"  but  in  these  cases  it  is  not, 
strictly  speaking,  the  loss  of  blood  which  kills:  death  is  the  result  of  the 
peculiar  morbid  condition  which  constitutes  putridity. 

We  had  very  recently,  in  our  St.  Bernard  Ward,  bed  Xo.  5,  an  example 
of  this  hemorrhagic  putrid  fever. 

The  patient  was  a  woman  aged  22.  She  stated'  that  she  had  always 
enjoved  good  health,  and  that  she  had  been  confined  four  months  previ- 
ously. She  had  been  ill  for  five  days,  and  a  short  time  before  her  seizure 
she  had  menstruated  as  usual.  Her  illness  began  with  headache,  vertigo, 
singing  in  the  ears,  accompanied  by  obvious  deafness  and  fever.  All  these 
symptoms  were  present  when  I  first  saw  the  patient.  The  .-kin  was  hot, 
and  the  pulse  108.  The  patient  complained  of  general  lassitude,  pains  in 
the  limbs,  particularly  in  the  legs,  and  rachialgia.  She  also  complained  of 
pain  in  the  throat,  but  nothing  particular  was  visible  there.  The  tongue 
was  very  foul.  There  was  a  little  cough,  accompanied  by  the  expectoration 
of  stringy  mucus.  The  patient  complained  thai  .-lie  could  not  sleep,  and 
she  had  disturbed  reveries.  When  spoken  to,  however,  she  answered  ques- 
tions with  precision.  In  connection  with  the  digestive  organs,  the  symp- 
toms observed  were  nausea  and  constipation.  I  prescribed  five  centi- 
grammes of  calomel,  to  be  followed  in  a  quarter  of  an  hour  by  one  gramme 
of  the  powder  of  jalap. 

During  the  night,  there  was  noisy  delirium  mingled  with  speaking  ami 
laughing.  There  was  no  expression  of  hebetude  in  the  countenance  :  there 
was  not  much  fever,  and  the  skin  was  moderately  hot  :  the  tongue  was  red, 
and  covered  at  the  base  with  a  very  thick  slimy  fur.  On  drawing  the 
nail  lightly  across  the  skin  of  the  forehead,  abdomen,  and  arm-.  1  observed 

that  the  "  tache  C&r&yrale"  was  very  distinctly  produced,  and  that  it  remained 

nie  time.     I  prescribed  calomel  in  small  doses,  viz.,  5  centigrammes 

divided  into  ten  portion.-,  of  which  one  was  to  lie  taken  every  hour. 

On  the  third  day  after  admission,  and  the  eighth  of  the  disease,  tin' 
delirium  wa-  less  violent,  and  the  patient  answered  questions.  The  tache 
cerebrate  was  very  obvious,  and  remained  for  a  long  time:  the  bowels  were 
sluggish:  the  pulse  was  108:  the  gums  were  bleeding.  The  treatment  of 
the  previous  evening  was  continued. 

Next  day,  there  was  -iill  delirium  and  deafness.  The  pulse  wa-  rapid 
and  very  soft.  I  tiarrhoea  was  -nil  absent.  There  wen-  some  rosy  Lenticular 
spots  oil  the  abdomen.  The  gums  continued  to  bleed  :  and  on  causing  the 
patient  to  lie  on  her  1'aee,  we  .-aw  large  ecchymoses  on  the  posterior  surface 


DOTIIINENTERIA.  247 

of  the  body,  particularly  on  the  trunk  and  arms:  they  were  also  seen  on 
the  anterior  aspect  of  the  chest,  round  the  left  breast.  The  ecchymotic 
spots  were  prominent  in  their  centres. 

On  auscultation,  some  subcrepitant  rales  were  heard  on  both  sides,  and 
a  blowing  sound  over  the  right  infra-spinous  fossa.  I  ordered  four  grammes 
of  the  powder  of  cinchona,  to  be  taken  in  infusion  of  coffee:  also,  a  mix- 
ture of  four  grammes  of  eau  de  Babel,  four  grammes  of  syrup  of  rhatauy, 
and  100  grammes  of  water — to  be  taken  in  doses  of  a  dessertspoonful. 
For  diet-drinks,  iced  Seltzer  water  and  iced  milk  were  prescribed.  The 
excitement  and  delirium  continued  ;  and  diarrhoea  supervened.  The  ab- 
domen was  not  tympanitic.  The  thoracic  complications  increased.  The 
breathing  was  loud ;  and  the  blowing  sound,  still  audible  in  the  right  infra- 
spinous  fossa,  was  also  heard  at  the  base  of  the  left  lung.  I  substituted  a 
gramme  of  sulphate  of  quinine  for  the  cinchona,  the  same  formula  for  its 
administration  being  adhered  to. 

On  the  eleventh  day  of  the  disease,  the  woman  died.  The  cerebral 
symptoms  continued  till  the  last.  The  chest  symptoms  had  increased,  the 
blowing  sound  being  audible  from  base  to  apex  in  both  lungs.  The  dysp- 
noea had  become  intense,  the  inspirations  beiug  fifty-six  in  the  minute. 
The  pulse  was  136.     Blood  was  flowing  from  the  mouth. 

The  autopsy  was  made  on  the  following  day.  We  found  no  trace  of 
hemorrhage  in  the  intestines.  In  the  lower  portion  of  the  ileum,  three  of 
Peyer's  patches  were  softened,  but  not  ulcerated.  Some  of  the  solitary 
glands  were  turgid.-  The  mesenteric  glands  were  congested,  and  of  a  rosy 
color.  The  spleen  was  enlarged,  and  in  color  was  deep-red,  like  the  lees 
of  wine :  its  parenchyma  was  pulpy.  The  liver  was  soft.  The  posterior 
portion  of  the  lower  lobes  of  both  lungs  was  the  seat  of  apoplectic  engorge- 
ment:  the  pulmonary  tissue  was  soft  and  blackish.  The  membranes  of  the 
brain  were  only  slightly  injected. 

What  is  the  mechanism  by  which  intestinal  hemorrhages  take  place  in 
putrid  fever  ?  At  the  autopsy  of  persons  who  have  died  of  clothinenteria 
we  often  find  bare  mesenteric  vessels  at  the  bottom  of  the  intestinal  ulcera- 
tions. Hence  it  might  be  supposed,  that  these  hemorrhages  are  attributable 
to  the  rupture  of  a  mesenteric  vessel  during  the  process  by  which  the 
furuncular  core  is  eliminated.  Still,  for  the  most  part,  if  not  always,  this 
is  not  what  occurs.  The  blood  is  exuded  by  the  mucous  surface,  exactly 
as  it  is  in  haknateniesis  and  epistaxis,  as  well  as  in  many  other  similar 
circumstances.  The  immediate  cause  of  this  sanguineous  exhalation  is  an 
essential  change  in  the  blood,  which  is  in  a  dissolved  state,  a  fact  you  can 
verify  by  examining  the  blood  abstracted  from  patients  in  our  hospital 
wards  which  are  under  the  charge  of  physicians  who  have  recourse  to  blood- 
letting in  the  treatment  of  typhoid  fever.  Such  of  you  as  have  attended 
the  excellent  clinical  lectures  of  my  honorable  and  very  accomplished 
colleague  Professor  Bouillaud,  the  most  ardent  advocate  of  this  antiphlo- 
gistic method  of  treatment,  are  aware  that  the  blood  drawn  in  such  cases 
from  a  vein,  or  obtained  by  cupping,  presents  a  fluidity  very  different  from 
that  taken  in  acute  inflammatory  diseases  such  as  pneumonia  and  acute 
articular  rheumatism.  This  particular  condition  of  the  blood,  seen  in  a 
very  high  degree  in  the  hemorrhagic  putrid  fever  (a  case  of  which  I  have 
just  detailed  to  you),  this  decomposition  of  the  blood  is  also  met  with  in 
other  fevers,  for  example,  in  yellow  fever,  that  singular  malady  in  which 
hemorrhages  from  the  stomach  and  bowels  are  so  pathognomonic,  that  in 
some  regions  of  South  America,  and  in  the  Antilles,  where  the  disease  is 
endemic,  its  common  name  is  vomito  negro  or  black  vomit.  In  scarlatina, 
diphtheria,  measles,  and  small-pox,  the  blood  is  generally  in  this  dissolved 


248  DOTHIXEXTERIA. 

state,  and  to  it  are  attributable  the  intestinal,  renal,  and  nasal  hemorrhages 
met  with  in  them,  and  of  which  I  mentioned  cases  when  treating  of  these 
diseases.  Neither  in  these  diseases  nor  in  yellow  fever  are  there  intestinal 
ulcerations  to  which  we  can  attribute  the  hemorrhages.  Still,  we  can 
understand  how  the  intestinal  lesions  of  dothinenteria  may  favor  the  ten- 
dency to  exudation  of  blood,  just  as  in  hemorrhagic  small-pox,  measles, 
and  scarlatina,  or  in  diphtheria,  an  excoriation  of  the  nasal  mucous  mem- 
brane may  favor  the  production  of  epistaxis,  or  a  surface  deuuded  by  a 
blister  may  more  readily  become  the  seat  of  cutaneous  hemorrhage. 

So  far  is  ulceration  of  the  intestine  from  being  a  condition  essential  to 
the  production  of  hemorrhages,  tha.t  they  often  come  on  at  a  period  of  the 
disease  very  far  removed  from  that  to  which  ulceration  belongs. 

Four  years  ago,  I  was  sent  for  to  meet  Dr.  Olliffe  in  consultation,  in  the 
case  of  a  young  Englishwoman  who  had  been  seized  with  intestinal  hem- 
orrhage. In  this  patient,  the  hemorrhage  occurred  at  the  ninth  day  of 
putrid  fever,  a  period  at  which  the  existence  of  ulcers  was  very  improb- 
able, as  they  are  seldom  formed  till  the  fourteenth,  fifteenth,  or  sixteenth 
day.  The  hemorrhage  continued  for  two  days,  and  was  so  great  as  to 
cause  extreme  anaemia.  Oa  the  fourteenth  day  of  the  disease,  however,  an 
obvious  improvement  took  place  in  the  patient's  general  state,  and  in  seven 
days  afterwards,  she  had  completely  recovered  from  the  typhoid  fever.  All 
that  remained  of  her  attack  was  the  anaemia  consecutive  on  excessive  loss 
of  blood. 

I  have  asked  myself  whether  the  influence  of  a  prevailing  "medical 
constitution"  might  not  sometimes  explain  the  occurrence  of  these  hemor- 
rhages. Some  years  ago,  I  was  meeting  with  them  in  typhoid  fever,  and 
at  the  same  time  was  also  meeting  with  passive  hemorrhages  in  other  dis- 
eases :  I  had  at  that  time  cases  of  purpura  hemorrhagica,  black  small- 
pox, and  numerous  examples  of  the  petechial  scarlatiniform  eruptions, 
which  I  have  pointed  out  to  you  as  occurring  at  the  beginning  of  varioloid 
affections. 

You  have  seen  me  treat  intestinal  hemorrhages  with  preparations  of 
rhatany  and  sulphuric  acid.  I  generally  prescribe  a  mixture  of  four 
grammes  of  eau  de  Rahel,  forty  grammes  of  syrup  of  rhatany,  and  one 
hundred  grammes  of  water,  ordering  it  to  be  taken  during  the  day  in  doses 
of  a  tablespoonfuL  To  prevent  a  recurrence  of  the  hemorrhage,  I  rely  on 
cinchona:  I  prescribe  four  grammes  of  the  powder  of  yellow  cinchona  to 
be  taken  daily  in  a  small  cup  of  coffee  without  milk.  As  a  means  of  ar- 
resting the  flux,  this  remedy  certainly  does  not  produce  a  sufficiently  rapid 
effect;  but  for  correcting  the  disposition  to  a  recurrence,  cinchona  in  pow- 
der is  undeniably  efficacious.  Essence  of  turpentine  has  also  been  lauded 
by  Graves  in  the  treatment  of  these  hemorrhages. 


(ri-iiniitnr  mill  \Vn.nj  Degeneration  oftht  Striated  Muscles  in  Typhoid  Fever. 
— Nature  and  Consequences  of  this  Degeneration. — Special-  Course  <>(  thr 
Rise  and  Fall  of  Temperature  in  Typhoid  Fever:  (his  is  Characteristic. 
— Parallelism  between  the  Course  of  Temperature  and  ih<  Evolution  of 
On  Intestinal  Lesions. 

A  distinguished  anatomist,  Professor  Zenker,  when  the  prosector  of  my 
friend  hi-.  Walther  of  Dresden,  discovered  the  existence  of  interesting 
anatomical  lesions  in  typhoid  lever — granular  and  waxy  degeneration  of 


DOTIIINENTERIA.  249 

the  striated  muscles.*  Rokitansky  had  previously  examined  very  thor- 
oughly the  subject  of  the  fatty  variety  of  granular  degeneration  :  Virchow 
afterwards  gave  a  very  exact  description  of  waxy  degeneration  winch  he 
regarded  as  connected  with  myositis,  and  he  explained  by  this  secondary 
alteration  the  rupture  of  muscular  fibres  observed  must  frequently  in  cases 
of  typhoid  fever:  but  Dr.  Zenker  has  studied  with  the  greatest  care,  and 
upon  a  considerable  Dumber  of  subjects,  the  different  phases  of  the  altera- 
tions which  take  place  in  muscles  in  typhoid  fever.  You  must  remember 
that  this  kind  of  degeneration  is  not  peculiar  to  typhoid  fever:  it  has  been 
observed  in  several  other  diseases.  Without  inquiring  what  it  may  be  in 
the  abstract,  let  us  now  describe  what  has  been  observed  in  relation  to  it 
in  dotbinenteria. 

In  typhoid  fever,  different  groups  of  striated  muscles  are  subject  to  de- 
generation, variable  in  intensity  and  extension,  but  not  less  constant  than 
the  characteristic  dothinenteric  lesions  of  the  mucous  membrane  of  the  in- 
testines.    This  degeneration  is  either  granular  or  waxy. 

Granular  degeneration,  when  examined  with  the  aid  of  the  microscope, 
is  found  to  be  characterized  by  a  deposit  of  extremely  minute  molecules 
in  the  contractile  tissue  of  the  muscular  bundles.  This  induces  very  great 
fragility  in  that  tissue,  so  that  during  life,  muscular  contraction  may  cause 
rupture  of  the  affected  fasciculi. 

In  waxy  degeneration,  the  contractile  tissue  of  the  primary  muscular 
fasciculi  is  transformed  into  a  colorless  and  perfectly  homogeneous  mass, 
presenting  a  very  decided  waxy  lustre.  The  transverse  striae  and  the  nu- 
clei have  entirely  disappeared,  and  the  sarcolemma  remains  intact  as  in 
granular  degeneration.  The  waxy-looking  substance  is  a  protean  body, 
resulting  probably  from  a  transformation  of  the  fibrin  or  syntonin.  The 
altered  fasciculi  are  always  fouud  to  have  acquired  increased  volume,  and 
are  sometimes  twice  their  natural  diameter.  As  in  granular  degeneration, 
they  are  found  to  have  become  exceedingly  fragile,  and  to  be  the  seat  of 
numerous  transverse  fissures. 

In  addition  to  the  rupture  of  muscular  fibres,  the  rupture  of  vessels  may 
likewise  occur,  as  a  consequence  of  granular  or  waxy  degeneration  :  and 
this  leads  to  small  ecchymoses,  or  infiltrations  of  blood,  more  or  less  exten- 
sive in  proportion  to  the  thickness  of  the  altered  muscle,  and  the  diameter 
of  the  ruptured  vessel.  These  hemorrhages  occur  most  frequently  in  the 
second  or  third  week  of  the  disease. 

Suppuration  is  a  sequel  of  muscular  degeneration  which  occurs  much 
more  rarely  than  rupture  of  vessels.  But  it  would  appear  that  degenera- 
tion of  the  contractile  tissue  is  not  alwTays  the  cause  of  the  suppuration, 
which  latter  may  be  the  result  of  irritation  seated  in  the  perimysium  (or 
envelope  of  the  primary  fasciculi).  It  is,  therefore,  the  perimysium  which 
would  suppurate.  Generally,  there  is  only  cellular  proliferation  of  the 
perimysium,  that  hyperplasia  being  limited  to  the  work  of  muscular  regen- 
eration :  but  there  may  be  a  greater  amount  of  local  irritation,  so  as  to 
cause  the  limits  of  normal  hyperplasia  to  be  exceeded,  in  which  case  there 
will  be  more  cells  formed  than  can  advance  through  the  stages  required 
for  their  becoming  contractile  tissue :  the  cells  which  are  in  excess  will, 
therefore  be  devoted  to  destruction,  and  be  transformed  into  pus.  This  is 
the  histological  explanation  of  the  inflammation,  and  subsequent  suppura- 
tion of,  the  muscular  tissue. 

*  Zenker  :  Sur  les  Alterations  des  iluscles  Volontaircs  dans  la  Fievre  Typboide. 
[Archives  Generates  de  Medeeine.  1866.]  I  am  indebted  to  this  work  for  most  of 
the  details  which  I  give  above  on  the  degeneration  of  muscles  in  typhoid  lever. 


250  DOTHINENTERIA. 

The  association  in  the  same  muscle  of  granular  and  waxy  degeneration, 
according  to  Dr.  Zenker,  does  not  prove  that  the  waxy,  which  is  the  more 
serious  of  the  two,  is  the  ultimate  result  of  the  granular.  From  their 
very  commencement,  the  two  forms  of  degeneration  are  distinct  from  each 
other. 

To  the  naked  eye,  the  following  are  the  appearances  which  altered  mus- 
cles present :  they  seem  perfectly  intact,  when  the  degeneration  is  but  little 
advanced,  which  explains  how  this  condition  escaped  notice  prior  to  the 
employment  of  the  microscope :  when  the  lesion  is  greater,  there  is  a  very 
apparent  change  of  color,  and  in  proportion  as  the  degeneration  increases, 
the  discoloration  becomes  more  decided :  the  muscles  have  at  first  a  rose- 
gray  tint  which,  becoming  gradually  paler,  is  finally  yellowish-gray,  with 
sometimes  a  very  slightly  reddish  or  brownish  color.  The  discoloration 
proceeds  by  small  spots  or  lines  corresponding  to  the  points  where  there  is 
degeneration.  When  cut  into,  the  altered  muscles  present  an  appearance 
resembling  the  flesh  offish. 

During  the  first  phases  of  the  degeneration — the  second  and  third  week 
of  the  dothinenteria — the  affected  muscles  are  in  general  very  tense,  smooth 
on  the  surface,  and  in  their  substance  dry,  friable,  and  easily  torn.  They 
are  increased  in  bulk,  which  arises  from  the  thickening  of  the  degenerated 
primary  fasciculi.  In  the  more  advanced  stages  of  the  degeneration  the 
muscles  are  relaxed,  the  surfaces  of  a  section  often  present  a  humid  aspect, 
and  there  is  even  sometimes  more  or  less  infiltration  of  serum  not  only  into 
the  muscle,  but  also  into  the  loose  cellular  tissue  which  surrounds  it,  there 
being  no  similar  infiltration  in  other  parts  of  the  body — a  circumstance 
which  proves  that  it  is  the  result  of  the  morbid  changes  in  the  muscle. 
My  friend  Mr.  Walther  has  frequently  seen  on  the  living  subject,  over  the 
recti  muscles  of  the  abdomen,  a  slight  oedema  corresponding  to  the  lesion 
I  have  been  describing,  and  recognizable  by  making  strong  pressure  upon 
the  part  with  the  finger.  I  confess  to  you  that  I  have  not  been  so  fortu- 
nate as  to  find  this  appearance. 

According  to  Professor  Zenker,  muscular  degeneration  always  occurs  in 
typhoid  fever  :  in  every  autopsy  he  has  found  it,  when  he  looked  for  it. 
The  waxy  is  much  more  common  than  the  granular  alteration:  Professor 
Zenker  met  with  the  former  seventy  and  the  latter  only  nine  times. 

The  process  of  degeneration  is  generally  at  its  height  towards  the  end  of 
the  second  week,  from  which  it  may  be  inferred  that  alteration  commences  as 
early  as  the  disease  itself.  It  continues  with  undiminished  intensity  during 
the  third  and  fourth  week.  It  is  about  this  period  that  absorption  of  the 
detritus  of  the  altered  muscular  tissue  seems  to  take  place:  this  hails  to 
softening  of  the  muscles,  often  accompanied  by  serous  infiltration,  and  the 
possibility  of  observing,  like  M.  Walther,  a  little  oedema  during  life. 

These  details  in  pathological  anatomy  are  too  full  of  interest  for  me  to 
refrain  from  making  you  acquainted  with  them.  The  constancy  of  the 
occurrence  of  muscular  degeneration  in  typhoid  fever  prows  that  it  is  an 
integral  part  of  the  disease,  and  the  generalization  of  the  lesion  shows 
that  it  is  not  the  accidental  result  of  a  morbid  action  exclusively  local,  but 
the  expression  of  a  general  disturbance  of  the  economy;  the  muscular 
system  is  attacked,  just  as  the  other  systems  are  attacked. 

Here  again,  however,  gentlemen,  I  much  fear  that  a  consequence  has 
been  mistaken  for  a  cause.  It  is  evident  that  the  weakness  and  disorder 
of  the  Locomotive  functions  which  cause  the  patient  to  totter  from  the  very 
beginning  of  an  attack  of  dothinenteria  cannot  be  due  to  muscular  degenera- 
tion, inasmuch  as  it  does  not  then  exist,  or  at  least  bas  only  begun.  The  func- 
tional disturbance  is  caused  by  the  morbid  state  of  the  cerebro-spinal  system. 


DOTHINENTERIA. 


251 


The  general  disturbance  of  all  the  functions,  and  the  special  disturbance  of 
the  muscular  system,  which  we  see  in  dothinenteric  patients,  arise  from 
imperfect  innervation.     It  is  at  a  later  stage  of  the  disease  that  granular 

and  waxy  degeneration  of  muscles  is  produced  by  alterations  in  nutrition, 
consequences  of  disordered  circulation.  Disorder  of  the  circulation  pro- 
duces hyperemia  everywhere,  and  everywhere  consecutively,  either  pseudo- 
inflammations  (long  ago  described),  or  the  forms  of  degeneration  upon 
which  I  have  been  addressing  you.  It  is,  then,  in  a  somewhat  advanced 
period,  and  particularly  during  convalescence,  that  the  granular  and 
waxv  degeneration  of  the  muscles  affords  a  physical  explanation  of  the 
feebleness  which  is  felt.  Besides,  I  cannot  refrain  from  remarking  that 
the  degeneration  affects  in  the  greatest  degree  the  recti  muscles  of  the 
abdomen  and  the  adductors  of  the  thighs,  which  certainly  are  not  the  prin- 
cipal muscular  performers  in  the  act  of  locomotion.  We  must,  therefore, 
while  we  record  as  interesting  the  anatomical  details  which  I  have  given 
you,  seek  elsewhere  for  the  cause  of  the  long-continued  feebleness  of  doth- 
inenteria :  the  cause  is  exhaustion — exhaustion  from  the  morbid  poison 
which  produced  the  fever — exhaustion  from  every  kind  of  affection  of  the 
nervous  system,  such  as  sleeplessness,  delirium,  and  convulsions — exhaustion 
from  diarrhoea — exhaustion  from  suppuration  in  the  situation  of  the  sloughs 
— exhaustion  from  embarrassment  in  sanguification — exhaustion,  finally, 
from  inanition.  Is  there  not  in  this  more  than  enough  to  account  for  the 
feebleness,  without  requiring  to  seek  an  explanation  of  it  in  the  partial 
alteration  of  the  muscles?  And  do  you  not  agree  with  me  in  thinking 
that  it  amounts  to  a  sort  of  trifling  to  give  or  to  accept  such  an  explanation? 
Gentlemen,  I  am  now  going  to  give  you  an  account  of  the  valuable 
clinical  information  which  the  thermometer  furnishes  in  dothinenteria. 
At  the  beginning  of  this  fever  the  temperature  rises  slowly,  just  as  the 
symptoms  are  slow  in  developing  themselves.  During  the  first  three,  four, 
or  five  days,  the  temperature  is  from  eight-tenths  of  a  degree  to  one  degree 
higher  than  on  the  previous  evening,  while  on  each  succeeding  morning 
there  is  a  slight  remission  of  about  five-tenths  of  a  degree  from  the  temper- 
ature of  the  previous  evening.  Thus,  in  each  twenty-four  hours  there  is 
observed  an  increase  of  temperature  both  in  the  morning  and  evening,  as 
compared  with  the  morning  and  evening  of  the  preceding  day,  although 
there  is  every  twelve  hours  a  slight  remission  in  the  morning,  as  compared 
with  the  temperature  of  the  preceding  evening.  Here  is  a  table  exhibiting 
this  movement  of  temperature,  as  it  occurred  in  one  of  our  patients  during 
the  first  four  da37s  : 


Day  of  the 
disease. 

Morning.     Evening. 

Exacerbation 

between  morning 

and  evening. 

Remission  be- 
tween evening 
and  morning. 

Rise 

between 

mornings. 

Rise 
between 
evenings. 

Degrees,  j  Degrees. 

Degrees. 

Degrees. 

Degrees. 

Degrees. 

First,    .     . 
Second, 

37.             38.2 
37.8           39  2 

1A  { 

0.4 

0.8 

1. 

Third,  .     . 

38.4 

39.8 

1.4} 

0.8 

0.6 

0.6 

Fourtb,     . 

39.4 

40.4 

1.  } 

0.4 

1. 

0.6 

Definitive 

5. 

1.6 

fourth  da 

y,  3.4°. 

elevatior 

of  temp 

erature  up  to  the 

evening  of  the 

This  table,  drawn  up  by  my  chef  de  clinique,  M.  Peter,  shows  you  at  a 
glance  the  progressive  ascent  of  the  temperature,  which,  although  there 


252  DOTHINENTERIA. 

was  a  daily  remission  every  morning  from  the  temperature  of  the  previous 
evening,  had  a  positive  increase  every  twenty-four  hours  both  morning  and 
evening.  You  will  also  observe  from  the  table,  that  if  the  temperature  had 
always  remained  in  the  morning  at  the  point  at  which  it  was  on  the  pre- 
ceding evening,  there  would  have  been  at  the  end  of  the  fourth  day  a  de- 
finitive elevation  of  five  degrees,  but  as  it  fell  every  morning,  the  actual 
increase  was  only  3.4°  over  the  temperature  of  the  first  day.  The  table 
also  shows  you,  that  on  the  evenings  of  the  third  and  fourth  days,  the  tem- 
perature was  oscillating  at  about  40  degrees,  that  is  to  say,  between  39.8° 
and  40.4°.  This  is  about  the  usual  temperature  at  that  period  ;  and  for  a 
long  time  the  average  of  the  evening  exacerbation  is  39.5°.  From  these 
facts,  which  were  first  ascertained  by  Thierfelder,  the  following  conclusions 
have  been  deduced  by  Wunderlich  :  When  the  temperature  is  40D  from  the 
first  or  second  day  of  the  attack,  the  disease  is  not  typhoid  fever:  and  again  : 
When  by  the  evening  of  the  fourth  day,  the  temperature  has  not  attained  39.5°, 
the  disease  is  not  typhoid  fever. 

Need  I,  gentlemen,  insist  upon  the  clinical  importance  of  these  state- 
ments? With  their  assistance  you  can  from  the  very  first  make  a  differen- 
tial diagnosis  between  dothinenteria,  ephemeral  fever,  and  an  eruptive 
fever,  such  for  example  as  scarlatina,  and  at  the  fifth  day  of  a  case  hitherto 
doubtful,  you  will  be  furnished  with  data  for  stating  that  it  is  not  dothin- 
enteria. Let  me  give  you  the  proof  of  this  statement,  derived  from  an 
excellent  little  work  by  Dr.  Laclame  of  Neuchatel,  from  which  I  have  taken 
numerous  extracts : 

"At  the  beginning  of  January,  1864,"  says  this  young  physician,  "I  was 
appointed  to  take  the  place  of  one  of  the  interne*  of  Professor  Griesinger, 
who  had  charge  of  the  typhoid  fever  patients  in  the  building  set  apart  for 
contagious  diseases  in  the  cantonal  hospital  of  Zurich.  The  cases  at  that 
time  were  very  severe  and  numerous,  and  the  student  whose  post  I  took  was 
ill  of  the  fever,  which  he  had  contracted  by  contagion.  When  I  had  been 
but  a  few  days  on  duty  in  the  fever  wards,  I  was  seized  one  morning,  during 
the  clinical  lecture,  with  slight  shivering,  great  prostration  of  strength,  ano- 
rexia, and  violent  headache.  I  went  to  bed  under  the  conviction  that  I  was 
at  the  commencement  of  an  attack  of  typhoid  fever.  In  the  evening  I  took 
my  temperature.  The  thermometer  rose  to  40  degrees!  Notwithstanding 
the  high  fever  from  which  I  suffered,  1  was  quite  tranquillized  as  to  my  state. 
Next  morning,  convalescence  began.  The  only  treatment  I  had  was  low 
diet,  cooling;  drinks,  and  one  centigramme  and  a  half  of  acetate  of  morphia."* 

I  have  just  told  you  that  in  out-  patient  the  temperature  gradually  rose 
during  the  first  four  days  of  the  firsl  week.  In  the  three  last  days  of  the 
same  week,  it  was  40.6°  in  the  evening,  and  fell  between  six  and  eight-tenths 
of  a  degree  in  the  morning.  This  is  what  generally  takes  place  in  the  second 
half  of  the  firsl  week  :  the  evening  temperature  keeps  up  to  at  least  39.6  . 
and  usually  to  40°  or  more,  the  morning  temperature,  according  to  the 
researches  of  Wunderlich,  always  remaining  half  a  degree  lower.  Hence 
you  perceive,  that  if  you  arc  called  to  a  patient  who  has  been  confined  to 
bed  for  Bome  days,  and  has  symptoms  which  lead  you  to  suspect  dothin- 
enteria, you   can  decide  that  it  is  not    that    disease  if  the   thermometer  doefl 

not  indicate  an  evening  temperature  of  39.5  ',  or  if  it  on  any  one  morning 

show   the  normal  temperature  of  37°. 

At  the  end  of  the  firsl  stage,  that  IS  to  say  of  the  first  week,  the  tem- 
perature  has   leached    the   point  at  which  it  will    remain   during   the  whole 

course  of  the  fever.     It  oscillates  aboul  39.5  '.  which  it   rarely  exceeds  in 


Paul  Lad  a  me  :   Le  Thermomdtre  au  Lit  du  Malade.     Neuch&tel:  1&6U. 


DOTIIINENTERIA.  253 

the  evening,  and  in  mild  cases  almost  never  attains  in  the  morning.  In 
sum.-  severe  cases,  the  temperature  exceeds  39. <>3  in  the  morning, as  well  as 
in  the  evening. 

I  have  hitherto  spoken  of  the  diagnostic  indications  furnished  by  the 
thermometer.  I  now  proceed  to  speak  of  it  as  a  guide  to  prognosis.  Ac- 
cording to  Wunderlich  and  Ladame,  it  is  during  the  second  week  that  one 
can  best  prognosticate  the  course  of  the  disease  from  thermometrical  obser- 
vations. 

1.  If  the  evening  temperature  is  maintained  between  39.5°  and  40°,  and 
the  morning  temperature  remain  always  from  half  a  degree  to  a  degree 
Lower  than  that  of  the  previous  evening,  the  attack  will  probably  be  mild, 
and  convalescence  begin  about  the  third  or  fourth  week,  particularly  if  the 
temperature  commence  to  fall  a  little  between  the  eleventh  and  fourteenth 
days. 

2.  When  during  the  second  week,  the  temperature  of  the  morning  is 
maintained  at  39°  or  39.5°,  and  when  the  evening  temperature  reaches  or 
exceeds  40.5°,  without  any  commencement  of  a  diminution  of  heat  being 
observable  by  the  middle  of  that  week,  there  is  a  certainty  that  conva- 
lescence will,  at  the  soonest,  not  begin  before  the  fourth  wreek. 

3.  All  irregularities  of  temperature  occurring  during  the  second  week 
demand  attention. 

4.  Even  when  the  temperature  does  not  rise  above  40°,  the  absence  of  a 
remission  during  the  latter  half  of  the  second  week,  or  an. increase  of  tem- 
perature toward  the  end  of  that  week,  are  always  unfavorable  signs. 

5.  The  case  is  very  serious,  when  the  temperature  is  at  40°  or  more  in 
the  morning,  and  41°  or  more  in  the  evening;  or  when,  towards  the  end  of 
the  second  week,  the  temperature  goes  on  increasing.  Speaking  generally, 
it  may  be  stated  that  a  temperature  of  41°  is  not  often  met  with,  and  in 
general  only  in  cases  which  terminate  in  death.  Mark  the  great  prognostic 
value  of  this  figure!  A  temperature  of  41.5°  or  42°  indicates  inevitable 
death.  The  prognosis  is  also  unfavorable  when  the  morning  temperature 
reaches  or  exceeds  40°  for  several  days  in  succession. 

Let  me  here  notice,  in  relation  to  prognosis,  this  very  high  temperature, 
and  extreme  frequency  of  pulse.  Dotkinenteria  is  not  a  disease  in  which 
the  pulse  is  very  frequent,  the  normal  range  being  from  100  to  110.  When 
it  gets  up  to  or  above  120  in  an  adult  suffering  from  this  fever,  the  prog- 
nosis is  as  unfavorable  as  when  the  temperature  reaches  or  exceeds  41°. 

6.  From  the  commencement  of  the  third  week,  the  mild  and  serious  cases 
can  be  distinguished  from  each  other  with  the  greatest  precision.  In  the 
mild  cases,  there  are  great  remissions  of  heat  in  the  morning,  the  morning 
temperature  being  a  degree  and  a  half  or  even  two  degrees  lower  than  that 
of  the  previous  evening.  During  this  week,  the  morning  temperature  be- 
comes normal,  and  the  evening  temperature  likewise  goes  on  falling  rapidly, 
but  does  not  reach  the  normal  standard  till  about  the  middle  of  the  fourth 
week.  In  bad  cases,  on  the  other  hand,  the  temperature  remains  what  it 
was  during  the  second  week;  and  it  is  only  at  the  end  of  the  third,  or  be- 
ginning of  the  fourth  week,  that  great  remissions  of  temperature  take  place. 

7.  Defervescence  never  proceeds  so  rapidly  as  in  exanthematous  typhus.* 
It  takes  place  in  different  ways.  The  most  usual  manner  is  by  the  tem- 
perature beginning  to  fall  considerably  in  the  morning,  even  when,  as  I 
have  just  said,  the  evening  exacerbations  continue  the  same  for  some  days; 
thus  you  may  have,  I  repeat,  a  normal  heat  in  the  morning,  while  the  even- 
ing temperature  may  still  be  39°  or  even  40°.    At  other  times,  defervescence 

*  See  the  Lecture  on  Typhus  in  this  volume. 


254  DOTHINENTERIA. 

goes  on  in  a  regular  and  parallel  manner,  morning  and  evening,  during  a 
period  of  eight  or  ten  days. 

8.  Convalescence  may  be  said  to  have  begun,  when  the  evening  tempera- 
ture has  returned  to  its  natural  standard  of  37°. 

9.  The  temperature  generally  rises  at  the  time  of  death,  or  a  few  hours 
before  it.  Drs.  Thomas  and  Lade  found  the  temperature  as  follows,  imme- 
diately before  death  in  fourteen  cases: 

Five  times,  from  40.25°  to  40.70°. 
Twice,  "     41.12°  "  41.25°. 

Seven  times,  "     42°        "42.75°.* 

In  seven  of  the  cases,  therefore,  the  temperature  reached  or  exceeded  42°, 
a  temperature  which  according  to  Wunderlich  is  hyperpyretic,  and  only  met 
with  in  cases  which  terminate  in  death.  Under  such  circumstances,  there 
is  almost  always  a  predominance  of  nervous  symptoms,  such  as  furious  de- 
lirium, excessive  restlessness,  exhaustion,  and  paralysis. 

Nevertheless,  in  contrast  to  these  cases,  I  ought  to  tell  you  that  there  are 
others  in  which  the  temperature  is  normal,  or  very  low.  The  pulse  is  at 
the  same  time  small  and  very  frequent:  the  skin  is  covered  with  a  cold 
sweat:  the  extremities  are  livid:  and  in  a  word,  the  patient  dies  in  a  col- 
lapse, which  is  sometimes  preceded  by  hemorrhage. 

Finally,  there  are  cases  in  which  death  takes  place  although  the  tem- 
perature has  neither  been  very  high  nor  very  low  ;  the  patients  die  ex- 
hausted after  a  profuse  and  obstinate  diarrhoea,  accompanied  by  tympanites, 
and  nervous  symptoms  of  no  very  great  severity. 

The  thermal  condition  and  the  intestinal  lesions  follow  an  almost  strictly 
parallel  course.  You  will  remember  I  told  you  that  the  alteration  in  the 
glands  of  Peyer  and  in  the  solitary  glands  begins  on  the  fourth  or  fifth  day  ; 
and  I  have  now  to  say,  that  it  is  from  the  same  period  that  the  tempera- 
ture rises  definitely  to  somewhere  about  39.5°  or  40.°  There  is,  therefore, 
you  see,  a  parallelism  between  the  two  phenomena.  I  have  also  told  you 
that  in  mild  cases  the  lesion  of  the  Peyerian  patches  may  be  proceeding 
towards  resolution:  now,  in  mild  cases,  it  is  precisely  at  this  time — about 
the  middle  of  the  second  week — that  we  observe  the  great  morning  remis- 
sions of  temperature.  The  parallelism  continues:  at  the  end  of  the  third 
week,  resolution  of  the  Peyerian  patches  may  be  complete;  and  that  is  the 
period  at  which  the  evening  temperature  becomes  normal.  I  also  told  you 
that  in  the  most  severe  cases,  resolution  proceeded  in  certain  patches,  whilst 
others  increased  in  size,  and  became  more  and  more  affected  :  so  that  in  this 
way,  the  intestinal  lesion  continued  till  the  third  or  even  fourth  week  :  and 
we  have  just  ^vcw  that  in  severe  eases  defervescence  does  not  begin  till  that 
period:  here  again  is  parallelism. 

To  sum  up:  In  the  first  period,  or  the  period  during  which  the  intestinal 
lesions  are  formed  and  developed,  and  which  extends  from  the  liisl  day  of 
the  attack  to  the  second  half  of  the  second  week,  the  fever  is  continued  or 
slightly  remittent,  that  is  to  say,  that  in  the  morning  and  evening  the 
temperature  is  febrile  :  in  the  secortdpi  riod,  or  period  of  resolution,  embrac- 
ing the  third  week  and  more,  the  fever   is   intermittent,  that    is   to   -ay,  the 

temperature  isfebrile  in  the  evening, and  normal  in  the  morning.  During 
convalescence,  there  is  no  lever,  ami  the  temperature  is  either  normal  or 
low  both  in  the  morning  and  evening.     Finally,  to  give  a  general  idea  of 

the  thermal  movement  in  typhoid  fever,  it  ma\  be  said  thai  then'  is  a  slow 
and  gradual  upward  movement  of  the  curve  from  the  beginning  of  the  dis- 

*  A.  Lad£:    Recherches  sur  la  Temperature  dans  lee  Maladies,     Geneve:  1866. 


DOTIIINENTEItlA.  255 

ease;  then  a  state,  Dearly  stationary,  in  which  there  is  only  a  slight  morn- 
ing descent ;  after  which  comes  a  regular  but  a  slow  defervescence. 

In  conclusion  let  me  add,  that  when  defervescence  does  not  take  place  at 
its  proper  time,  or  when  the  temperature  rises  at  the  time  at  which  defer- 
vescence ought  to  begin,  there  is  a  complication  for  which,  if  its  nature  is 
not  evident  from  the  symptoms,  you  ought  carefully  to  search.  There 
again,  gentlemen,  the  thermometer  may  assist  you  in  dealing  with  an 
insidious  affection.* 


Rosy  Lenticular  Spots. — Successive  Eruptions. — Miliary  Eruption. — Blue 

Spots. 

I  have  already  said,  gentlemen,  that  while  I  disagree  entirely  from  those 
authors  who  hold  that  the  rosy  lenticular  spots  constitute  the  specially 
characteristic  eruption  of  dothinenteria,  and  who  look  on  the  intestinal 
lesion  as  a  secondary  affection,  I  do  not  the  less  admit  that  the  cutaneous 
eruption  is  of  very  great  importance  in  the  symptomatology  of  the  disease. 

The  slightly  prominent  rosy  papules,  Avhich  disappear  under  the  pres- 
sure of  the  finger,  do  not  begin  to  show  themselves  till  from  the  seventh  to 
the  tenth  day  of  the  fever,  and  it  is  not  unusual  for  their  appearance  to  be 
even  longer  delayed;  but  when  this  delay  occurs,  the  general  symptoms, 
which  till  then  have  been  very  mild,  become  strongly  marked.  It  was  so 
in  the  case  of  a  young  man  in  St.  Agnes's  Ward,  who  after  having  shown 
us  no  symptoms  for  fourteen  days,  except  a  little  prostration  without  fever, 
and  a  slightly  saburral  tongue,  was,  at  that  period  of  the  attack,  and  coin- 
cidently  with  the  appearance  of  the  cutaneous  typhoid  eruption  on  the 
abdomen,  seized  with  symptoms  of  the  most  serious  character.  There  are 
also  cases  in  which  the  cutaneous  eruption  never  appears  during  the  whole 
course  of  the  disease,  a  fact  to  which  I  have  already  called  your  attention, 
by  mentioning  that  in  some  epidemics  of  certain  departments  in  France,  it 
had  not  been  met  with. 

This  eruption  does  not  come  all  out  on  the  skin  at  once,  as  is  the  rule  in 
the  exanthematous  fevers.  Some  papules  first  show  themselves :  on  follow- 
ing days  others  consecutively  appear.  Each  papule  considered  by  itself 
has  a  duration  of  from  three  to  fifteen  days,  and  those  which  appear  first 
are  fading  when  new  ones  are  coming  out.  The  total  duration  of  the 
whole  eruptive  period  averages  eight  days,  but  it  varies  between  the 
extreme  terms  of  three  days  and  twenty  days. 

Its  profusion  and  prolonged  duration  generally  coincide  with  an  excep- 
tional severity,  or,  to  express  it  more  correctly,  with  a  greater  prolonga- 
tion of  the  disease.  You  have  been  frequently  in  a  position  to  verify  this 
statement  for  yourselves  in  numerous  cases  which  have  been  brought  under 
your  notice.  Thus,  in  two  cases  in  which  there  was  a  total  absence  of  the 
rosy  lenticular  spots,  you  saw  recovery  take  place  at  the  end  of  the  third 
wTeek,  reckoning  from  the  time  at  which  the  patients  were  obliged  to  remain 
in  bed,  till  the  day  on  which  convalescence  was  thoroughly  established. 
This  was  also  the  duration  of  the  illness  in  six  other  individuals  who  had 
the  usual  number  of  spots,  but  it  was  longer  in  eleven  patients  in  whom 
you  saw  a  very  confluent  eruption.  The  coincidence  which  I  am  pointing 
out,  in  the  confluence  of  the  spots  and  the  severity  of  the  disease,  is  never 

*  Alf.  Duclos  :  Quelques  Kecherches  sur  l'etat  de  la  Temperature  dans  les 
Maladies.     Paris,  1864. 

Hirtz  :  Article  "  Chaleur"  dans  le  Dietionnaire  de  Medecine  et  de  (Jhirurgie 
Pratiques,  T.  vi.     Paris,  1867. 


256  DOTHINENTERTA. 

more  evident  than  when  the  eruption  after  having  disappeared  comes  out 
again  once  or  several  times.  Simultaneously  with  the  appearance  of  new 
spots,  which  are  often  more  numerous  than  their  predecessors,  the  general 
symptoms  acquire  new  intensity. 

A  woman,  aged  nineteen,  who  occupied  bed  Xo.  25  of  our  St.  Bernard 
Ward,  was  attacked,  eight  days  before  admission,  with  headache,  pain  in 
tbe  abdomen,  and  a  feeling  of  general  lassitude,  prostration,  and  pains  in 
the  limbs.  The  abdomen  was  not  tympanitic,  but  pressure  caused  gurg- 
ling in  the  right  iliac  fossa.  The  fever  was  rather  moderate.  Typhoid 
spots  were  visible  when  the  patient  was  admitted  into  hospital:  that  first 
eruption  disappeared,  and  a  second  showed  itself  on  the  eighteenth  day,  at 
a  time  when  there  had  been  an  amelioration  in  the  general  symptoms  for 
four  days.  Simultaneously  with  the  second  appearance  of  the  spots,  there 
was  a  reuewal  of  the  other  symptoms  iu  an  aggravated  form:  the  prostra- 
tion was  greater,  the  fever  higher,  and  the  diarrhoea  more  profuse  than  be- 
fore. Five  days  later  the  severity  of  the  symptoms  subsided,  and  on  the 
twenty-seventh  day  from  the  beginning  of  the  attack  the  patient  was  quite 
convalescent,  and  five  days  afterwards  was  in  a- state  to  leave  the  hospital. 

In  the  case  which  I  am  now  going  to  relate  there  were  two  reappear- 
ances of  the  cutaneous  eruption.  The  patient  was  a  young  woman  whom 
you  saw  occupying  bed  Xo.  30  in  the  same  ward.  When  received  into  the 
H6tel-Dieu  she  had  been  ill  fifteen  days,  and  ten  days  confined  to  bed. 
She  had  all  the  symptoms  of  typhoid  fever.  We  found  numerous  rosy  spots. 
They  had  disappeared  on  the  thirteenth  day  of  the  attack :  next  day  an 
improvement  was  observed,  there  being  less  diarrhoea,  tympanites,  and  pros- 
tration. Three  days  later  the  patient  experienced  nausea:  there  was  a 
renewal  of  the  abdominal  tympanitic  distension,  and  at  the  same  time  gurg- 
ling was  perceived.  There  was  high  fever,  and  a  new  eruption  as  abundant 
as  the  former.  The  severity  of  the  symptoms  after  a  time  abated.  The 
spots  were  completely  faded  on  the  twenty-seventh  day  ;  and  on  the  thirtieth 
convalescence  seemed  sufficiently  secured  to  enable  the  patient  to  be  allowed 
a  little  solid  food  ;  but,  on  the  thirty-fourth  day,  there  set  in,  for  the  third 
time,  abdominal  pains,  gurgling,  nausea,  vomiting,  and  diarrhoea.  The 
tongue  was  red,  dry,  and  destitute  of  epidermis;  the  skin  was  hot,  and  the 
urine  contained  albumen,  which  coagulated  on  the  application  of  heat.  On 
the  morrow  a  new  eruption  of  rosy  spots  appeared,  which  remained  till  the 
fortieth  day  of  the  disease;  and  on  the  forty-fifth  day  convalescence  was 
definitely  established. 

In  neither  of  these  cases  could  any  cause  be  assigned  for  the  severe  relapse 
of  the  dotbinenteria ;  but  relapses  are  sometimes  attributable  to  errors  in 
diet,  to  a  fit  of  indigestion,  so  difficult  to  guard  against  in  self-willed  patients. 

This  occurred  in  a  third  case  in  which  there  was  a  return  of  the  symp- 
toms. The  patient  occupied  bed  No.  5  of  St.  Bernard's  Ward.  On  the 
twenty-eighth  day  of  her  dothinenteria  this  woman,  who  was  entering  upon 
her  convalescence,  had  a  til  of  indigestion,  and  was  very  soon  afterwards 
seized  with  delirium  and  liver.  On  the  following  day  an  eruption  of  rosy 
spots — which    had    been  observed   since   her  admission    to  hospital  and   had 

disappeared — again  came  out.     The  relapse  was  ool  of  long  duration.     The 

genera]  symptoms  abated:    the  -pots  had    faded  away  in  live  days  from  the 

date  of  their  reappearance,  and  by  the  end  of  the  fifth  week  recovery  was 
complete. 

The  existence  of  this  exanthematous  eruption  at  periods  very  remote  from 
that  before  which  it  has  generally  disappeared  may  sometime-  lead  to  mi.-- 
take-;  and  when  one  has  notobserved  the  disease  from  the  beginning,  when 
there  is  a  want  of  precise  information  regarding  the  previous  history  of  the 


DOTHINENTERIA.  257 

case,  the  dothinenteria  may  be  supposed  to  have  reached  a  more  advanced 
Btage  than  it  really  has.  An  autopsy  recently  performed  in  your  presence 
has  a  very  interesting  bearing  on  that  point. 

A  man,  aged  thirty,  was  brought  to  the  hospital  with  all  the  symptoms 
of  very  severe  putrid  fever.  The  delirium  was  violent,  the  fever  intense, 
the  skin  hot  and  dry:  the  abdomen  was  tympanitic,  and  covered  with  a 
very  confluent  eruption  of  rosy  lenticular  spots.  Although  the  persons  who 
brought  him  to  the  hospital  told  us  that  he  had  been  ill  thirty-five  days, 
the  profuse  eruption  led  us  to  believe,  considering  the  general  rule  of  the 
disease,  that  the  typhoid  fever  dated  back  only  sixteen  or  eighteen  days. 
We  inquired  whether  the  patient  had  not  had  some  other  malady  before 
that  under  which  he  labored  at  the  time  of  his  admission  to  the  hospital. 
The  patient  died ;  and,  on  opening  the  body,  it  was  found  that  the  typhoid 
fever  really  did  date  back  to  a  period  thirty-five  days  before  we  saw7  him. 
"We  found  intestinal  ulcerations  nearly  cicatrized.  The  eruption  which  he 
had  on  admission  was  therefore  a  second  eruption. 

To  explain  the  intensified  returns  {recrudescences)  of  the  fever  and  the 
successive  eruptions,  Ave  must  suppose  that  the  morbid  poison  has  not  ex- 
hausted itself  in  the  first  outbreak,  and  that  the  economy,  to  get  rid  of  it, 
requires  repeated  efforts.  These  returns  of  the  fever  are  neither  relapses 
(rechutcs),  nor  still  less  are  they  new  attacks  (recidives)  :  it  is  the  same 
attack,  the  symptoms  of  which,  temporarily  interrupted,  recur  under  the 
influence  of  the  same  morbid  cause  which  produced  them  in  the  first  in- 
stance. However  complete  the  symptoms  may  be,  and  although  the  erup- 
tion reappears,  the  characteristic  intestinal  lesion  never  returns.  In  the 
patient  whose  case  I  have  just  brought  before  you,  we  only  found  cicatrized 
ulcei'ations :  there  was  no  trace  of  a  renewal  of  the  intestinal  ulceration. 

The  possibility  of  the  symptoms  returning  at  a  time  when  convalescence 
is  supposed  to  have  begun  ought  to  make  the  physician  very  cautious. 
When  at  this  period  he  thinks  that  he  may  feed  up  his  patient,  he  ought 
to  proceed  with  very  great  prudence,  and  avoid  being  guided  by  the  appe- 
tite of  the  patient,  which  is  often  deceitful :  he  ought  in  particular  to  be 
exceedingly  reserved  in  his  prognosis  during  the  whole  course  of  dothinen- 
teria, as  cases  which  seem  at  first  to  be  exceedingly  mild,  may  one  day  have 
a  very  serious  exacerbation.  In  reference  to  successive  eruptions,  I  would 
say,  that  while  they  do  not  absolutely  imply  danger,  they  at  least  indicate 
that  the  case  will  be  more  protracted  than  usual,  and  consequently  that 
recovery  will  be  retarded. 

I  have  still  to  mention  two  other  forms  of  eruption  to  which  I  have  often 
directed  your  attention  at  the  bedside  of  the  patient.  I  am  not  at  present 
referring  to  petechice,  those  small  spots  of  a  violet-red  color,  which  do  not 
disappear  under  pressure  of  the  finger,  true  subcutaneous  ecchymoses,  which 
belong  to  the  history  of  hemorrhagic  putrid  fever,  and  still  more  to  the 
history  of  typhus.     I  refer  to  the  miliary  eruptions  and  the  blue  spot*. 

The  transparent  miliary  vesicular  eruption  [la  miliairepellucide']  improperly 
called  sudamina,  generally  appears  between  the  eleventh  and  twentieth  days 
and  sometimes  later,  and  consists  of  small  blebs  of  round  or  oblong  shape 
like  tears,  which  are  filled  with  a  transparent  fluid.  This  eruption  is  some- 
times very  profuse,  but  there  is  a  great  difference  in  respect  of  the  number 
of  blebs.  The  situations  which  it  occupies  are  the  abdomen,  particularly 
in  the  vicinity  of  the  groins,  the  front  of  the  neck,  and  the  anterior  part  of 
the  axillae:  in  some  cases  it  extends  over  the  entire  trunk,  and  also  appears 
on  the  limbs.  This  eruption  is  hardly  visible,  unless  you  are  very  close  to 
the  patient,  but  it  is  easily  recognizable  by  the  touch,  on  account  of  the 
sort  of  rugosity  of  the  skin  caused  by  the  small  blotches  of  which  it  con- 

VOL.    I. — 17 


258  DOTHINENTERIA. 

sists.  It  is  never  seen  on  the  face.  It  is  more  usual  to  meet  with  this  exan- 
thern  in  typhoid  fever  than  in  any  other  disease,  but  it  is  by  no  means  pecu- 
liar to  it ;  and  I  agree  with  Huxham  and  Professor  Bouillaud  in  regarding 
it  as  simply  the  symptom  of  a  symptom,  miliary  eruption  being  generally 
the  consequence  of  sweating. 

You  have  seen  in  many  patients  an  eruption  of  spots  of  a  blue  color. 
These  blue  spots,  you  have  remarked  with  me,  are  only  seen  in  exceedingly 
mild  cases  terminating  favorably.  Is  this  a  mere  coincidence,  or  is  the 
eruption  of  blue  spots  an  inherent  characteristic  of  a  mild  form  of  the  dis- 
ease ?     These  are  questions  which  I  cannot  solve. 


Intestinal  Dothinenteric  Catarrh. — Its  Specific  Character. — Predominance  of 
Intestinal  and  Pulmonary  Catarrhal  Affections  constitutes  the  Forms  of 
the  Disease  called  "  Abdominal"  and  "  Thoracic." 

We  had,  gentlemen,  in  bed  No.  11  ter  of  St.  Agnes's  Ward,  a  youth  who 
came  into  the  Hotel-Dieu  five  days  ago  with  giddiness,  headache,  high  con- 
tinued fever,  the  tongue  red  at  the  point,  thirst,  anorexia,  some  fits  of  cough, 
and  a  profuse  diarrhoea.  At  first,  there  was  room  for  supposing  the  case  to 
be  one  of  incipient  typhoid  fever,  and  for  a  moment  I  did  entertain  that 
idea.  The  diarrhoea,  however,  had  set  in  so  suddenly,  and  had  from  the 
very  first  been  so  severe,  that  I  hesitated  :  the  symptoms  seemed  not  to  be 
those  of  the  enteritis  which  accompanies  putrid  fever,  but  those  rather  of 
simple  intestinal  catarrh.  I  deferred  my  diagnosis ;  for  it  is  especially 
necessary  in  such  circumstances  not  to  pronounce  a  too  absolute  opinion. 
In  twenty-four  hours,  the  fever  had  abated,  and  on  the  third  day  it  en- 
tirely ceased :  the  general  symptoms  likewise  improved,  the  headache  be- 
came less  severe,  the  appetite  returned,  and  with  these  changes  for  the  better, 
the  diarrhoea  also  stopped.  In  fact,  this  youth  who,  at  the  most,  had  been 
ill  six  days,  had,  at  the  end  of  these  six  days,  regained  his  usual  health. 

I  should  certainly,  gentlemen,  have  played  a  lucky  game,  if  I  had  given 
at  my  first  visit  a  decided  opinion  based  upon  the  symptoms  which  were 
then  present.  If  without  allowing  the  case  for  a  moment  to  follow  its 
natural  course,  I  had  begun  active  treatment,  in  place  of  confining  myself 
to  prudent  waiting,  I  might  have  believed,  and  I  might  have  told  you, 
that  I  had  cured  a  case  of  dothinenteria  in  six  days,  as  some  physicians 
who  do  not  take  into  account  the  specific  character  of  the  disease  asserl 
they  can  do,  and  as  homoeopaths  particularly  pretend  to  do.  1  should 
have  deceived  myself  like  these  physicians,  and  like  these  homoeopaths:  1 
speak  of  honest,  homoeopaths,  lor  it  is  necessary  to  distinguish  between  the 
honest  and  dishonest  of  that  sect.  Of  the  dishonest  homoeopaths,  the  great 
majority,  grossly  ignorant,  and  without  any  kind  of  medical  creed,  only 
see  in  homoeopathy  a  road  to  riches,  by  attracting  to  themselves  the  public, 
always  favorable  to  the  mysterious;  while  others,  still  more  culpable,  shame- 
less charlatans  of  the  worst  description,  educated  in  our  art.  knowingly 
deceive  themselves  in  deceiving    their   patients.      But    by  the  side   of  these 

dishpnesl  men,  thoroughly  deserving  of  the  contempl  into  which  they  have 

fallen,  there  are  others,  educated,  conscientious,  and  convinced  of  the  truth 

of  the  doctrine  which  they  have  embraced:  it  was  to  them  only  that   1 
made  allusion. 

Well!  when  these  practitioners  fancy  thai  they  have  arrested  in  their 
career  maladies  which  must  pursue  an  inevitable  course,  it    is  because  they 

do  not  regard  this  inevitability  from  the  same  point  of  view  with  me.    Let 

me  explain  myself  l>y  giving  you  an  illustration  of  my  meaning.    We  know 
heforcliand,  when    we    inoculate   >niall-po\    or   COW-pOX,   that    the    morbific 


DOTHINENTERIA.  259 

germs  will  grow  up  and  produce  a  disease,  the  characters  of  which  will  be 
rigorously  determined  by,  and  absolutely  dependent  upon,  the  nature  of 
the  cause  whence  they  spring — as  absolutely — the  comparison  is  strictly 
correct — as  absolutely  as  the  germ  of  a  plant  grows  up  reproducing  the 
characters  of  the  species  which  furnished  it,  and  of  no  other  species,  the 
acorn  reproducing  the  oak,  and  the  seed  of  corn  reproducing  corn.  In 
disease,  though  we  cannot  lay  hold  of  the  first  cause,  the  same  thing  takes 
place,  that  is  to  say,  different  causes  engender  diseases  of  different  species 
having  respectively  their  special  symptoms  and  peculiar  career;  and,  to 
return  to  our  subject,  the  morbific  cause  which  engenders  simple  intestinal 
catarrh,  will  not  engender  the  catarrhal  enteritis  of  dothinenteria  anymore 
than  the  virus  of  small-pox  will  engender  scarlatina  :  each  has  its  own 
special  characters  and  course,  and  I  am  not  of  those  who  believe  that  the 
one  can  be  transformed  into  the  other,  unless  it  be  under  peculiar  circum- 
stances, as  for  example,  when,  under  an  epidemic  influence,  an  individual 
seized  originally  with  a  simple  intestinal  catarrh  is  attacked  with  putrid 
fever,  which  then  puts  its  stamp  on  the  non-specific  enteritis.  To  continue 
still  farther  our  comparison  derived  from  the  germination  of  the  seed,  I 
would  remark,  that  while  it  is  difficult,  even  after  long  practice,  to  distin- 
guish the  different  kinds  of  plants  at  the  period  when  there  is  nothing  to 
be  seen  but  the  nascent  leaflets  in  the  cotyledons  of  the  seed,  while  we  must 
wait  till  the  formation  of  the  plant  is  more  advanced  before  we  can  tell 
the  family,  genus,  species,  and  variety  to  which  it  belongs,  it  is  also  diffi- 
cult to  distinguish  the  particular  disease  with  which  one  has  to  do,  so  long 
as  it  is  only  beginning  to  manifest  itself.  Hence  the  frequency  with  which 
simple  intestinal  catarrh  is  mistaken  for  the  intestinal  catarrh  of  dothinen- 
teria ;  and  the  frequent  necessity  of  allowing  some  days  to  elapse  before 
pronouncing  a  decided  diagnosis.  It  is,  therefore,  an  immense  point  in 
medicine  to  know  the  natural  course  of  diseases,  and  to  wait  a  little  till 
their  characters  are  precisely  drawn  :  before  beginning  treatment,  it  is  y 
necessary  to  know  whether  the  case  is  one  in  which  our  intervention  ought 
to  be  active,  or  one  in  which  we  ought  to  rely  on  the  unaided  therapeutic 
efforts  of  nature,  satisfying  ourselves  by  being  always  ready  to  assist  na- 
ture should  that  be  requisite. 

The  intestinal  catarrh  of  dothinenteria  is  a  catarrh  of  a  specific  charac- 
ter, and  we  may  use  means  for  moderating  it,  just  as  we  adopt  means  for 
moderating  other  catarrhs ;  but  if  we  try  entirely  to  remove  it,  we  shall 
fail.  The  diarrhoea  which  characterizes  it  is  one  of  the  most  frequent 
symptoms  of  the  disease ;  but  no  more  than  the  other  symptoms  is  it  pro- 
portionate to  the  extent  or  intensity  of  the  intestinal  lesions.  It  may  set 
in  during  the  first  twenty-four  hours,  or  not  till  the  third  day,  the  ninth 
day,  or  even  not  till  a  more  advanced  period  ;  and  in  some  exceptional  cases, 
the  intestinal  flux  is  absent,  and  sometimes  even  there  is  obstinate  consti- 
pation during  the  whole  course  of  typhoid  fever.  You  have  seen  several 
examples  of  this  in  the  clinical  wards. 

In  the  generality  of  cases,  the  stools  are  few  and  scanty  at  the  beginning 
of  the  attack,  and  vary  during  the  remainder  of  its  course  in  number  and 
character.  Sometimes  a  patient  has  only  one  in  twenty-four  hours,  while 
another  patient  has  more  than  twenty.  The  evacuations  are  liquid,  yel- 
lowish, greenish,  or  sometimes  they  consist  of  a  stercoraceous  pulp,  or  they 
have  a  semi-liquid  consistence ;  their  odor  is  fetid,  and  sui  generis.  The 
motions  are  seldom  accompanied  by  severe  pain,  and  never  or  almost  never 
with  gripes ;  they  may  be  passed  involuntarily,  as  when  the  patient  is  in  a 
state  of  delirium  or  stupor,  and  likewise  when  he  is  in  no  such  circum- 
stances. 


260  DOTHINENTERIA. 

The  catarrhal  feature  of  the  disease  is  also  met  with  in  the  pulmonary 
apparatus,  where  auscultation  always  reveals  a  certain  amount  of  bron- 
chitis, characterized  by  dry,  moist,  sibilant,  and  mucous  rales,  which  are 
heard  from  the  beginning,  or  at  least  from  the  first  days  of  the  attack. 
The  cough  is  generally  in  proportion  to  the  abundance  of  the  rales :  the 
expectoration,  which  is  exceedingly  small  in  quantity,  consists  of  mucous 
sputa. 

The  catarrhal  affections  do  not  always  coexist ;  and  when  the  abdominal 
symptoms  occur  alone,  or  when  they  dominate  over  the  other  symptoms, 
"  abdominal"  is  the  name  given  to  the  form  of  the  disease.  It  is  chiefly  in 
the  mucous  form  of  dothinenteria  that  we  meet  with  this  almost  exclusively 
abdominal  character  in  the  symptoms. 

Thoracic  complications,  whatever  may  be  the  leading  general  symptoms, 
may  assume  great  intensity,  and  then  there  may  be  either  an  exacerbation 
of  the  ordinary  bronchial  catarrh,  or  inflammation  of  the  pulmonary 
parenchyma :  the  existence  of  pneumonia  is  ascertained  by  hearing  fine 
crepitant  rales  and  bronchial  blowing  on  auscultation,  and  by  dulness  on 
percussion  over  the  affected  part.  On  examination  after  death,  the  lung 
is  found  to  be  highly  congested,  and  hepatizecl,  and  to  tear  in  handling,  a 
condition  which  I  remarked  in  the  case  of  the  young  lad  of  St.  Agnes's 
"Ward,  the  particulars  of  which  I  will  afterwards  recapitulate.  This  pneu- 
monia occurring  in  the  course  of  typhoid  fever  is  one  of  the  most  serious 
complications :  it  very  greatly  imperils  the  patient,  and  when  it  does  not 
lead  to  an  immediately  fatal  issue,  it  prolongs  and  thwarts  convalescence. 

You  saw  to-day,  in  bed  28  of  St.  Bernard's  Ward,  a  woman  presenting 
an  example  of  what  is  called  the  thoracic  form.  But  in  her  case  bronchial 
catarrh,  without  parenchymatous  inflammation,  is  the  leading  symptom. 
The  patient  had  bronchitis  when  she  came  into  the  Hotel  Dieu  on  the  loth 
of  August  last.  She  has  resided  in  Paris  for  the  last  two  years ;  she  has 
generally  enjoyed  good  health.  She  was  confined  seven  months  ago,  when,' 
fifteen  days  before  she  came  into  our  wards,  she  was  seized  with  headache, 
abdominal  pain,  and  slight  diarrhoea.  From  that  time  she  was  distressed 
by  sleeplessness.  When  we  saw  her  for  the  first  time,  she  had  a  copious 
eruption  of  rosy  lenticular  spots.  The  circumstance  which  especially  at- 
tracted my  attention  was,  that  the  chief  complaint  this  woman  made  was 
of  difficulty  in  her  breathing,  which  was  loud  and  quick.  On  percussion 
of  the  chest,  we  found  that  the  sounds  elicited  were  everywhere  equally 
clear :  on  auscultation,  we  heard  rales  in  every  part  of  the  chest — mucous 
rales  which  were  coarse  at  the  upper  part,  and  finer  at  the  base  of  the  lungs. 
The  fever  was  very  moderate. 

This  patient  is  still  in  hospital,  and  in  the  report  of  her  ease,  which  is 
taken  regularly  day  by  day,  you  will  sec  that  her  slight  abdominal  symp- 
toms had  subsided  by  the  19th  of  August,  that  by  the  21st  the  stools  had 
become  natural,  and  the  fever  had  left  her,  but  that  the  pulmonary  symp- 
toms had  improved  very  slowly.  For  some  days,  the  expectoration  has 
become  more  and  more  abundant,  and  has  assumed  a  muco-purulenl  ap- 
pearance; the  plessimetric  and  stethoscopic  signs  remain  as  before,  and 
there  is  no  decrease  in  the  dyspmea.  To-day,  the  thirty-second  day  of  the 
disease,  you   see  this  woman  slill  very  much  in  the  same  -lale  in  respeel  of 

her  bronchitis.  You  will  find  her  Beated  on  her  bed,  always  suffering  from 
oppressed  respiration,  and  frequent  fits  of  coughing.  Her  spittoon  contains 
a  large  quantity  of  niuco-purulcnt  expectoration.  The  digestive  functions, 
however,  seem  to  have  returned  to  their  natural  state,  the  appetite  is  re- 
stored, and  she  eats  half  the  ordinary  daily  diet  of  a  patient.  There  is  very 
little  feverish 1 1 ess. 


DOTIIINENTERIA.  261 


Forms  of  Dotkinenteria,  viz.,  the  Mucous,  Bilious,  Inflammatory,  Adynamic, 
Ataxic,  Spinal,  Cerebrospinal,  and  Malignant. 

A  mason,  aged  sixteen,  born  in  the  department  of  Haute-Vienne,  and 
who  had  only  been  resident  in  Paris  for  a  few  months,  came  into  the  Hotel- 
Dieu  on  the  14th  June,  and  was  placed  in  St.  Agnos's  Ward.  When  I  saw 
him  next  morning,  he  could  not  give  the  least  information  as  to  the  begin- 
ning of  the  malady  from  which  he  was  suffering.  He  was  in  a  state  of  high 
fever ;  the  pulse  was  100,  regular,  but  soft.  There  was  profound  coma ; 
he  had  been  delirious  during  the  whole  niejit ;  and  I  observed  convergent 
strabismus  of  both  eyes.  The  tongue  was  red  and  dry;  the  abdomen  was 
tympanitic,  with  gurgling  in  the  right  iliac  fossa,  and  diarrhoea.  The  symp- 
toms became  more  severe  every  day,  and  on  the  17th  I  noted  that  the  limbs 
were  rigid.  On  the  19th,  five  days  after  his  admission  to  hospital,  the 
patient  died.  On  the  morning  of  his  death,  his  appearance  was  deplorable; 
the  eyes  were  haggard  ;  the  nostrils,  lips,  and  teeth  were  covered  with  black 
sordes ;  the  tongue,  dry  and  covered  with  little  cracks,  lay  motionless  be- 
tween the  upper  and  lower  teeth;  the  abdomen  was  tympanitic;  the  pulse 
was  thready,  and  exceedingly  quick  ;  the  skin  of  the  hands  was  cold, 
clammy,  and  blue  as  in  cholei*a,  while  that  of  the  body  was  dry  and 
burning.  , 

At  the  autopsy,  we  found  great  gaseous  distension  of  the  intestines :  the 
glands  of  Peyer  were  swollen,  but  not  ulcerated,  some  of  them  forming  an 
elevation  of  the  thickness  of  a  five  franc  piece:  some  of  the  solitary  glands 
were  swollen:  the  mesenteric  glands  were  enlarged.  The  spleen  was  hyper- 
trophied,  measuring  seventeen  centimetres  in  length  and  thirteen  in  breadth. 
Its  tissue  was  easily  reduced  to  a  thin  pulp.  The  liver,  blackish  and  soft, 
broke  down  under  the  least  pressure,  making  it  difficult  at  first  sight  to  dis- 
tinguish its  two  component  tissues.  The  lungs,  black,  gorged  with  blood, 
and  softened,  tore  easily:  they  did  not  contain  any  apoplectic  sanguinolent 
masses.  The  heart,  pale,  and  anaemic,  contained  some  clots.  The  mem- 
branes of  the  brain  were  only  slightly  vascular :  there  was  neither  opaline 
nor  even  discolored  effusion  in  the  sulci :  there  was  no  thickening  of  the 
membranes,  nor  were  they  adherent  to  the  substance  of  the  brain.  The 
brain,  when  sliced,  presented  only  a  slight  appearance  of  bloody  points. 

Gentlemen,  during  the  two  months  which  preceded  the  occurrence  of  this 
case,  you  saw  two  other  typhoid  fever  patients  in  whom  the  symptoms  which 
predominated  were  similar  to  those  which  we  met  with  in  this  young  man. 
One  was  a  man,  and  the  other  a  woman  :  both  recovered.  A  month  after 
leaving  the  Hotel-Dieu,  the  woman  was  received  into  La  Pitie  Hospital, 
having  had  a  relapse.  The  man,  aged  eighteen,  whose  life  was  for  a  long 
time  in  danger,  left  our  wards  on  the  thirty-fourth  day,  completely  recovered 
from  the  attack  of  typhoid  fever,  and  also  from  sores  over  the  sacrum  which 
had  formed  during  the  severe  period  of  his  illness. 

These  are  cases  of  adijnamic  typhoid  fever,  which  our  predecessors  con- 
sidered a  distinct  disease;  just  as  the  mucous,  bilious,  inflammatory,  ataxic, 
and  malignant  forms  were  looked  on  as  separate  diseases  till  the  progress 
of  pathological  anatomy,  influenced  mainly  by  the  labors  of  Bretonneau, 
showed  that  they  were  not  different  species,  but  simply  varieties  of  one 
species. 

Nevertheless,  in  reducing  all  the  varieties  to  a  pathological  unity,  spe- 
cially based  on  the  constant  existence  of  the  dothinenteric  eruption,  it  is 
impossible  to  deny  that  predominance  of  a  certain  class  of  phenomena  gives 
a  particular  stamp  to  the  dothinenteria,  which  it  is  important  to  take  into 


262  DOTHINENTERIA. 

consideration  at  the  bed  of  the  patient,  in  respect  both  of  prognosis  and 
treatment.  Is  not  this  predominance  of  particular  pathological  manifesta- 
tions conspicuous  in  other  diseases,  upon  which  it,  in  the  same  way,  im- 
presses its  own  character  ?  For  example,  does  not  pneumonia,  generally 
an  acutely  inflammatory  disease,  become,  under  certain  circumstances, 
bilious,  adynamic,  ataxic,  or  malignant  ?  In  consequence  of  dothinenteria 
having  a  greater  tendency  than  any  other  disease  to  present  variety  of  dom- 
inant symptomatic  phases,  the  older  physicians,  unable  to  grasp  the  patho- 
logical unity  of  this  variety,  regarded  each  different  form  as  a  distinct 
disease. 

The  simplest  form  of  dothinenteria  is  the  mucous:  it  is  distinguished  from 
the  others  by  its  purely  negative  characters,  there  being  no  decided  pre- 
dominance of  one  or  several  symptoms.  You  have  seen  numerous  exam- 
ples of  this  form.  To  it  belonged  the  cases  in  which  the  patients  reached 
the  hospital  in  a  state  of  prostration  approaching  insensibility,  complaining 
of  a  little  headache,  and  feeling  giddy.  Some  have  had  sleeplessness,  and 
others  slight  delirium.  The  fever  was  moderate,  and  the  pulse  was  often 
below  the  normal  standard.  You  have  sometimes  observed  epistaxis  at  the 
beginning  of  an  attack :  but  it  is  generally  absent,  and  the  course  of  the 
disease  is  not  influenced  by  its  presence  or  absence. 

You  have  seen  that  the  leading  symptoms  are  connected  with  the  diges- 
tive functions.  The  patients  complained  of  want  of  appetite,  an  insipid 
taste  in  the  mouth,  and  rather  urgent  thirst.  The  tongue,  saburral  to  a 
slight  degree,  was  covered  with  a  thin  whitish  fur:  it  was  moist,  swollen, 
retained  the  impression  of  the  teeth,  and  was  red  at  the  point  and  edges. 
In  some  cases,  there  was  vomiting.  Some  patients  had  profuse  bilious  diar- 
rhoea, while  others  had  obstinate  constipation.  Gurgling  in  the  right  iliac 
fossa  was  always  observed.  Auscultation  established  the  existence  of  bron- 
chitis characterized  by  sibilant,  sonorous,  and  mucous  rales,  with  occasional 
fits  of  coughing  accompanied  by  mucous  expectoration.  In  some  patients, 
the  rosy  lenticular  spots  were  wanting,  while  in  others,  they  came  out  in 
successive  eruptions.  This  mucous  fever  is  a  mild  form  of  dothinenteria, 
but  nevertheless  an  attack  may  be  prolonged  for  twenty  or  thirty  days,  or 
longer.  I  have  always  seen  it  terminate  favorably  ;  but  you  must  remem- 
ber that  in  this  mild  form  of  the  disease,  as  well  as  in  the  still  milder  cases 
to  which  the  designation  oi'  latent  typhoid  fever  has  been  given,  death  may 
occur  from  an  unforeseen  perforation,  from  hemorrhage,  or  from  one  of 
those  spontaneous  attacks  of  peritonitis  of  which  I  have  spoken.  Conva- 
lescence is  often  very  slow;  and  when  this  lias  been  the  ease,  I  have  seen 
relapses  which  were  worse  than  the  original  attack. 

Under  the  prevailing  influence  of  certain  medical  constitutions,  the  dis- 
ease assumes  the  bilious  form.  Although  this  form  has  lately  occurred 
pretty  frequently  in  town,  we  have  aol  met  with  any  well-marked  cases  of 
it  in  the  clinical  wards.  Gentlemen,  you  know  the  characteristics  of  the 
bilious  form  of  dothinenteria.      The  saburral  condition  is  more  decided  than 

in  the  mucous  form.  The  complexion  is  yellow,  particularly  on  the  alee  ^' 
the  nose,  and  in  the  naso-labial  hollow:  the  Bclerotic  has  an  icteric  hue: 
there  is  greater  want  of  appetite  than  in  the  mucous  form,  and  the  patienl 
complains  of  a  very  bitter  taste  in  the  month,  accompanied  by  nausea,  and 
vomiting  of  yellowish  and  greenish  matters.    The  fur  upon  the  tongue  is 

thicker  than  in  the  mucous  form  of  the  disease,  and  has  a  greenish-yellow 
appearance,  particularly  at  the  base.      There  18  also  more  headache.      The 

bilious  is  generally  combined  with  one  of  the  other  forms  of  which    1   am 

going  to  speak. 

The  inflammatory  is  likewise  generally  combined  with  other  forms  of  the 


DOTIIINENTERIA.  263 

disease.  It  is  characterized  at  the  commencement  of  the  attack  by  intense 
fever,  a  pulse  which  is  full  and  often  bis  feriens,  a  moist  heat  of  skin,  aud, 
in  a  word,  with  the  symptoms  of  general  febrile  plethora.  This  inflamma- 
tory condition,  which,  according  to  the  prevailing  medical  constitution,  is 

frequently  met  with,  rarely  continues  from  the  beginning  to  the  end  of  an 
attack  :  it  usually  gives  place  to  an  adynamic  or  ataxic  state. 

Except  in  this  last  form — this  state  of  prostration — the  collapse  of  the 
animal  functions,  particularly  of  muscular  contractility,  is  one  of  the  most 
constant  generic  characters  in  all  the  varieties  of  typhoid  fever.  When  it 
is  not  in  excess  of  its  usual  degree,  it  does  not  call  for  more  anxious  con- 
sideration than  any  other  symptom  ;  but  when  it  becomes  the  predominat- 
ing character  of  the  attack,  and  when  with  the  prostration  of  the  functions 
of  animal  life,  there  is  combined  collapse  of  the  organic  functions  more  im- 
mediately essential  to  the  maintenance  of  life,  a  condition  exists  to  which  is 
given  the  name  of  adynamia.  This  adynamic  typhoid  fever,  of  which  I  have 
brought  under  your  notice  several  examples,  was  characterized  in  our  pa- 
tients by  extreme  softness  of  the  pulse,  by  very  deep  and  protracted  stupor, 
by  very  great  insomnia,  by  quiet  delirium,  by  muttering,  by  picking  the 
bedclothes,  by  deafness,  and  by  paralysis  of  the  bladder  requiring  the  use 
of  the  catheter.  You  recollect  a  woman  who  in  her  delirium  refused  to 
take  food,  and  to  whom  it  was  necessary  to  administer  soups  by  the  oesopha- 
geal tube.  In  this  form  of  the  disease,  the  tongue  is  clammy  and  trem- 
bling, and  the  tongue,  gums,  and  teeth  are  covered  with  black  sordes.  There 
is  profuse  diarrhoea,  and  an  extreme  degree  of  tympanites.  In  some  epi- 
demics intractable  vomiting  has  been  observed.  In  this  form  of  the  disease, 
you  will  observe  that  the  perspiration,  breath,  and  urine  have  a  fetid  smell. 
There  is  a  tendency  to  hemorrhages ;  and  also  to  sphacelus,  as  is  indicated 
by  sloughs  forming  in  the  seat,  the  heels,  and  over  the  great  trochanters, 
caused  by  pressure,  contact  with  excrementitious  matters,  and  still  more  by 
the  general  condition  of  the  patient.  The  symptoms  which  I  have  last  men- 
tioned— the  very  great  fetor  of  the  breath,  sweat,  and  urine,  and  the  ten- 
dency to  hemorrhage  and  sphacelus — have  been  given  as  the  characters  of 
putridity,  which  must  not  be  considered  as  quite  the  same  with  adynamia. 
This  putridity  is  compatible  with  a  high  temperature,  a  turgid  and  very  in- 
jected state  of  the  skin  and  mucous  membranes,  a  great  increase  of  the 
pulse,  and,  in  a  word,  with  high  fever;  the  causus  of  our  predecessors  was 
nothing  else  than  this  congestion,  although  true  adynamia  has  as  its  lead- 
ing characteristic  a  state  of  fever  either  suspended  or  notably  below  that 
which  is  absolutely  indispensable  for  the  complete  and  regular  accomplish- 
ment of  the  long  sequence  of  pathological  operations  of  which  the  organism 
is  the  theatre. 

The  adynamic  form  of  dothinenteria  is  serious,  but  less  serious  than  the 
ataxic  form,  and  medical  treatment  can  often  do  a  great  deal  to  assist  the 
failing  powers  of  nature.  The  therapeutic  indication  is  to  excite  reaction, 
and  to  fulfil  that  intention,  stimulants  and  tonics  are  evidently  the  appro- 
priate remedies. 

Generous  wines,  and  cinchona  in  various  forms  constitute  the  basis  of  the 
treatment.  Stimulants  such  as  ether  and  camphor,  excitants  such  as  am- 
monia and  the  acetate  and  cai'bonate  of  ammonia  ought  to  be  administered 
for  the  purpose  of  awaking — if  I  may  use  the  expression — of  awaking  the 
organic  powers,  while  tonics  ought  to  be  employed  for  maintaining  them. 
As  tonics  auxiliary  to  cinchona,  I  may  mention  infusions  of  wormwood,  ser- 
pentaria,  anise,  cascarilla,  and  all  similar  remedies.  Malaga  wine  is  pref- 
erable to  other  wines,  whether  French  or  Spanish :  it  may  be  given  in 
spoonful  doses  every  two  hours,  every  hour,  or  even  at  shorter  intervals,  the 


264  DOTHINENTERIA. 

quantity  taken  in  the  twenty-four  hours  being  from  125  to  250  grammes. 
The  ordinary  tisane  of  the  patient  is  a  vinous  lemonade  with  the  addition 
of  Seltzer  water. 

Cinchona  is  prescribed  in  the  form  of  extract,  in  doses  of  from  four  to 
ten  grammes,  in  draughts  ;  or  in  the  form  of  powder,  in  a  cup  of  infusion  of 
coffee  without  milk ;  or  the  sulphate  of  quinine  may  be  ordered  in  doses  of 
a  gramme  and  upwards.  As  a  beverage,  a  weak  decoction  of  the  bark 
sweetened  with  lemon  syrup  is  employed.  If  the  stomach  does  not  tolerate 
this  beverage,  the  decoction,  with  the  addition  of  camphor,  may  be  given  as 
a  lavement ;  or  sulphate  of  quinine  may  be  administered  in  the  same  man- 
ner, combined  with  musk,  as  in  the  following  formula  :  sulphate  of  quinine, 
from  one  to  four  grammes  ;  sulphuric  acid,  enough  to  dissolve  the  sulphate  ; 
musk,  two  grammes;  and  water,  a  hundred  grammes. 

Fomentations  of  wine  and  camphorated  alcohol  are  employed. 

In  the  clinical  wards,  I  have  seen  benefit  result  from  placing  the  patient 
in  a  mustard-bath.  Two  kilogrammes  of  the  flour  of  mustard,  made  into  a 
soft  paste  with  water,  are  tied  up  in  a  coarse  cloth  and  put  into  the  bath : 
the  cloth  is  pressed  sufficiently  to  give  a  yellow  color  to  the  water.*  Under 
the  influence  of  such  baths  you  have  seen  improvement  take  place,  the 
general  aspect  becoming  better,  the  pulse  regaining  volume  and  diminish- 
ing in  frequency,  the  blueness  of  the  extremities  giving  place  to  the  natural 
color  of  the  skin,  and  the  abdomen  becoming  softer.  This  treatment  is  re- 
peated every  twenty-four  hours :  it  is  not  discontinued  till,  under  its  in- 
fluence, the  skin  has  regained  its  warmth,  till  the  pulse  has  become  firmer, 
and  the  senses,  the  motor  apparatus,  and  the  intellect,  have  emerged  from 
their  state  of  stupor  and  lethargy. 

It  is  especially  in  this  class  of  cases  that  we  require  to  give  nourishment 
to  the  patients  in  accordance  with  my  plan :  this  is  a  cardinal  point  in  the 
treatment  of  dothinenteria ;  but  I  will  reserve  what  I  have  to  say  upon  this 
subject  till  I  come  to  discuss  it  in  a  special  manner. 

In  the  ataxic  form  of  dothinenteria  the  symptoms  are  of  an  entirely  dif- 
ferent description.  There  is  no  prostration,  nor  collapse  of  the  animal 
functions;  but  they  are  in  a  state  of  disorder,  incoherence,  and  discord. 
When  the  ataxia  involves  the  vital  functions  over  which  the  sympathetic 
nervous  system  presides,  and  the  active  and  constant  exercise  of  which  is 
essential  to  the  continuance  of  life,  we  say  that  the  form  of  the  disease  is 
malignant.  We  must  not,  however,  confound  malignity  with  ataxia,  a  term 
which  embraces  everything,  and  strictly  speaking  specifies  nothing,  for  its 
application  has  been  limited,  as  I  now  limit  it,  to  the  cases  in  which  the  cor- 
relation of  the  animal  functions  is  broken  up.  Ataxic  typhoid  fever,  then, 
is  characterized  by  disturbance  of  the  nervous  system:  the  cerebral  symp- 
toms consist  in  more  or  less  violent  delirium,  accompanied  by  cries,  vocif- 
erations, disturbed  sleep,  nightmare,  hallucinations  of  every  kind,  convul- 
sions, tetanic  contraction  of  the  limbs,  strabismus,  picking  the  bedclothes, 
spasmodic  jerking  of  the  tendons,  and  sudden  exaltation  followed  by  as 
rapid  a  collapse  of  the  muscular  power.  There  is  intense  ['cwr.  The  pa- 
tient complains  of  excessive  Lassitude,  cramps,  very  severe  pains  particu- 
larly in  the  Lumbar  region,  and  violent  headache. 

This  is  the  most  mortal  of  all  the  forms  of  dothinenteria:  it  destroy.-  pa- 
tients as  if  by  a  thunderbolt.     We  have  Been   it   carry  off  in  four  days  a 

*  The  mustard  generally  used  in  Franco  is  a  much  feebler  irritant  than  English 
mustard,  eo  that  in  place  of  two  kilogrammes  (a  little  more  than  four  pounds)  it 
would  be,  perhaps,  sufficient  to  employ  two  pounds  of  English  mustard. — Tbakb- 
latob. 


DOTHINENTERIA.  265 

young  girl  brought  by  it  to  our  St.  Bernard  Ward.  Five  days  previously, 
she  had  been  in  perfect  health.  I  am  enabled  bya  special  circumstance  to 
fix  with  precision  the  date  at  which  her  attack  commenced  :  she  was  present 
at  the  public  fetes  given  to  celebrate  the  Emperor's  marriage,  and  on  the 

following  day  experienced  the  first  symptoms  of  the  disease  from  which  she- 
died.  It  began  with  violent  pain  in  the  head,  and  a  state  of  insomnia  dis- 
turbed by  dreams  and  frightful  nightmares.  When  brought  to  the  Ilotel- 
Dieu,  she  complained  of  racking  headache,  accompanied  by  pain-,  which 
were  dreadful  in  the  limbs,  and  still  more  dreadful  in  the  loins.  The  fever 
was  intense;  the  pulse  was  very  rapid;  and  the  .skin  was  burning,  dry,  and 
colored.  When  this  young  woman  was  admitted  into  our  ward-,  she  was 
subjected  to  the  cold  affusion.  From  this  she  experienced  a  little  tempor- 
ary relief,  but  on  the  same  evening  she  succumbed  to  the  violence  of  the 
symptoms,  which  had  never  ceased  for  an  instant. 

The  autopsy  disclosed  the  existence  of  one  of  the  most  confluent  dothin- 
enteric  eruptions  which  I  ever  saw ;  and  it  is  a  remarkable  fact,  that  this 
was  seen  at  the  fifth  day  of  the  disease.  In  my  early  medical  studies,  I 
saw  an  exactly  similar  case  in  the  practice  of  my  illustrious  master,  Bre- 
tonneau,  at  the  hospital  of  Tours. 

The  predominance  of  ataxic  phenomena  may  sometimes  depend  on  the 
nervous  temperament  of  the  patients,  or  on  moral  emotions  experienced 
before  or  during  the  attack ;  but  generally,  it  is  dependent  on  the  charac- 
ter of  the  epidemic,  and  the  prevailing  medical  constitution. 

Having  now  spoken  of  the  symptoms  referable  to  the  brain,  it  is  neces- 
sary that  I  should  point  out  to  you  those  to  which  dothinenteria  gives  rise 
in  connection  with  the  spinal  marrow,  to  which  the  late  Dr.  Fritz,  an  ob- 
server of  the  greatest  merit,  has  directed  special  attention.*  I  refer  to 
lumbar  pains,  very  similar  to  those  which  occur  so  often  in  small-pox,  ac- 
companied sometimes,  but  not  so  frequently  as  in  that  disease,  by  incom- 
plete paralysis  of  the  lower  extremities,  or  more  generally  by  cutaneous 
and  muscular  hyperesthesia,  and  by  lancinating  pains  in  the  extremities  : 
there  are  also  rachialgic  pains  of  greater  or  less  severity  in  the  dorsal 
region,  often  a  very  intense  pain  in  the  neck,  shooting  to  the  occiput,  im- 
peding the  movements  of  the  head  and  neck,  and  sometimes  causing,  like 
the  pains  in  the  inferior  extremities,  a  feeling  of  inconvenient  stiffness  in 
the  muscles ;  and  finally,  there  is  acute  sensibility  to  pressure  made  over 
the  spinous  processes  of  the  vertebra  of  the  region  of  pain,  thus  indicating 
a  true  spinal  hyperesthesia. 

These  symptoms,  which  are  almost  never  absent,  generally  continue  till 
about  the  middle  or  end  of  the  first  week,  and  then  disappear,  just  as  hap- 
pens in  respect  of  the  cerebral  symptoms  in  a  great  many  cases.  But  this 
is  not  the  invariable  course  of  events.  And  occasionally,  just  as  cerebral 
disturbance  is  seen  to  be  the  predominating  feature  of  an  attack,  so  spinal 
symptoms  may  occupy  the  leading  place  in  the  symptomatology  of  dothin- 
enteria, and  continue  to  do  so  till  the  advanced  phases  of  the  malady. 

But  it  is  important  to  observe  with  Fritz,  that  even  in  cases  in  which 
the  spinal  symptoms  have  attained  a  very  remarkable  degree  of  severity, 
the  autopsies,  as  well  as  the  clinical  observations  during  life,  show  that 
there  was  neither  inflammation  of  the  spinal  marrow  nor  of  its  membranes 
accidentally  complicating  the  typhoid  fever.  At  the  very  utmost,  it  is 
only  in  an  exceedingly  limited  number  of  cases,  that  one  can  in  part  at- 
tribute the  spinal  symptoms  to  congestion  of  the  membranes  of  the  spinal 

*  G.  Fritz  :  Etude  Clinique  sur  Divers  Symptomes  Spinaux  dans  la  Fievre  Ty- 
phoi'de.     Paris:  1864. 


266  DOTHINEXTERIA. 

cord  :  generally,  the  cord  and  its  coverings  present  no  appreciable  material 
lesion. 

We  may,  therefore,  admit  with  Fritz,  that  there  is  a  spinal  form  of 
typhoid  fever,  when  spinal  symptoms  predominate,  just  as  we  allow  that 
there  is  a  cerebral  form  when  cerebral  symptoms  predominate.  In  the  cases 
of  which  I  speak,  the  complete  series  of  spinal  symptoms  may  be  observed  : 
thus,  in  respect  of  sensibility,  and  occupying  the  most  important  place,  is 
cutaneous  hyperesthesia  extending  over  a  great  part  of  the  body,  some- 
times involving  the  four  extremities,  the  trunk  and  the  neck,  and  often 
accompanied  by  muscular  hyperesthesia  ;  then  there  is  hyperesthesia  ex- 
tending from  the  atlas  to  the  sacrum ;  then  again  there  is,  but  not  so  fre- 
quently, rachialgia  accompanied  by  shooting  pains  in  different  parts  of  the 
body,  and  suffering  of  almost  unbearable  severity  in  the  superior,  and  oc- 
casionally, though  not  often,  in  the  inferior  extremities ;  also,  pain  in  the 
loins ;  violent  pains  in  the  chest ;  bilateral  and  symmetrical  neuralgic  pains 
in  the  trunk  ;  anomalous  sensations  of  cold,  formication,  a  feeling  of  prick- 
ing along  the  spine  or  in  the  limbs.  Finally,  along  with  this  exaltation 
of  the  sensibility,  we  may  have  its  extinction  or  perversion  ;  for  example, 
analgesia  and  anesthesia  of  the  skin,  and  muscular  anesthesia. 

There  is  quite  as  much  diversity  in  the  disorders  of  the  motor  system  : 
for  example,  we  meet  with  paralytic  symptoms,  numbness  of  the  extremi- 
ties, paraplegia,  partial  paralysis  of  the  respiratory  muscles,  constipation, 
retention  of  urine,  paralysis  of  the  sphincters,  spasmodic  affections,  dysuria 
from  spasm,  spasmodic  contraction  of  the  respiratory  muscles  and  muscles 
of  the  extremities,  stiffness  of  the  muscles  of  the  neck,  contraction  of  the 
limbs,  and  even  tetanic  symptoms. 

In  conclusion,  let  me  point  out,  with  Fritz,  a  special  group  of  symptoms 
having  its  origin  in  the  medulla  oblongata,  such  as  extreme  dyspnoea  inde- 
pendent of  any  affection  of  the  respiratory  passages  or  muscles,  spasm  of 
the  pharynx  and  larynx,  convulsive  cough,  aphonia,  alalia,  inability  to 
use  the  tongue  in  mastication,  spasmodic  or  rhythmic  contraction  of  the 
sterno-mastoid  and  trapezius  muscles,  and  paralysis  of  the  pharynx. 

The  spinal  symptoms  of  typhoid  fever  are  often  accompanied  by  cerebral, 
thoracic,  and  other  symptoms  of  great  severity.  The  concurrence  of  spinal 
with  formidable  cerebral  symptoms  constitutes  the  cerebrospinal  form  of 
Wunderlich,  which  presents  some  difficulties  in  diagnosis. 

It  is  not  by  chance  or  indifferently  that  the  spinal  symptoms  show  them- 
selves: in  children,  in  young  women,  and  in  anaemic  subjects,  tin-  spinal 
marrow  seems  to  be  peculiarly  liable  to  be  seriously  affected  in  dothinen- 
teria. 

Independently  of  the  treatmenl  which  ought  to  be  pursued,  in  accord- 
ance with  indications  of  which  I  will  speak  when  reviewing  the  general 
question  of  treatment  in  typhoid  fever,  the  cold  affusion  is  of  essential  use 

in  the  ataxic  for f  the   disease.      When    lecturing  on   scarlatina.  I    told 

you  what  the  cold  affusion  is,  and  how  it  ought  to  he  administered.  The 
mode  of  application  is  the  same  in  typhoid  fever.  I  will  only  remark  that 
you  will  not  meet  with  that  opposition  to  its  employment  on  the  part  of  the 
relations  of  the  patient,  which  is  so  often  encountered  in  cases  of  scarlatina 
and  other  eruptive  fever-.  They  have  do  dnad  of  an  imaginary  driving  in 
of  the  eruption,  and  consequently  you  are  left  much  freer  in  your  movements. 
I  f  circumstances  prevent  your  using  the  cold  affusion,  you  may  have  recourse 
to  cooling  lotion-,  such  a-  bathing  the  skin  with  vinegar  and  water.  Tepid 
baths,  particularly  at  the  beginning  of  the  disease,  are  of  undoubted  benefit : 

the  patient  may  remain  ill  the  hath  as  long  as  he  can  hear  it. 

I  will  now  go  hack  to  the  subject  of  malignity,  that  1   may  point  out  the 


DOTHINENTERIA.  267 

differences  between  it  and  ataxia.  Malignity,  as  I  have  already  said,  is  a 
kind  of  ataxia,  but  it  is  an  ataxia  of  these  organic  functions  the  regular  and 
continuous  exercise  of  which  is  indispensable  to  life.  Here,  the  morbific  cause 
having  struek  directly  in  its  essence  the  force  presiding  over  vital  functions, 
the  correlation  of  winch  is  broken,  and  there  is  not  only  collapse  as  in  ady- 
namia, hut  annihilation,  existence  being  threatened  with  an  immediate  and 
insidious  termination.  The  older  physicians  perfectly  understood  these 
differences,  recognizing  a  true,  primitive,  protopathic  malignity,  declaring 
itself  all  at  once  at  the  beginning  of  the  disease,  and  a  secondary,  deutero- 
pathic  malignity  supervening  at  a  later  stage.  You  cannot  do  better,  in 
relation  to  this  subject,  than  to  read  the  aphorisms  of  Stoll  on  febrile  de- 
bility and  malignity. 

Malignity  arises  in  two  very  distinct  ways.  It  may  be  dependent  on 
causes  in  themselves  injurious  to  life,  such  as  mental  emotions,  depressing 
passions,  and  vegetable  or  animal  septic  poisons,  to  wbich  probably  belong 
the  morbific  principles  which  engender  epidemic,  endemic,  and  contagious 
diseases — principles  which  vary  in  their  activity  according  to  the  epidemic, 
and  according  to  the  nature  of  certain  unknown  influences.  At  other 
times,  the  conditions  which  give  rise  to  malignity  belong  exclusively  to  the 
individual.  Those  which  are  known  geuerally  depend  upon  impaired  vital 
energy  arising  from  prolonged  excess  of  any  kind,  or  upon  excessive  san- 
guineous or  other  discharges  consecpient  upon  previous  diseases.  Any 
morbid  cause  taking  the  economy  by  surprise  when  under  such  conditions, 
may  bring  on  maladies  which  will  assume  the  character  of  malignity. 

The  characteristic  signs  of  malignity  are  the  occurrence  of  symptoms 
having  no  apparent  relation  to  the  nature  of  the  disease,  the  constitution 
or  temperament  of  the  patient,  or  the  ordinary  influence  of  external  or  in- 
ternal modifying  causes ;  and  great  anomalies  in  the  symptoms,  for  ex- 
ample, the  exclusive  predominance  and  confused  mixture  of  some  symp- 
toms, such  as  very  high  temperature  associated  with  very  feeble  pulse — the 
alteration  of  symptoms,  such  as  extreme  cold  succeeding  burning  heat — 
the  moderation  and  apparent  regularity  of  the  symptoms  during  the  first 
period  of  the  disease,  and  their  fatal  severity  at  a  more  advanced  stage, 
without  any  apparent  or  adequate  cause.  Other  signs  of  malignity  are 
sudden  debility,  disorder  of  the  circulation,  irregularity  of  the  pulse,  great 
acceleration  of  the  respiratory  movements ;  also,  great  dyspnoea,  of  which 
the  patient  makes  no  complaint,  and  which  is  neither  explained  by  auscul- 
tation during  life,  nor  by  examination  of  the  thoracic  organs  after  death. 

This  malignity  is  met  with  in  every  species  of  fever,  in  intermitteuts 
(then  called  "  pernicious"),  and  in  eruptive  and  nou-eruptive  continued 
fevers.  Thus  we  have  seen  malignity  in  scarlatina,  measles,  and  small- 
pox ;  but  malignity  is  more  commonly  met  with  in  typhoid  fevei",  in 
combination  with  its  simple,  adynamic,  and  ataxic  forms,  and  constituting 
a  variety  of  the  disease,  which  has  been  erroneously  regarded  as  a  distinct 
species,  and  designated  "  malignant  fever." 


Parotitis  and  Deafness  as  Prognostic  Signs  of  Dothinenteria. 

Gentlemen,  such  of  you  as  have  attended  my  clinical  wards  for  some 
years,  must  have  seen  patients  affected  with  parotitis  at  the  termination  of 
dothinenteric  attacks.  Very  recently,  you  may  have  observed  this  occur- 
rence in  a  young  man  of  twenty,  in  St.  Agnes's  Ward.  This  is  what  the 
old  physicians  would  have  called  a  crisis  or  metastasis ;  but  I  call  it  a  very 
evil-boding  complication.     The  significance  of  parotitis  is  very  differently 


268  DOTHINENTERIA. 

regarded  ;  some  look  on  it  as  always  a  serious  complication,  while  others  con- 
sider its  appearance  as  an  announcement  of  the  favorable  termination  of 
the  disease.  For  my  part,  gentlemen,  I  regard  parotitis  as  a  very  formid- 
able complication  ;  it  is  an  affection  from  which  I  have  almost  never  seen 
dothinenteric  or  other  fever  patients  recover. 

It  is  not  so  with  deafness,  in  respect  of  which,  however,  differences  have 
to  be  established.  When  the  deafness  is  only  on  one  side,  the  prognosis 
ought  to  be  guarded :  there  is  reason  to  fear  a  lesion  of  the  organ  of  hear- 
ing, and  suppuration  often  supervenes,  resulting  it  may  be  from  simple 
catarrh  of  the  mucous  membrane  of  the  external  auditory  canal,  or — and 
•then  the  case  is  more  serious — in  an  alteration  in  the  petrous  portion  of  the 
temporal  bone,  which  leads  to  affections  of  the  brain.  I  saw  an  example 
of  this  in  a  woman  who  died  from  an  affection  of  this  kind,  developed  spon- 
taneously and  without  antecedent  typhoid  fever ;  at  the  autopsy  we  found, 
as  you  will  recollect,  inflammation  at  the  base  of  the  brain.  When  the 
deafness  occurs  on  both  sides,  I  generally  look  on  the  prognosis  as  favor- 
able ;  I  have  often  called  your  attention  to  this  point,  stating  that  I  have 
almost  never  seen  persons  die  from  dothinenteria  who  had  been  deaf  on  both 
sides  during  the  course  of  the  disease.  In  these  cases,  I  look  on  the  deaf- 
ness as  depending  upon  the  propagation  of  the  catarrh  to  the  Eustachian 
tubes.  I  do  not  say  that  the  deafness  is  the  cause  of  these  patients  recover- 
ing ;  but  simply  that  I  have  rarely  seen  dothinenteric  patients  die  who  had 
been  deaf  on  both  sides.  Without  being  able  to  explain  this  clinical  fact 
any  better  than  those  who  have  stated  it  before  me,  I  state  it  to  you,  and 
ask  you  to  verify  it  in  }Tour  practice. 


Dothinenteria  may  at  first  Simulate  Intermittent  Fever ;  and  Marsh  [Inter- 
mittent'] Fever  may  likewise  at  the  beginning  of  the  attack  Simulate  Doth- 
inenteria. 

Gentlemen,  there  is  in  bed  No.  29  bis  of  our  St.  Bernard  Ward  a  woman 
twenty-eight  years  of  age,  ill  of  dothinenteria,  whose  case  up  to  the  fifteenth 
day  presented  peculiarities  which  I  must  point  out  to  you.  This  woman 
has  been  resident  in  Paris  for  the  last  four  years  and  a  half,  and  up  to  her 
present  illness,  has  always  enjoyed  good  health.  One  day,  without  any 
known  cause,  she  had  a  feeling  of  a  sort  of  feebleness.  Next  day,  she  sat 
down  as  usual  to  her  needlework,  going  to  the  shop  where  she  worked, 
although  she  experienced  a  certain  degree  of  discomfort,  and  had  less 
appetite  than  usual.  She  tried  to  eat,  but  digestion  was  difficult.  This 
condition  continued  for  five  days,  and  was  accompanied  by  weariness  and 
pains  in  the  limbs,  sonic  pain  in  the  loins,  nausea,  several  tits  of  vomiting, 
and  a  very  constipated  state  of  the  bowels.  She  stated  that  once  in  two 
days,  she  had  had,  ahont  four  o'clock  in  the  afternoon,  an  attack  of  shiver- 
ing followed  by  heat  and  then  by  sweating;  and  she  informed  us  that  these 
paroxysms  of  fever  soon  came  on  every  day,  assuming  a  double  tertian 
type,  a  fad   which  she  indicated  by  mentioning  that  they  were  more  violent 

one  day  than  another.  She  was  a  native  of  Champagne ;  and  had  never 
had  intermittent  fever.  When  she  entered  the  BLdtel-Dieu,  on  the  1 1th 
June,  she  stated  that  she  had  been  so  ill  since  the  4th  as  t<»  lie  obliged  to 
keep  her  hed,  and  discontinue  her  occupations. 

When   I  saw  her  for  the  fust    time,  she  had  very  moderate  fever,  but    on 

the  previous  afternoon  (he  fever  had  been  very  high  ;  and  every  evening  it 
returned.  There  was  enlargemenl  of  the  spleen,  which  extended  several 
anger-breadths  beyond  the  false  ribs.     There  was  obstinate  constipation. 


DOTHINENTERIA.  269 

The  day  after  the  patient's  arrival,  a  mild  purgative  was  prescribed.  On 
the  third  day,  the  lever  was  continuous.  There  was  no  diarrhoea,  but  the 
tongue  was  red,  clammy,  and  coated  with  a  thin  dirty  fur.  On  the  fourth 
day — the  sixteenth  from  the  beginning  of  the  disease — we  found  rosy  len- 
ticular spots  on  the  abdomen,  and  one  of  the  same  spots  afterwards  appeared 
on  the  face.  This  fever,  which  began  as  an  intermittent,  at  first  tertian  ami 
then  double  tertian,  became  remittent  and  then  continued,  and  was  in  point 
of  fact  an  exceedingly  well-marked  case  of  dothinenteria. 

There  is  no  novelty,  gentlemen,  in  this  case.  Those  who  have  read  the 
writings  of  physicians  of  past  ages  know  that  those  great  masters  of  Un- 
healing art  were  struck  with  similar  cases,  which  you  will  find  recorded  in. 
the  works  of  Sydenham,  Morton,  Huxham,  Van  Swieten,  Stoll,  and  many 
others.  While  they  pointed  them  out,  however,  they  did  not  explain  them 
as  I  do:  they  saw  in  them  a  transformation  of  intermittent  into  putrid  con- 
tinued fever,  produced  under  the  influence  of  bad  diet,  and  bad  treatment, 
when,  for  example,  cinchona  had  been  given  too  soon,  in  too  great  quan- 
tity, or  for  too  long  a  time.  Now,  as  I  pointed  out  to  you,  when  speaking 
of  intestinal  catarrh,  in  particular  circumstances,  whilst  one  morbid  cause  is 
acting  upon  an  individual,  and  has  already  affected  him  with  a  disease,  a 
new  malady  may  supervene  and  place  its  stamp  upon  that  which  previously 
existed ;  but  this  is  not  transformation,  and,  correctly  speaking,  there  is  no 
sueh  thing  as  a  real  transformation  of  one  disease  into  another. 

We  can  in  this  way  understand  the  mistake  of  those  illustrious  practi- 
tioners of  whom,  in  spite  of  their  errors,  we  must  say  what  Fontaine  said  of 
the  poets  :  "  We  cannot  go  in  advance  of  the  ancients :  they  have  left  us 
only  the  glory  of  following  them  well."  In  point  of  fact,  gentlemen,  the 
great  masters  of  whom  I  speak — less  informed  than  the  moderns  in  the 
detailed  information  furnished  by  pathological  anatomy,  ignorant  of  means 
of  investigation  which  we  possess,  such  as  auscultation,  brought  all  at  once 
to  a  very  high  degree  of  perfection  by  Laennec  its  inventor — the  Sydenhams, 
the  Van  Swietens,  the  Stolls,  and  a  host  of  others,  inspecting  nature  with 
scrupulous  attention,  knew  the  patient  better  than  we  know  him,  though  we 
know  better  how  to  make  the  diagnosis  of  the  lesion.  Read  the  magnifi- 
cent descriptions  which  they  have  given  us;  and  when  they  refer  to  diseases 
of  which  all  the  manifestations  were  accessible  to  their  observation,  I  doubt 
whether  you  will  find  in  modern  authors  anything  to  compare  to  them. 
Even  when  some  features  are  wanting  in  the  picture,  still,  with  what  vigor 
is  the  sketch  drawn  ! 

Guided  alone,  however,  by  the  phenomena  which  they  observed  with 
marvellous  sagacity,  they  could  not  avoid  falling,  and  in  point  of  fact  did 
fall,  into  inevitable  errors.  Thus,  with  respect  to  typhoid  fever,  which  they 
saw  presenting  itself  with  very  different  symptoms,  they  found  themselves 
under  the  necessity  of  making  as  many  species  as  there  are  forms  of  the 
disease :  they  were  unable  to  gather  them  up  into  one  bundle,  which  Bre- 
tonneau  accomplished  when  he  discovered  that  whatever  other  symptoms 
might  be  present  in  typhoid  fever,  there  was  one  lesion  which  was  charac- 
teristic and  constantly  met  with.  If  our  early  predecessors  had  found  the 
specific  intestinal  eruption,  they  would  have  had,  like  us,  their  testing  sign 
to  distinguish  the  disease  in  a  precise  and  positive  manner;  they  would 
have  avoided  confusion ;  they  would  no  more  have  mistaken  dothinenteria 
under  its  different  aspects,  than  they  would  have  mistaken  small-pox,  scar- 
latina, or  measles. 

But  since  their  day,  how  many  steps  has  it  taken  to  arrive  at  the  truth  ! 
Prost,  in  his  work,  published  in  1804,  entitled  "La  Medeczne  Eclairee  p<n- 
V  Ouverture  des  Corps,"  was  first :  he  described,  upon  the  whole,  very  well, 


270  DOTHINENTERIA. 

some  of  the  alterations  of  tissue  peculiar  to  cloth inenteria,  the  ulcerations 
■which  he  met  with  being  in  his  opinion  the  last  stage  of  a  phlogosis,  of 
which  the  first  stage  "was  redness:  afterwards,  finding  this  redness  in  the 
intestines  of  all  persons  dying  from  different  diseases,  provided  they  were 
not  anaemic,  he  concluded  that  intestinal  inflammation  was  almost  always 
the  cause  of  death,  a  false  notion,  which  at  a  later  period  was  taken  up  bv 
Broussais,  and  gave  birth  to  the  celebrated  doctrine  of  the  Val-de-Grace, 
entirely  founded  on  a  heresy  in  pathological  anatomy.  Seven  years  after 
the  treatise  of  Prost,  MM.  Petit  and  Serres  wrote  their  work — "  Traitc  de 
la  Ficvre  Entero-mcsenterique :"  they  advanced  a  little  nearer  to  a  concep- 
tion of  the  truth,  by  establishing  the  specific  character  of  the  intestinal 
lesion,  which  they  very  justly  compared  to  small-pox  or  cow-pox;  but  they 
were  still  far  from  grasping  the  true  bearing  of  the  facts,  for,  not  realizing 
what  was  due  to  the  progress  of  the  eruption,  and  not  perceiving  that  the 
lesion  varies  in  appearance  according  to  the  stage  of  the  disease,  they  recog- 
nized three  varieties  of  the  fever,  viz.,  the  simple,  the  papular,  and  the 
ulcerous.  Then  came  the  remarkable  labors  of  Bretonneau,  which  shed  a 
perfectly  new  light  upon  the  history  of  fevers,  and  by  using  which  no  one 
in  the  present  day  can  be  deceived. 

Dothinenteria  being  in  the  present  day  characterized  in  an  exact  manner, 
we  have  nothing  to  do  with  the  transmutations  which  our  predecessors  were 
in  the  habit  of  pointing  out :  we  no  longer  see  intermittent  fevers  change 
into  putrid  fevers,  though  we  observe  that  under  certain  circumstances  the 
latter  at  their  commencement  assume  the  aspect  of  the  former.  It  often 
happens  that,  on  interrogating  and  attentively  examining  the  patient,  we 
find  a  more  or  less  conspicuous  group  of  symptoms  not  met  with  in  marsh 
fevers,  and  commonly  occurring  in  continued  putrid  fevers,  which  put  us 
on  the  way  to  a  correct  diagnosis.  To  such  groups  of  symptoms  belong 
headache,  insomnia,  and  vertigo;  also,  softness  of  the  pulse,  tendency  to 
diarrhoea,  and  gurgling  in  the  right  iliac  fossa,  brought  on  by  pressure  over 
the  part. 

Besides,  after  the  first  paroxysms,  the  type  itself  of  the  fever  assists  in 
clearing  up  the  nature  of  the  case.  The  further  we  are  from  the  onset  of 
the  disease,  the  shorter  is  the  interval  between  the  paroxysms:  at  first  there 
is  a  paroxysm  of  fever  once  in  two  days,  then  it  occurs  daily,  or  the  type 
becomes  double  tertian,  as  in  the  woman  of  bed  No.  26  bis;  then  the  fever 
in  place  of  being  intermittent  is  remittent,  and  so  by  degrees  assumes  the 

continued  type,  with  which  at  last  it  is  < ipletely  invested.     From  the 

beginning  the  case  is  so  absolutely  dothinenterie,  and  so  removed  from  the 
nature  of  an  intermittent  transformed  into  a  continued  fever,  that  if  the 
patient  were  to  be  carried  off  about  the  seventh  or  eighth  day  by  an  acci- 
dent, before  the  disease  had  become  permanently  invested  with  its  own  ex- 
ternal characters,  the  specific  intestinal  lesion  would  be  seen  at  the  autopsy. 

Enlargement  of  the  spleen,  which  occurred  in  the  case  1  have  just  de- 
scribed, may  had  to  an  error  in  diagnosis.  Splenic  enlargement,  which 
exists  in  nearly  all  cases  of  marsh  fever,  of  which  indeed  it  is  the  anatomical 
characteristic,  is  likewise  present  in  nearly  all  cases  of  dothinenteria.    There 

is  a  circumstance  which  may  perhaps  serve  to  distinguish  the  one  from  the 

other:  in  putrid  feverthere  is  engorgement  of  the  spleen  from  the  beginning 

of  the  attack,  which  often  diminishes  as   the   malady  goes  on;   whereas,  in 

marsh  fever,  it  is  al  first  slight,  bul  increases  with  each  repetition  of  the 
febrile  paroxysm,  till  at  lasl  it  sometimes  attains  an  extraordinary  size.     It 

is  particularly  in  district-  where  marsh  fevers  are  endemic,  and  in  persons 
who  have  not  been  lon^  absent  from  such  localities,  that  we  see  dothinen- 
teria begin  by  Bhowing  the  intermittent  type      We  had  an  example  of  this 


DOTHINENTERIA.  271 

in  a  woman  who  presented  at  the  beginning  of  the  fever  symptoms  similar 
to  those  experienced  by  the  patient  who  occupied  bed  'l1,)  bix :  she  had  lived 
for  a  long  time  in  a  district  where  intermittent  fevers  were  always  prevailing. 

Change  in  the  type  of  a  fever  also  occurs  in  an  inverse  order;  and  it  is 
likewise  in  places  poisoned  by  emanations  from  marshes  that  this  is  observed. 
A  true  marsh  fever  which  has  at  first  shown  itself  with  the  continued  type, 
and  has  simulated  dothinenteria,  soon  assumes  the  regular  intermittent  type, 
and,  as  the  case  advances,  becomes  tertian,  double  tertian,  or  quartan. 

The  term  "intermittent"  cannot,  therefore,  be  reserved,  as  is  usually  the 
case,  to  designate  only  one  species,  of  fever,  the  phenomenon  of  intermitting 
being  a  very  variable  sign,  and  one  met  with  in  every  kind  of  fever,  as  I 
have  just  said.  Consequently,  I  think  we  ought  to  substitute  for  the  term 
"intermittent"  fever,  the  term  "marsh"  or  "palustral"  fever.  Now  marsh 
fever  is  just  as  incapable  of  being  transformed  into  dothinenteria  as  is  dothin- 
enteria of  being  transformed  into  marsh  fever;  but  it  is  quite  necessary  to 
know  that  changes  of  type  take  place.  A  case  of  marsh  fever,  which  at  the 
beginning  was  a  strongly-marked  intermittent,  may  become  continued, 
though  this  is  not  a  frequent  occurrence;  just  as  a  marsh  fever  may  at  first 
be  continued,  and  soon  assume  in  a  well-marked  manner  its  own  intermit- 
tent type.  Cases  collected  in  the  French  possessions  of  Africa  (where  our 
military  physicians  have  elucidated  this  important  question),  have  conclu- 
sively shown  that  marsh  fevers  undergo  these  changes  of  type.  Science 
and  art  are  particularly  indebted  to  Dr.  Boudin  for  having  cleared  up  this 
point  in  nosology  better  than  any  one  who  preceded  him.*  The  malady, 
then,  does  not  change  its  nature  when  it  undergoes  change  of  type :  under 
all  its  different  forms  it  remains  the  same  marsh  fever;  and  the  proof  of 
this  is  that  it  is  always  as  necessary  in  treating  it  to  have  recourse  to  cin- 
chona (or  its  substitutes,  such  as  the  arsenical  preparations  lauded  by  Bou- 
din), when  intermittents  become  remittent,  as  in  those  which  are  continued 
before  they  assume  their  ordinary  type. 

If,  then,  gentlemen,  you  are  practicing  in  a  district  where  marsh  fevers 
are  not  endemic,  do  not  be  too  confident  as  to  the  character  of  the  inter- 
mittents you  meet  with,  when  they  are  not  quartans  nor  well-marked  ter- 
tians :  be  distrustful  of  them  when  they  are  double  tertians,  but  particu- 
larly when  they  are  quotidians.  Before  administei'ing  cinchona  or  sulphate 
of  quinine,  wait,  and  observe  whether  the  type  is  not  going  to  change  :  it 
may  not  be  long  till  you  see  the  intervals  between  the  paroxysms  become 
shorter  and  shorter,  and  the  paroxysms  become  less  and  less  paroxysmal, 
so  that,  for  example,  if  during  the  first  three  or  four  days  the  rigors  con- 
tinued for  an  hour  accompanied  by  chattering  of  the  teeth  and  great  dis- 
comfort, by  the  fifth,  sixth,  or  seventh  day,  they  will  not  last  more  than 
half  an  hour,  and  by  the  eighth  or  ninth  day  they  will  be  quite  transient. 
But  whilst  the  paroxysm  becomes  less  defined,  its  duration  becomes  longer 
every  day,  the  continued  form  of  fever  becomes  more  and  more  decided, 
and  very  soon  dothinenteria  is  fully  characterized.  On  the  other  hand,  if 
you  are  practicing  in  a  locality  where  marsh  fevers  generally  prevail,  do 
not  be  in  a  hurry  to  begin  the  treatment  of  a  malady  which,  though  it 
commenced  with  the  symptoms  of  continued  fever,  may  present  the  parox- 
ysms of  a  remittent  at  the  end  of  four  or  five  days.  You  will  probably 
soon  see  the  fever  assume  a  well-marked  paroxysmal  character. 

Though  the  manner  in  which  the  old  physicians  interpreted  the  facts 
was  erroneous,  the  facts  themselves  were  not  the  less  real ;  and  they  were 

*  Boudin  :  Traite  des  Fievres  Intermittentes,  1842  ;  Traite  de  Geographie  Medi- 
cate.    Paris,  1857,  t.  ii,  p.  530. 


272  DOTHINENTERIA. 

right,  when,  following  the  precept  of  Hippocrates,  they  refrained  from  in- 
terfering with  an  intermittent  till  after  the  seventh  paroxysm.  By  acting 
thus,  you  will  avoid  the  risk  of  being  led  to  believe  that  you  have  reduced 
an  incipient  dothinenteria  to  the  proportions  of  a  regular  intermittent  fever 
which  can  be  easily  cut  short  by  cinchona,  when  in  reality  you  have  only 
had  to  do  with  a  marsh  fever  which  had  at  first  the  continued  type.  On 
the  other  hand,  if  you  have  a  case  of  mild  synocha,  such  as  is  so  common 
at  Paris,  which  in  the  beginning  of  the  attack  assumes  the  intermittent 
type,  and  in  general  terminates  spontaneously  in  recovery,  you  will  not 
make  the  mistake  of  supposing  that  you  have  cured  a  real  intermittent 
fever,  whether  it  be  with  cinchona  or  the  sulphate  of  quinine,  or  with  pre- 
tended febrifuges,  such  as  the  bark  of  the  horse-chestnut,  table-salt,  &c, 
recently  extolled,  and  which  owe  their  apparently  successful  results  to  the 
fact  of  their  having  been  administered  in  cases  similar  to  those  of  which  I 
am  now  speaking.  Finally,  when  you  perceive  that  you  have  to  do  with 
a  case  of  dothinenteria,  exhibiting  at  the  outset  the  phenomena  of  inter- 
mittent fever,  you  will  not  have  to  take  blame  to  yourself  for  having  had 
recourse  to  unsuitable  treatment,  nor  will  you  accuse  cinchona  of  having 
changed  a  fever  which  is  not  generally  serious  into  a  formidable  disease. 


Contagion. —  Conditions  under  ichich  Dothinenteria  occurs. 

Opinions,  gentlemen,  are  still  divided  on  the  question  of  the  contagious- 
ness of  dothinenteria,  but  the  number  of  the  disbelievers  in  contagion  is 
daily  diminishing.  "We  cannot  attain  the  solution  of  so  complex  a  prob- 
lem in  Paris,  where,  as  in  all  large  cities,  we  want  the  information  neces- 
sary to  enable  us  to  trace  cases  up  to  their  origin.  The  question  has,  how- 
ever, been  answered  by  physicians  practicing  in  small  places,  where  it  is 
easy  to  know  the  patient  who  was  first  seized.  It  is  therefore  to  physicians 
who  are  so  situated  that  the  question  has  to  be  put. 

On  examining  the  reports  annually  received  by  the  Academy  upon  epi- 
demics prevailing  in  the  departments,  one  becomes  convinced  that  the  con- 
tagious character  of  typhoid  fever  is  among  the  ascertained  facts  of  science. 
So  far  back  as  1829,  the  fact  was  announced  by  Bretonneau,  by  Gendron 
of  Chateau-du-Loir,  and  by  Leuret :  it  was  repeatedly  confirmed  by  Le- 
tanelet,  Lombard,  Mayer,  and  Thirial,  and  more  recently  by  Piedvache, 
Letenneur,  Ragaine  of  Mortagne,  and  many  others. 

"Without  seeking  to  accumulate  further  proofs  in  support  of  my  proposi- 
tion, 1  will  confine  myself  to  making  you  acquainted  with  some  character- 
istic facts,  which  have  already  been  placed  before  the  Academy  in  the 
report  1  was  commissioned  to  present  on  the  epidemics  which  prevailed  in 
Fiance  in  1857.  By  quoting  exactly  the  narrative  of  the  observers  them- 
selves, we  shall  be  better  enabled  to  sec  the  degree  in  which  the  term  WOr 
tagion  is  applicable  to  the  transmission  of  dothinenteria.  The  importation 
of  the  disease  into  the  locality  where  it  is  spreading,  by  an  inhabitant  who 
has  contracted  it  elsewhere,  can  almost  always  he  made  out,  if  the  circum- 
stances arc  carefully  inquired  into.  When  the  malady  is  once  installed, 
its  propagation  goes  on  by  a  series  of  transmissions,  which  are  sometimes 

very  easy,  and  at  other  time.-  im|io<>il>|r,  to  follow. 

At  Maylargues,  in  the  departmenl  of  Lot,  according  to  the  report  of  Dr. 
Mayneur,  then-  arrived,  about  the  end  of  November,  1856,  a  soldier,  dis- 
charged from  the  army  of  Airica  :  a  month  afterwards,  ho  died  of  typhoid 
fiver.  Towards  the  Close  of  his  illness,  a  woman,  a  Deighbor  who  had  at- 
tended upon  him  with  the  most  caivful  assiduity,  took  the  same  disease,  and 


DOTHINENTERIA.  273 

died.  A  brother  of  the  soldier,  aged  sixteen,  also  died  of  it  on  the  6th  of 
March.  Two  of  his  sisters,  in  the  same  month,  contracted  the  disease  suc- 
cessively, and  recovered  after  tedious  convalescence.  The  female  neighbor 
whom  I  have  mentioned  communicated  the  disease  to  a  son,  aged  seven- 
teen, who  died  on  the  22d  of  May.  In  a  short  time  after  this,  the  fever 
struck  down  so  many  people  that  it  became  impossible  to  follow  its  progress. 

Dr. Moussillac  states  that  typhoid  fever  was  imported  toCarriol  (Gironde) 
by  a  young  workman,  a  cooper,  who  came  home  sick  to  his  relations.  The 
family,  consisting  of  seven  individuals,  lived  in  a  large,  well-ventilated 
house :  they  all  took  the  disease  in  a  severe  form,  and  three  of  them  died 
of  it.  The  disease  radiated  from  that  centre,  showing  itself  in  persons  in 
communication  with  those  affected ;  and  the  persons  so  contracting  it,  by 
removing  to  other  and  sometimes  distant  localities,  took  it  with  them  to 
places  where  it  had  not  previously  appeared. 

The  epidemic  of  the  arrondissement  of  Ambert  (Puy-de-D6me),  observed 
by  Dr.  Mavel,  seems  to  have  originated  in  a  manufactory.  The  house- 
servant  fell  ill  on  the  11th  January ;  he  was  taken  to  his  home,  in  a  village 
distant  two  kilometres,  where  he  was  attended  by  his  wife :  he  recovered. 
His  wife  took  the  fever,  and  died.  A  sister-in-law  and  an  uncle,  both  of 
whom  had  waited  on  him,  contracted  the  disease,  and  died  of  it.  Soon 
afterwards,  every  house  in  the  village  had  cases  of  typhoid  fever.  A 
woman,  who  was  cook  in  the  factory,  and  her  sister,  who  was  a  workwoman 
there,  upon  feeling  the  first  symptoms  of  the  disease,  were  taken  home  to 
their  family,  a  distance  of  five  kilometres :  one  died,  and  the  other  recovered. 
The  malady  soon  spread  in  their  village  ;  and  one  of  the  villagers  who  took 
the  disease,  having  been  removed  to  his  home  at  a  little  distance,  marked 
by  his  arrival  the  beginning  of  the  epidemic  in  that  place. 

On  the  31st  May,  1857,  says  Dr.  Fourrier,  I  was  called  to  Audon-le- 
Roniain  (Moselle),  to  a  young  man  of  twenty,  who  had  arrived  from  Paris, 
where  he  had  been  unwell  for  some  days.  He  had  all  the  symptoms  of 
typhoid  fever,  and  the  intestinal  affection  was  very  acute.  Companions 
who  came  to  see  him  were,  after  him,  my  first  patients ;  and  subsecpiently, 
his  father,  brother,  and  twTo  sisters  were  successively  struck  down  by  the 
disease.  So  long  as  field-work  kept  the  inhabitants  of  Audon  away  from 
their  dwellings,  the  fever,  though  scattered  about  in  the  village,  remained 
limited  to  a  small  number  of  individuals ;  but  when  harvest  was  finished, 
and  the  people  remained  constantly  with  the  sick,  a  general  infection  of  the 
community  took  place,  and  at  one  time,  among  the  442  inhabitants,  there 
were  40  cases.  A  workman  of  Anderny  went  to  work  at  Audon  during 
August ;  he  there  contracted  the  disease,  and  on  his  return  home  gave  it  to 
his  wife  and  father-in-law.  Up  to  his  return  there  had  been  no  cases  of 
typhoid  fever  in  Anderny.  A  man,  aged  sixty,  went  on  business  to  Audon, 
and  notwithstanding  his  advanced  age,  took  typhoid  fever  on  returning 
to  the  village  where  he  resided.  When  he  had  been  ill  for  fifteen  days,  his 
son,  aged  twenty,  took  the  disease,  and  soon  afterwards  two  daughters,  aged 
respectively  seventeen  and  thirteen.  If,  adds  Dr.  Fourrier,  people  are  so 
skeptical  as  to  see  nothing  but  coincidence  in  all  this,  I  ask,  wherein  will 
they  see  the  relation  of  cause  to  effect? 

Dr.  Reignier  mentions  the  following  circumstances :  On  the  29th  July, 
1855,  a  girl,  aged  twenty -four,  called  Theobald  (de  Trombern),  experienced 
the  first  symptoms  of  an  attack  stated  by  a  physician  to  be  typhoid  fever. 
The  Theobald  family  was  in  easy  circumstances  in  the  village ;  the  most 
assiduous  cares  were  adopted  with  a  view  to  overcome  the  disease ;  and  at 
the  end  of  six  weeks  the  patient  was  re-established  in  health.  This  re- 
mained an  isolated  case  for  eight  days  :  a  second  case  then  occurred  in  the 
vol.  i. — 18 


274  DOTHINENTERIA. 

next  house :  some  days  later  there  were  new  cases  in  another  house ;  but 
none  of  the  persons  affected  had  had  any  communication  with  the  girl 
Theobald.  The  contagious  character  of  the  epidemic  afterwards  became 
well  marked.  It  is  worthy  of  notice  that  the  earliest  case  of  the  disease 
occurred  in  the  first  house  of  the  village  on  the  northeastern  side,  and  that 
the  subsequent  cases  appeared  in  order  of  succession  from  house  to  house, 
till  the  opposite  or  southwestern  extremity  was  reached. 

A  boy,  twelve  years  of  age,  cowherd  to  the  mayor  of  Bievres  (Aisne), 
whose  wife  and  daughters  successively  had  had  typhoid  fever,  contracted 
it,  and  brought  it  with  him  to  his  village,  Orgeval,  distant  three  kilometres, 
and  where  there  had  been  no  case  of  the  kind.  He  there  communicated  it 
to  a  female  relation  who  waited  on  him,  and  she  gave  it  to  another  female 
relative  who  came  from  the  other  end  of  the  village  to  assist  her.  From 
that  time,  typhoid  fever  spread  in  the  village.  Nor  was  that  all :  a  young 
man,  employed  as  a  servant  in  the  house  at  Orgeval,  took  the  disease,  was 
sent  to  his  home,  a  distance  of  six  kilometres,  whither  he  carried  the  dis- 
ease, which  became  epidemic  in  the  place.  This  case  and  others  of  the  same 
kind  are  mentioned  by  Dr.  Pierme,  a  resident  practitioner,  under  whose 
observation  they  occurred. 

At  Chamomile,  in  the  same  department,  Dr.  Guipon,  who  observed  the 
disease  with  scrupulous  exactitude  from  the  beginning  of  its  outbreak,  has 
published  an  account  of  the  epidemic  accompanied  by  an  ingeniously  ex- 
pressive little  map  of  the  localities.  A  young  man,  Louis  Meurice,  took 
typhoid  fever,  without  any  known  cause,  between  the  26th  June  and  the 
13th  July,  1857.  His  aunt,  living  at  Bertraud's  Mill,  two  kilometres  from 
Chamomile,  brought  the  disease  into  her  house,  where  her  husband  and 
three  children  took  it  in  succession  between  the  end  of  July  and  the  1st 
October.  The  woman  died ;  and  on  her  death  one  of  the  sick  children  was 
taken  to  Chamomile,  to  the  house  of  a  woman  called  Millepas,  forty-five 
years  of  age,  who  after  attending  on  the  child,  took  the  fever,  and  was  under 
treatment  from  the  15th  September  to  the  1st  October.  Eight  days  after- 
wards, a  woman,  her  neighbor,  took  to  her  bed.  On  the  17th  September, 
a  woman  of  the  name  of  Deguay,  aged  forty,  who  had  attended  upon  the 
patients  at  the  mill,  contracted  the  fever,  and  suffered  under  it  from  the 
17th  October  to  the  3d  November.  Two  months  after  its  first  appearance 
in  Chamomile,  the  fever  became  epidemic  there.  In  a  population  of  224, 
there  were  27  attacked. 

Similar  facts  were  observed  in  the  epidemics  of  1856.  Typhoid  fever 
was  carried  to  a  hamlet  in  the  department  of  Loir-et-Cher,  by  a  young  man 
who  went  there  to  be  attended  upon  by  his  family.  His  father  ami  mother, 
two  brothers,  a  sister,  and  the  house-servant,  all  of  whom  were  almost  con- 
stantly with  him,  contracted  the  disease:  the  sister  and  the  servant  died. 
The  young  man,  who  was  a  servant  at  Pont-Levoy,  was  succeeded  in  his 
service  by  a  person  who  was  lodged  in  the  room  which  his  predecessor  had 
left:  in  a  short  time  he  also  took  the  disease.  M.  Yvonneair,  who  gives 
these  details,  traced  out  with  praiseworthy  care  the  history  of  the  spread  of 
the  fever  within  these  narrow  limits  of  the  epidemic,  ami  the  documents 
which  he  has  furnished  on  the  subjecl  may  he  profitably  consulted. 

At  Paris  even,  unexceptionable  farts  of  the  same  description  have  been 
pointed  out  ;  ami  one  was  recently  communicated  to  me  by  Dr.  Firmin, 
under  whose  observation  it  came.  ML  de  G.,  aged  twenty-four,  employed 
ha  the  service  of  the  Western  Railway,  tools  fever  at  Batignolles.     He  was 

removed    to  his  lirol  Iut's  house   in    the  Kue  Buresnes,  where    he  was  waited 

upon  by  his  mother,  who  was  recalled  to  Paris,  after  an  absence  of  two 

months,  to  attend  upon  him.      On  the  twenty-second  day,  this  lady  fell  the 


DOTniNENTERIA.  275 

pains,  lassitude,  and  prostration  characteristic  of  the  beginning  of  the  fever, 
and  she  very  soon  had  all  the  symptoms  of  thoroughly  confirmed  dothinen- 
teria. 

From  tlic  examples  I  have  now  given,  the  contagious  nature  of  dothinen- 
teria  is  incontestable.  When  in  opposition  to  these  positive  tacts,  negative 
facts  are  adduced,  and  an  exaggerated  importance  is  assigned  to  them  : 
when  we  are  asked  to  explain  why  it  is  so  rare  to  see  persons  contract  the 
disease  in  our  hospital  wards  from  the  patients  who  have  it;  when  we  are 
referred  for  example  to  the  statement  that  of  439  cases  observed  at  the 
Hotel-Dieu  by  Chomel  and  Louis  only  10  began  in  the  hospital — we  men- 
tion, among  other  possible  explanations,  that  the  individuals  who  thus 
escaped  may  at  some  former  time  have  had  the  disease.  An  explanation 
of  a  more  general  character  consists  in  the  admission  which  must  perhaps 
be  made,  that  the  energy  of  the  eontagium  is  less  when  cases  are  only  occur- 
ring sporadically,  than  when  typhoid  fever  is  prevailing  as  an  epidemic. 

As  it  is  frequently  impossible,  notwithstanding  the  most  painstaking  re- 
searches, to  discover  the  origin  of  the  contagion,  and  as  it  is  obvious  that 
typhoid  fever  at  some  time  or  another  had  a  beginning,  we  cannot  refuse  to 
admit  the  possibility  of  its  arising  spontaneously,  although  we  hold  that  it 
is  a  contagious  disease.  Let  us  see  then  under  what  conditions  it  is  devel- 
oped. Some  of  the  conditions  must  be  sought  in  the  individual  himself, 
and  others  external  to  him.  The  first  are  the  exciting  causes,  the  chief  of 
which  is  contagion;  the  second  are  the  predisposing  causes.  Both  classes  of 
causes  are  difficult  of  recognition.  Were  I  to  discuss  the  influence  of  an 
atmosphere  vitiated  by  putrid  emanations,  the  influence  of  spoiled  articles 
of  food  and  contaminated  drinks,  I  should  be  occupying  your  time  with 
trivialities,  because  these  are  nothing  more  than  hypothetical  causes.  I 
will  pass  over  these  topics  as  well  as  the  influence  of  mental  emotions,  ex- 
cessive fatigue,  constitution,  temperament,  which  have  great  importance  in 
the  opinion  of  many,  and  briefly  consider  the  influence  of  age,  overcrowding, 
and  acclimatization. 

Dothinenteria  is  a  disease  of  adolescence  and  youth.  However,  it  is  not 
so  unusual  as  was  long  supposed  for  it  to  attack  children,  and  even  those 
of  a  very  early  age.  At  Paris,  and  in  other  places  where  the  disease  is 
endemic,  it  is  very  frequently  met  with  in  childhood :  there  are  cases  men- 
tioned in  which  it  occurred  in  children  between  two  and  seven  months : 
and  the  nearer  we  come  to  the  age  of  puberty,  the  more  common  is  doth- 
inenteria. In  my  own  family,  my  daughter's  three  children  had  it.  The 
disease  is  generally  milder  before  than  after  puberty :  still,  even  in  child- 
hood the  disease  often  terminates  fatally,  and  I  lately  saw  a  little  girl  of 
five  and  a  half  die  of  it  after  having  been  ill  for  little  more  than  twentv 
days.  Between  the  ages  of  eight  and  fourteen,  dothinenteria  becomes 
more  common  :  and  it  is  between  the  ages  of  fourteen  and  thirty  that  per- 
sons usually  contract  typhoid  fever.  You  have  remarked  that  in  the  dif- 
ferent epidemics  of  which  I  have  been  speaking,  cases  were  mentioned  in 
which  the  patients  were  forty  and  forty-five  years  of  age :  you  recollect 
the  case  of  a  woman  of  sixty-four,  who  died  of  intestinal  hemorrhage,  and 
at  whose  autopsy  Ave  found  dothinenteric  ulceration.  MM.  Lombard  and 
Fauconnet  of  Geneva  have  recorded  similar  ages  of  typhoid  fever  patients, 
and  they  even  mention  a  case  which  proved  fatal  in  a  man  of  seventv,  at 
whose  autopsy  they  found  the  characteristic  lesions  of  the  Peyerian  patches. 
Dothinenteria,  then,  does  not  spare  old  people,  though  it  is  not  a  common 
disease  in  advanced  life. 

If  overcrowding  does  not  of  itself  engender  the  disease,  it  is  at  least 
a  powerful  auxiliary  in  producing  it,  as  it  favors  contagion,  increases  the 


276  DOTHINENTERIA. 

severity  of  the  attack,  and  is  even  the  cause  of  its  assuming  the  most  deadly 
epidemic  character. 

In  respect  of  acclimatization,  you  have  had  an  opportunity  in  our  own 
patients  of  verifying  a  fact  to  which  the  attention  of  physicians  has  long 
been  directed,  viz.,  that  persons  coming  to  Paris  from  the  provinces  are 
very  often  attacked  with  typhoid  fever  soon  after  their  arrival.  In  the 
cases  registered  during  the  first  six  months  of  this  year,  you  will  see  it 
noted  that  a  very  small  number  of  our  patients  belonged  to  Paris,  and  that 
those  who  did,  had  lived  in  it  only  for  periods  of  seven  years,  six  years,  four 
years,  two  years,  eight  months,  five  months,  and  two  months. 

But  if  we  bear  in  mind  that  what  is  observed  in  dothinenteria  is  likewise 
observed  in  small-pox  and  scarlatina,  we  shall  be  less  inclined  to  consider 
non-acclimatization  as  a  predisposing  cause.  We  shall  recollect  that  among 
the  numerous  young  persons  of  both  sexes  who  ceaselessly  crowd  to  Paris, 
some  to  complete  their  education,  the  majority  to  pursue  occupations  of 
many  kinds,  the  greatest  number,  having  lived  in  country  places  where 
typhoid  fever  only  prevails  at  occasional  intervals,  have  not  paid  their 
tribute  to  the  disease,  and  are  consequently  in  a  condition  to  become  im- 
mediately subject  to  the  influence  of  the  contagion,  which  they  everywhere 
encounter  in  a  populous  city  where  the  disease  is  in  j)errnanence.  I  have 
already  told  you,  that  if  adults  born  in  Pai'is  take  the  disease  less  frequently 
than  new  comers,  it  is  because  the  former  have  generally  had  dothinenteria 
during  childhood  or  early  adolescence. 

I  will  conclude  what  I  have  to  say  on  the  etiology  of  typhoid  fever  by 
mentioning  a  curious  fact  first  pointed  out  by"  Dr.  Louis  le  Cottier,  a  phy- 
sician at  Mazieres.  He  says  that  typhoid  fever,  within  forty  years,  broke 
out  as  an  epidemic  three  times  among  the  inhabitants  of  the  farm  of  Haut- 
Verger  in  the  commune  of  Chapelle-Baton  (Deux-Sevres),  and  upon  each 
occasion,  the  outbreak  occurred  after  the  cutting  down  of  a  wood  upon  the 
outskirts  of  which  the  farmhouse  is  situated.*  Though  I  cannot  explain 
this  fact,  I  do  not  consider  it  the  less  deserving  of  being  here  mentioned. 

Treatment  of  Dothinenteria. — Regimen  of  the  Patients. 

Gentlemen,  you  observe  that  in  a  great  number  of  cases  of  dothinenteria, 
I  remain  almost  passive.  When  it  follows  its  natural  course,  when  the 
symptoms  and  special  complications  do  not  demand  active  measures,  my 
treatment  is  limited  to  prescribing  infusion  of  chamomile  as  a  tisane,  acid- 
ulated drinks  such  as  lemonade  or  orangeade,  and  water  sweetened  with 
gooseberry  or  cherry  syrup. 

The  intervention  of  art  is  generally  useless  in  the  eruptive  fevers,  to 
which  dothinenteria  presents  striking  analogies.  Their  progress  is  but  very 
slightly  modified  by  the  available  resources  of  medicine.  When  the  cases 
are  mild,  recovery  lakes  place  spontaneously ;  and  a  judicious  physician 
will  avoid  disturbing  the  curative  efforts  of  nature1  by  unreasonable  med- 
dling. On  the  other  hand,  when  the  eases  are  severe,  the  disease  often 
shows  threatening  tendencies  as  it  advances,  and  (hen  our  interference  may 
be  of  real  benefit.  But  such  fortunate  occasions  are  more  frequently  mel 
with  in  scarlatina,  measles,  and  small-pox  than  in  dothinenteria,  yet  in  all 
of  them  we   are   most  commonly  obliged    to    recognize   our   impotence  and 

submit  to  consequences  which  we  cannol  prevent. 

Indications  for  recourse  to  active  treatment  present  themselves, however, 

much  more  freipienl  ly  in  dot  hineiileria  than  in  the  other  erupt  iye  levers. 
This  arises  from  the  circumstance  that  dothinenteria,  much  le—  precisely 

_K, . . — _________ 

*  See  the  Union  Mediculc,  for  5th  January,  1858. 


DOTHINENTERIA.  277 

characterized,  much  less  distinct  in  its  symptoms  than  is  generally  the  case 
iti  scarlatina  and  measles,  and  still  more  in  small-pox,  is  accompanied  much 
oftener  than  they  are  by  manifestations  which,  while  they  do  not  take  away 
anything  from  its  nature,  impart  to  it  that  great  diversity  of  form  which  I 
have  pointed  out,  and  against  which  we  have  to  contend  :  it  also  arises  from 
the  various  forms,  even  the  mildest  being  subject  to  local  complications  of 
greater  or  less  severity,  which  play  an  important  part  in  the  course  of  the 
disease. 

In  speaking  of  the  adynamic  and  ataxic  forms,  I  stated  that  in  the  former 
the  efforts  of  the  physician  ought  to  be  directed  to  the  support  of  the  failing 
powers  of  nature,  and  that  as  the  therapeutic  indication  is  to  promote  reac- 
tion, it  is  necessary  to  have  recourse  to  stimulants  and  tonics :  I  at  the  same 
time  entered  into  some  details.  With  reference  to  the  ataxic  form,  I  said 
that  cold  affusions  were  decidedly  useful  in  moderating  the  excitement  and 
irregularity  of  action  in  the  nervous  system. 

I  have  already  explained  my  treatment  of  intestinal  hemorrhage. 

When  there  is  very  severe  bronchitis,  or  when  there  is  pneumonia,  I  give 
antimonials,  and  I  produce  counter-irritation  of  the  skin  by  applying  a 
lotion  of  the  tincture  of  iodine.  This  is  a  powerful  counter-irritant,  and 
one  the  effects  of  which  can  be  regulated :  it  has  not,  moreover,  the  incon- 
veniences of  a  blister,  which  sometimes,  as  you  know,  gives  rise  to  a  gangre- 
nous sore. 

I  have  still  to  recapitulate  the  measures  I  pursue  in  ordinary  cases,  par- 
ticularly in  respect  of  diet,  not  only  the  diet  during  the  course  of  the  dis- 
ease, but  likewise  in  convalescence.  I  look  upon  dietetic  management  as 
the  chief  feature  in  the  treatment,  and  I  attribute  the  success  which  I  have 
had  in  typhoid  fever  to  the  dietetic  plan  which  I  follow.  So  much  impor- 
tance do  I  attach  to  dothinenteric  patients  having  proper  food,  that  it  is  by 
dietetic  means,  aided  by  medicines,  that  I  endeavor  to  subdue  the  symptoms 
referable  to  the  digestive  canal,  and  to  regulate  its  functions  as  much  as 
possible.  It  is  in  this  way  that  I  moderate  profuse  diarrhoea,  correct  obsti- 
nate constipation,  modify  a  saburral  condition,  and  restore  impaired  appetite. 

When  the  bilious  or  saburral  condition  is  very  decided,  you  have  seen 
me  begin  by  giving  ipecacuan  as  an  emetic.  I  generally  prescribe  three 
grammes  of  the  powder  divided  into  three  equal  parts,  directing  one  to  be 
taken  every  ten  minutes  till  vomiting  is  induced.  This  treatment  not  only 
modifies  the  saburral  state,  but  likewise  exercises  a  beneficial  influence  on 
the  diarrhoea. 

When  the  stools  are  excessive  both  in  number  and  in  quantity,  I  usually 
begin  by  ordering  a  saline  purgative — for  example,  25  or  30  grammes  of 
the  sulphate  of  soda,  or  of  the  tartrate  of  potash  and  soda,  medicines  which 
probably  act  beneficially  by  modifying  the  intestinal  secretions.  This  treat- 
ment is  particularly  indicated  in  cases  in  which  the  diarrhoea  is  accompanied 
by  a  certain  degree  of  meteorism  :  in  such  cases  the  saline  purgative  may 
with  great  advantage  be  repeated  several  times.  When  I  do  not  succeed 
in  thus  obtaining  the  expected  modification  of  the  intestinal  secretions,  I 
prescribe  what  are  called  absorbent  powders.  One  of  these  powders,  con- 
taining 50  centigrammes  of  subnitrate  of  bismuth  and  an  equal  quantity  of 
prepared  chalk,  may  be  given  with  benefit  from  three  to  eight  times  in  the 
twenty-four  hours,  the  frequency  of  the  repetition  being  regulated  by  the 
severity  and  obstinacy  of  the  symptoms.  I  also  often  give  the  English  mix- 
ture, which  I  thus  formulate  : 

Prepared  chalk,    .         .         .         .30  grammes. 
Syrup  of  orange-peel,  .         .         .30  " 

Water, 90  " 


278  DOTHINENTERIA. 

I  also  frequently  order  the  powder  of  columbo  root  in  doses  of  50  centi- 
grammes up  to  a  gramme.  Finally,  when  these  prescriptions  prove  ineffec- 
tual, I  have  recourse  to  more  energetic  alteratives.  I  then  prescribe  5  centi- 
grammes of  nitrate  of  silver,*  to  be  taken  in  five  doses,  at  intervals  of  an 
hour.     The  following  is  my  formula  : 

Crystallized  nitrate  of  silver,  5  centigrammes. 
Water,  a  quantity  sufficient  to  dissolve  the  nitrate. 

Add  to  this  solution  enough  of  crumb  of  bread  to  make  a  mass,  and  then 
divide  the  mass  into  five  pills  of  equal  size. 

If,  as  sometimes  happens,  there  is  constipation  in  place  of  diarrhoea,  I 
open  the  bowels  by  giving  ten  or  fifteen  grammes  of  castor  oil,  a  purgative 
which  in  the  circumstances  is  very  much  to  be  preferred  to  the  neutral 
salts,  the  operation  of  which  is  soon  over,  and  is  succeeded  by  a  tendency 
to  confinement,  an  inconvenience  which  does  not  attend  the  employment 
of  castor  oil.  When  the  constipation  does  not  yield  to  castor  oil,  I  pre- 
scribe 5  centigrammes  of  calomel  in  the  form  of  pastel,  and  a  gramme  of 
the  powder  of  jalap,  the  latter  to  be  taken  a  quarter  of  an  hour  after  the 
former.  If,  notwithstanding  this  treatment,  the  constipation  still  continue, 
I  repeat  the  calomel,  and  in  place  of  giving  jalap  after  it,  I  give  10 
grammes  of  senna  in  the  form  of  a  very  'concentrated  infusion,  mixed  with 
infusion  of  roasted  coffee. 

Generally,  however,  the  regular  evacuation  of  the  bowels,  and  also  the 
removal  of  meteorism  when  present,  may  be  accomplished  by  the  patient 
taking  daily,  night  and  morning,  a  lavement  of  infusion  of  chamomile. 

In  the  mucous  form  of  dothinenteria,  which  is  sometimes  very  tedious, 
you  have  seen  me  stimulate  the  appetite  by  administering  bitters,  such  as 
the  decoction  of  quassia,  cinchona,  &c,  and  preparations  of  strychnia,  such 
as  5  centigrammes  of  the  powder  of  nux  vomica,  or  some  of  the  bitter 
tincture  of  Baume,  which  derives  its  stimulating  properties  from  St.  Igna- 
tius's  bean.  According  to  the  nature  of  the  case,  the  patient  may  take 
one,  two,  or  three  drops  of  this  tincture  immediately  before  his  soup. 

I  now  come  to  the  subject  of  diet.  Perhaps,  gentlemen,  it  has  seemed 
strange  to  you  that  I  should  insist  so  positively  upon  the  necessity  of  giving 
nutriment  to  dothinenteric  patients,  not  merely  as  most  of  my  colleagues 
now  do,  at  a  somewhat  advanced  period  of  the  attack,  when  the  fever  is 
moderate  and  the  tongue  less  coated,  that  is  to  say,  towards  the  end  of  the 
first  or  beginning  of  the  second  week,  but  from  the  very  commencement, 
and  during  the  whole  course  of  the  malady.  In  point  of  fact,  I  require  my 
dothinenteric  patients,  from  the  very  first,  to  take  daily  two  small  portions 
of  a  soup  made  without  meat,  and  also  some  tablespoonfuls  of  meal  broth, 
disregarding  the  repugnance  to  food  which  some  patients  show,  and  with- 
out being  deterred  even  when  there  is  vomiting,  which  is  apparently  a 
contraindication  of  feeding.  In  cases  where  there  is  vomiting,  I  advise 
that  broths  made  with  and  without  meat  should  be  given  daily  in  such 
quantities  as  can  be  borne. 

This  practice  is  now  recommended  by  a  great  Dumber  of  the  hospital 
physicians  of  Paris,  as  was  shown  by  an  interesting  discussion  on  the  sub- 
ject in  the  Si,ri,'i,'  de  Medecine  des  adpitanx,  in  October,  1857,  in  which  I 
was  asked  to  take  part,  with  men  whose  opinion  is  of  undoubted  weight. 
Some  of  these  gentlemen,  ray  honorable  professional  brethren  Drs.  Le- 
groux  and  Barth  for  instance,  do  not  allow  their  patients  to  have  aourish- 

*  Five  centigrammes — thai  is,  five  hundredths  of  u  grammi — Hre  about  ftve- 

seventlis  hi*  a  British  grain. — Trans]  itor, 


DOTIIINENTERIA.  279 

ing  diet  till  about  the  eighth  day,  while  Drs.  Aran,  Behier,  and  others, 
entertain  views  similar  to  my  own,  and  force  their  dothinenteric  patients 
to  take  food  from  the  beginning  of  the  attack.  In  this  discussion,  Dr. 
(alien,  judiciously  appealing  to  the  experiments  of  Chossat  on  inanition, 
pointed  out  that  medical  observation  and  physiological  experiment  entirely 
agree  in  showing  that  very  low  diet  is  injurious  in  diseases  of  long  dura- 
tion. Chossat  had  indeed  seen  that  entire  abstinence  caused  the  body 
to  lose  forty-two  thousandth  parts  of  its  weight,  and  that  death  was  the 
inevitable  result  when  the  loss  amounted  to  four-tenths  of  the  original 
weight.  Mr.  Cahen  says  that  in  typhoid  fever  we  see  great  loss  of  flesh 
rapidly  supervene,  and  that  it  even  proceeds  to  emaciation.  He  asks 
whether  it  is  not  probable  that  death  in  these  cases  is  less  the  result  .of  the 
progress  of  the  disease,  than  of  wasting  of  the  body  having  reached  a  point 
incompatible  with  the  continuance  of  life.  In  these  cases,  the  individual 
feeds  upon  his  own  body,  and  it  is  with  a  view  to  prevent  this  autophagy, 
which  brings  either  death  or  very  dangerous  symptoms  in  its  train  ;  it  is  to 
support  the  system  in  its  struggle  with  an  exhausting  disease  of  long  dura- 
tion, that  there  is  a  paramount  necessity  of  vigorously  prescribing  suitable 
food. 

I  say  suitable  food ;  for  while  the  low  diet  to  which  patients  were  con- 
demned when  medical  practice  was  ruled  by  the  deplorable  doctrines  in 
vogue  at  the  beginning  of  the  century,  while  a  ridiculous  abstinence  from 
food  is  productive  of  the  evils  which  I  have  pointed  out,  care  must  be  taken 
not  to  fall  into  the  opposite  extreme  of  those  who  are  not  afraid  to  give 
solid  food  at  the  beginning  and  during  the  course  of  continued  fevers. 
There  is  a  great  distance  in  the  dietetic  scale  between  the  broths  and  light 
soups  which  I  declare  to  be  indispensable — between  the  tenuis  victus  as 
Hippocrates  called  that  famous  diet-drink,  barley-water — and  the  minced 
butcher-meat  which  some  physicians  compel  their  unfortunate  patients  to 
swallow. 

"  Opportunum  medicamentum  est  opportune  cibus  datus,"  wrote  Celsus ; 
and  "  in  alimentis  medicamenta  sunt,"  repeated  Aretseus.  The  doctrine 
which  I  maintain  is  as  old  as  medicine  itself.  From  the  time  of  Hippoc- 
rates— who  devoted  a  book  to  the  subject — to  our  own  day,  the  great 
practitioners  of  the  past  have  always  attached  much  importance  to  dietet- 
ics, which  they  have  looked  on  as  embracing  the  most  powerful  therapeutic 
resources  of  our  art.  Morton  says  that  with  the  assistance  of  food  well 
regulated  from  the  beginning  of  the  attack,  he  has  seen  fevers  cured  by 
the  efforts  of  nature,  without  any  recourse  having  been  necessary  to  the 
pompous  arsenal  of  jtharmacy  ;  while  cases  which  at  first  were  mild  have 
become  malignant  under  a  repetition  of  copious  bleedings,  and  the  abuse 
of  emetics  and  cathartics. 

Permit  me,  gentlemen,  to  fortify  my  opinions  on  this  subject  by  the  au- 
thority of  Graves,  a  man  whom  I  regard  as  the  most  eminent  clinical 
teacher  of  our  age,  whom  I  delight  to  quote,  whom  I  constantly  consult, 
and  whose  work  ought  to  be  your  vade-mecum.  Allow  me  also  to  appeal 
to  the  authority  of  a  man  who,  in  our  own  France,  has  equalled  the  illus- 
trious physician  of  Dublin,  and  who  has  left  behind  him  the  light  of  a 
brilliant  career :  need  I  say,  that  I  refer  to  Bretonneau  ?  These  two  illus- 
trious physicians  may,  to  a  certain  extent,  be  said  to  have  passed  their 
youth  in  contending  against  the  abuse  of  abstinence  from  food  in  fevers  ; 
and  to  them  is  chiefly  due  emancipation  from  the  yoke  of  prejudice  im- 
posed on  practitioners,  by  the  school  of  Broussais,  to  the  great  detriment 
of  patients. 


280  DOTHINENTER1A. 

Allow  me  then,  gentlemen,  to  translate  some  paragraphs  of  Graves  upon 
the  subject  now  before  us  : 

"  In  a  disease  like  fever,  which  lasts  frequently  for  fourteen,  twenty-one, 
or  more  days,  the  consideration  of  diet  and  nutriment  is  a  matter  of  im- 
portance ;  and  I  am  persuaded  that  this  is  a  point  on  which  much  error 
has  prevailed.  I  am  convinced  that  the  starving  system  has  in  many  in- 
stances been  carried  to  a  dangerous  excess,  and  that  many  persons  have 

fallen  victims  to  prolonged  abstinence  in  fever Let  us  examine  the 

results  of  protracted  abstinence  in  the  healthy  state  of  the  system.  Take 
a  healthy  person,  and  deprive  him  of  food.  What  is  the  consequence  ? 
First,  hunger,  which  after  some  time  goes  away,  and  then  returns  again. 
After  two  or  three  days,  the  sensation  assumes  a  morbid  character,  and 
instead  of  being  a  simple  feeling  of  want  and  a  desire  for  food,  it  becomes 
a  disordered  craving  attended  with  dragging  pain  in  the  stomach,  burning 
thirst,  and  some  time  afterwards,  epigastric  tenderness,  fever,  and  delirium. 
Here  we  have  the  supervention  of  gastric  disease,  and  inflammation  of  the 
brain,  as  the  results  of  protracted  starvation." 

"  Read  the  accounts  of  those  who  perished  from  starvation  after  the 
wTreck  of  the  Medusa  and  Alceste,  and  you  will  be  struck  with  the  horrible 
consequences  of  protracted  hunger.  You  will  find  that  most  of  the  unhappy 
sufferers  were  raging  maniacs,  and  exhibited  symptoms  of  violent  cerebral 
irritation.  Now,  in  a  person  laboring  under  the  effects  of  fever  and  pro- 
tracted abstinence — whose  sensibilities  are  blimted  and  whose  functions  are 
deranged — it  is  not  at  all  improbable  that  such  a  person,  perhaps  also  suf- 
fering from  delirium  and  stupor,  will  not  call  for  food,  though  requiring 
it ;  and  that  if  you  do  not  press  it  on  him,  and  give  it  as  medicine,  symp- 
toms like  those  which  arise  from  starvation  in  the  healthy  subject  may  su- 
pervene, and  you  may  have  gastro-enteric  inflammation,  or  cerebral  disease. 
as  the  consequence  of  protracted  abstinence.  You  may,  perhaps,  think  that 
it  is  unnecessary  to  give  food,  as  the  patient  appears  to  have  no  appetite, 
and  does  not  care  for  it.  You  might  as  well  allow  the  urine  to  accumulate 
in  the  bladder,  because  the  patient  feels  no  desire  to  pass  it.  You  are 
called  on  to  interfere  where  the  sensibility  is  impaired,  and  the  natural 
appetite  is  dormant ;  and  you  are  not  to  permit  your  patient  to  encounter 
the  horrible  consequences  of  inanition,  because  he  does  not  ask  for  nutri- 
ment. I  never  do  so.  After  the  third  or  fourth  day  of  fever,  I  always 
prescribe  mild  nourishment,  and  this  is  steadily  and  perseveringly  continued 
through  the  whole  course  of  the  disease." 

"  Again,  let  us  see  how  close  a  resemblance  the  symptoms  generated  by 
long-continued  denial  or  want  of  food  bear  to  those  which  are  observed  in 
the  worst  forms  of  typhus.  Pains  of  the  stomach,  epigastric  tenderness, 
thirst,  vomiting,  determination  of  blood  to  the  brain,  suffusion  of  the  eyes, 
headache,  sleeplessness,  and,  finally,  furious  delirium,  are  the  symptoms  of 
protracted  abstinence,  and  to  these  we  may  add  tendency  to  putrefaction 
of  the  animal  tissues,  chiefly  shown  by  the  spontaneous  occurrence  of  ^aii- 
grene  of  the  lungs.  It  has  been  shown  by  M.  Guislain,  physician  to  the 
hospital  for  the  insane  at  Ghent,  thai  in  many  instances  gangrene  of  the 
lung  had  occurred  in  insane  patients  who  have  obstinately  refused  to  take 
food.  Out  of  thirteen  patients  who  died  of  inanition,  nine  had  gangrene 
of  the  lungs It  is  not,  therefore,  wrong  to  suppose  thai  when  a  sys- 
tem of  rigorous  abstinence  bas  been  observed  in  fever,  and  when  food  has 
been  too  long  withheld,  because,  forsooth,  the  patient  does  not  call  for  it. 
and  because  his  natural  sensibilities  are  blunted   and   impaired — it   is  not, 


DOTIIINENTERIA.  281 

I  Bay j  unreasonable  to  infer  that  gastric,  cerebral,  and  even  pulmonary 
symptoms  may  supervene,  analogous  to  those  which  result  from  actual 
starvation."* 

Gentlemen,  I  require  to  add  nothing  to  these  true  and  eloquent  para- 
graphs of  Graves,  who  said  to  his  pupils:  "  If  you  are  at  a  loss  for  an  epi- 
taph to  inscribe  on  my  tomb,  you  may  use  these  words — He  Fed  FEVERS."f 
We  are  not,  however,  prevented  from  inquiring  into  the  causes  of  the  terri- 
ble symptoms  produced  by  inanition. 

The  normal  constitution  of  the  blood  is  the  condition  under  which  all  the 
processes  of  interstitial  nutrition  take  place,  and  good  nutrition  is  the  con- 
dition essential  to  the  performance  of  the  functions  assigned  to  the  different 
organs.  It  is  by  alimentation  that  the  blood  is  renewed;  and  whenever 
there  is  a  deficiency  from  that  source  in  the  elements  required  for  the  recon- 
stitution  of  the  blood,  the  nutritive  processes  are  carried  on  at  the  expense 
of  the  materials  of  the  living  organism.  The  animal  will  then  live  upon 
itself;  and  as  it  will  be  unable  to  derive  from  its  own  substance  all  the  ele- 
ments requisite  for  sanguineous  renewal,  the  quality  of  the  blood  will  forth- 
with become  anomalous,  and  the  organs  which  the  blood  is  designed  to 
restore,  will  themselves  become  fundamentally  altered  in  structure.  The 
organs  being  thus  altered,  will  supply  the  already  altered  blood  with  ele- 
ments still  inferior;  and  thus  there  will  be  established  a  vicious  circle — 
the  circle  of  autophagy  as  Bretonneau  called  it — a  circle  in  which  the  disor- 
ganization of  the  blood  and  the  tissue  goes  on  constantly  increasing,  till  it 
ultimately  attains  a  point  at  which  the  functions,  which,  at  first  were  merely 
disturbed,  become  completely  deranged  and  disassociated,  death  constitut- 
ing the  climax  of  this  gradual  destruction  of  the  economy. 

The  most  essential  part  of  the  treatment,  then,  is  to  give  nutriment.  We 
must  observe  the  state  of  the  patient  with  respect  to  strength,  so  that  we 
may  be  able  to  put  him  into  a  condition  to  resist  the  fever  by  which  he  is 
being  devoured  :  according  to  the  degree  of  weakness,  and  according  to  the 
supposed  duration  of  the  disease,  it  is  necessary  to  give  food  more  or  less 
frequently,  but  always  in  small  quantity,  and  in  the  liquid  form.  The  age, 
temperament,  and  habits  of  the  patient,  ought  also  to  be  taken  into  consid- 
eration, as  is  remarked  by  Jodocus  Lommius  in  his  little  tract  "De  curandiis 
febribvs  continuis,"  a  work  several  chapters  of  which  are  devoted  to  the 
consideration  of  the  diet  suitable  to  the  different  periods  of  the  disease. 

Although  I  lay  particular  stress  upon  regular  feeding  in  dothinenteria, 
although,  as  you  have  seen  every  clay,  I  oblige  the  patient  to  take  light 
soups,  I  also  wait  longer  than  others  before  I  allow  him  to  return  to  a  more 
substantial  diet.  At  the  decline  of  the  fever,  some  of  my  professional 
brethren,  discontinuing  the  low  diet  which  they  had  imposed  up  to  that 
period,  allow  solid  food  to  be  taken  ;  but  I  insist  atthat  period  upon  the 
necessity  of  restricting  the  patients  to  light  farinaceous  food,  and  during 
convalescence  (even  when  it  is  fairly  established),  I  am  among  those  who 
keep  them  on  the  shortest  commons. 

Having  been  careful  to  maintain  the  strength  during  the  whole  course  of 
the  malady,  however  long  its  duration  may  have  been,  I  have  nothing  to 
fear  in  my  patients  from  the  diastrous  consequences  of  abstinence  and  in- 

*  Graves:  Clinical  Lectures  on  the  Practice  of  Medicine.  Second  edition,  edited 
by  J.  M.  Neli^an.M.D.     Two  volumes.     Dublin:   1848      Vol.  i,  p.  117-119. 

The  ^notation  in  the  text  is  an  exact  reprint  from  the  work  of  Dr.  Graves — not 
a  translation  of  Dr.  Trousseau's  French  version. — Translator. 

f  Quoted  at  p.  253  of  Dr.  Murchison's  work. 


282  DOTHINENTERIA. 

auition ;  and  can  more  easily  protect  them  from  the  unfavorable  occurrences 
to  which  they  continue  liable  at  the  very  time  that  they  suppose  their  re- 
covery to  be  complete.  I  thus  avoid  bringing  on  attacks  of  indigestion, 
which,  though  they  may  not  cause  serious  gastro-intestinal  mischief,  nor 
(as  sometimes  happens )  fatal  peritonitis,  may  nevertheless  lead  to  relapses, 
or  may  retard  restoration  to  health.  During  the  convalescence  of  dothin- 
enteric  patients,  it  is,  therefore,  absolutely  necessary  to  resist  their  demands 
for  food,  when,  as  is  usually  the  case,  they  have  a  craving  appetite. 

There  are  cases,  however,  in  which  it  is  requisite  during  convalescence, 
to  return  quickly  to  a  very  substantial  and  very  tonic  kind  of  feeding,  pro- 
ceeding always  with  extreme  caution.  That  is  the  period  during  which 
occur  the  symptoms  of  which  I  am  now  going  to  speak,  and  which  are  most 
frequently  met  with  in  persons  exhausted  by  a  rigorously  low  diet,  or  by 
hemorrhages. 


Affections  which  occur  during  Convalescence. —  Gastric  Disturbance. —  Vomit- 
ing.— Diarrhoea. — Nervous  Symptoms. —  Vertigo. — Delirium. — Impaired 
Mental  Power. — Paralysis. — Dropsical  Effusions. 

The  convalescence  from  typhoid  fever  is  sometimes  interrupted  by  gastric 
disorders,  which  unless  very  carefully  attended  to,  may  deceive  the  phy- 
sician from  their  seeming  to  demand  treatment  the  very  opposite  of  that 
which  they  really  require.  I  refer  to  vomiting  and  diarrhoea,  both  partic- 
ularly apt  to  occur  in  those  who  have  been  reduced  by  starvation.  It  seems 
as  if  the  stomach  and  intestines,  having  forgotten  how  to  perform  their  al- 
lotted functions,  can  digest  nothing.  The  smallest  quantity  of  liquid  food, 
or  even  of  tisane,  is  at  once  rejected  by  the  mouth  ;  and  there  is  a  notable 
increase  in  the  number  of  the  alvine  evacuations.  The  patients  are  exceed- 
ingly wreak,  their  circulation  is  languid,  and  their  temperature  is  percepti- 
bly lowered.  Not  only  are  the  liquid  ingesta  vomited,  but  there  is  regurg- 
itation of  mucous  and  bilious  matter  of  a  color  successively  varying  from 
yellow  to  apple-green,  bottle-green,  leek-green,  greenish-blue,  or  even  pure 
blue.  Under  the  belief  that  the  powers  of  the  stomach  are  inadequate,  and 
that  the  symptoms  are  the  result  of  gastritis,  the  use  of  every  kind  of  food 
is  ,-uspended  :  the  patient  is  given  skimmed  milk,  chicken-broth,  and  muci- 
laginous drinks,  which,  far  from  calming  the  disorder  of  the  functions,  in- 
crease it.  When  I  come  to  speak  of  dyspepsia,  and  its  different  forms,  I 
will  tell  you  that  gastritis,  regarding  which  so  much  that  is  erroneous  lias 
been  stated,  is  a  rare  disease;  and  that,  on  the  contrary,  the  food  apparently 
most  calculated  to  excite  inflammation  of  the  stomach  is  that  which  is  most 
easily  home.  1  now  refer  to  symptoms  connected  with  the  nervous  system, 
to  disorder  of  the  function  of  secretion,  the  hot  means  of  subduing  which  is 
to  give  solid  food.  In  these  cases,  it  is  not  broths  and  soups  thai  one  must 
prescribe,  hut  grilled  or  roasted  meal  in  small  quantities,  fermented  liquors, 
and  good  old  wine  in  moderation.     In  some  cases,  eating  what  are  called 

heavy  kinds  of  meat,  such  as  pork,  is  the  only  means  of  subduing  obstinate 

vomiting.  Under  the  influence  of  this  regimen,  the  digestive  canal  by  de- 
grees recovers  its  tone,  and  soon  digests  as  before:  the  vomiting  Btope,  and 
the  diarrhoea  gradually  ceases. 

But,  gentlemen,  beware  of  mistaking  the  symptoms  of  which  1  have  been 
speaking  for  the  relapses  which  occur  from  errors  in  diet.  In  the  latter, 
there  is  real  indigestion.  The  fever  also  is  rekindled,  the  stupor  recom- 
mences, the  exanthematous  spots  reappear  on  the  skin,  and  (as  in  cases 
which  I  have  described  to  you]  the  dothmenteria  seems  to  take  a  new  start. 


DOTHINENTERIA.  283 

In  such  circumstances,  it  would  be  exceedingly  dangerous  to  insist  upon 
feeding  the  patients  with  nutritious  aliment.  On  the  contrary,  it  is  neces- 
sary for  some  days  to  subject  them  to  a  rigorous  low  diet — to  restrict  them 
to  emollient  drinks  and  farinaceous  food;  to  give  chalk  and  bismuth  ;  and 
to  wait  till  the  storm  is  past,  before  returning  to  a  more  generous  diet. 

Vertigo  dependent  on  autophagy  is  more  common  than  the  other  patho- 
logical phenomenon  of  which  I  have  just  been  speaking.  I  will  not,  however, 
at  present  stop  to  consider  it,  but  will  reserve  what  I  have  to  say  regarding 
it  till  a  future  occasion,  when  I  shall  have  to  discuss  the  general  subject  of 
vertigo  arising  from  disordered  digestion. 

But  delirium  is,  of  all  the  nervous  symptoms  which  demand  the  attention 
of  the  physician  during  convalescence  from  putrid  fever,  that  which  is  most 
commonly  met  with  :  if  its  possible  occurrence  is  not  foreseen,  and  its  cause 
is  not  attentively  sought  out,  it  may  lead  to  the  belief  that  there  is  a  serious 
cerebral  affection. 

We  had  a  singular  illustration  of  this  remark  in  the  case  of  a  patient 
who  occupied  bed  No.  16  of  St.  Agnes's  Ward.  This  young  man,  at  the 
twenty-ninth  or  thirtieth  day  of  a  putrid  fever,  in  which  he  had  had  copious 
intestinal  hemorrhage  about  the  end  of  the  second  week,  was  convalescent, 
when  he  Avas  seized  with  delirium,  more  continuous  and  more  violent  than 
he  had  had  even  when  the  disease  was  at  its  height.  All  the  other  symp- 
toms, however,  were  for  a  long  time  in  abeyance :  regular  stools  had  suc- 
ceeded to  the  diarrhoea,  and  there  was  no  longer  any  pulmonary  catarrh : 
there  was  no  fever,  the  pulse  was  only  64,  and  the  temperature  of  the  skin 
was  natural. 

The  cerebral  symptoms  might  have  led  one  to  believe  that  there  was  a 
lesion  of  the  brain  similar  to  that  observed  by  Piednagel  in  a  certain  num- 
ber of  cases,  a  lesion  consequent  upon  irritation  or  subacute  inflammation 
of  the  pia  mater  and  gray  substance,  and  bearing  some  resemblance  to  what 
is  sometimes  met  with  in  persons  sinking  under  the  general  paralysis  of  the 
insane.  My  colleague  of  the  Hotel-Dieu  supposes  that  the  delirium  of  the 
convalescence  from  typhoid  fever  is  caused  by  the  persistence  of  this  inflam- 
mation; which  in  other  respects  he  regards  as  an  unimportant  affection,  and 
as  not  at  all  serious,  inasmuch  as  it  is  very  curable.  The  proposition  stated 
in  this  way  is  far  too  absolute.  I  at  once  grant  that  the  disturbance  of  the 
intellectual  faculties  is  dependent  upon  an  altered  state  of  the  encephalon : 
I  admit  that  this  alteration  may  be  the  result  of  congestion  and  inflamma- 
tion of  which  we  can  find  traces  on  examining  the  dead  body ;  but  it  is  also 
a  fact,  that  often  no  such  traces  are  discoverable.  Without  giving  an 
opinion  as  to  the  nature  of  this  affection,  it  may  be  stated,  that,  be  it  what 
it  may,  it  is  an  alteration  produced  under  the  influence  of  a  septic  malady 
which  produces  radical  changes  in  the  fluids,  and  acts  specially  upon  the 
nervous  system  :  and  it  may  likewise  be  stated,  that  in  proportion  to  the 
length  of  time  during  which  this  influence  operates  upon  the  economy,  is  the 
duration  of  the  period  required  for  a  return  to  a  normal  condition.  But 
disturbance  of  the  intellectual  faculties  may  also  arise  from  the  individual 
having  been  exhausted  by  great  loss  of  blood,  or  by  starving ;  the  brain 
under  such  circumstances  being  deprived  of  its  natural  excitant,  the  blood. 
Now,  the  organ  of  the  intellectual  faculties  will  be  longer  in  resuming  its 
original  activity,  in  proportion  to  the  longer  or  shorter  duration  of  the  state 
of  feebleness,  exactly  as  is  the  case  with  the  muscles,  which,  when  they  have 
been  inactive  for  a  long  time,  do  not  all  at  once  regain  their  power.  And 
possibly,  this  state  of  feebleness,  or  cerebral  atony,  is  the  most  common  cause 
of  the  symptoms  of  which  I  have  been  speaking. 

To  sum  up :  If  the  delirium  and  vertigo  which  supervene  during  con- 


284  DOTHINENTERIA. 

valescence  from  typhoid  fever,  and  that  hebetude  which  the  patients  retain 
for  even  from  five  to  ten  months  after  recovery,  and  which  some  never  lose, 
are  referable  to  a  subacute  inflammation  of  the  membranes  and  cortical 
substance  of  the  brain,  there  is  generally  no  appreciable  organic  lesion,  and 
the  pathological  phenomena  seem  to  be  dependent  upon  cerebral  ana?mia 
resulting  from  debility,  and  requiring  to  be  treated  by  tonics  and  stimu- 
lants, exactly  like  muscular  debility,  to  which  I  have  compared  it.  The 
correctness  of  these  views  is  shown  by  the  delirium  ceasing  and  the  intel- 
lectual faculties  returning  to  their  normal  state  under  the  influence  of  gen- 
erous diet.  You  saw  a  patient  who  occupied  bed  No.  8  of  our  St.  Bernard's 
Ward,  who  after  remaining  in  a  state  of  imbecility  for  six  weeks  after  re- 
covery from  severe  putrid  fever,  regained  simultaneously  her  intellectual 
faculties  and  her  muscular  power. 

In  such  cases,  it  would  be  a  serious  blunder,  leading  to  aggravation  of 
the  symptoms,  to  resort  to  antiphlogistic  treatment,  from  an  idea  that  there 
existed  inflammation  or  congestion.  In  a  case  similar  to  that  of  the  woman 
in  St.  Bernard's  Ward — the  case  of  the  man  who  occupied  bed  No.  16  of 
St.  Bernard's  Ward — you  saw  me  prescribe  stimulants  and  tonics,  wine  and 
coffee,  as  well  as  solid  sustaining  food. 

Typhoid  fever  is  not  the  only  disease  which  is  succeeded  by  disorder  of 
the  intellectual  faculties:  it  occurs  after  all  septic  diseases — after  small- 
pox, scarlatina  and  diphtheria — and  it  is  always  by  the  same  kind  of  treat- 
ment that  the  cure  has  to  be  brought  about. 

Still,  it  is  a  cardinal  point,  a  matter  of  absolute  necessity,  to  proceed 
with  very  great  caution,  so  as  not  to  exceed  reasonable  bounds.  While  the 
diet  is  essentially  tonic  and  reparative,  it  must  be  kept  strictly  within  the 
limits  of  the  digestive  power :  you  must  not  go  on  at  too  great  a  speed  from 
a  desire  to  proceed  without  loss  of  time.  If  the  quantity  of  food  taken  is  in 
excess  of  the  digestive  capability  of  the  individual,  the  gastro-intestinal 
symptoms  will  be  aggravated,  in  place  of  being  subdued,  the  vomiting  will 
continue,  and  increase  in  severity — the  diarrhoea  will  assume  a  much  greater 
intensity,  and  the  patient  will  succumb  under  the  inveterate  consequences 
of  indigestion. 

The  different  forms  of  parcdijsis  which  supervene  during  convalescence 
from  dothinenteria  also  belong  to  the  same  class  of  symptoms  as  those  which 
we  have  just  been  considering;  like  vertigo,  delirium,  and  mental  debility, 
the  different  paralytic  affections  originate  in  shock  of  the  nervous  system, 
in  organic  and  functional  modification  throughout  its  entire  extent,  caused 
by  the  morbid  poison,  which,  having  in  the  first  instance  acted  directly  on 
the  nervous  system,  continues  so  to  act  during  the  whole  course  of  the  dis- 
ease. We  ran  understand  that  the  longer  the  duration  of  the  malady,  the 
more  numerous  will  he  the  symptoms  indicative  of  disturbance  of  the  nerv- 
ous centres,  such  as  stupor,  prostration,  impaired  muscular  contractility, 
delirium,  and  convulsive  movements:  we  can  understand,!  say,  that  the 
more  decided  the  adynamic  or  ataxic  symptoms  are,  the  more  time  will  be 
required  for  things  to  return  to  their  normal  state.  Putrid  fevers,  when  the 
attacks  are  severe  and  protracted,  often  leave  patients  in  a  state  of  very 
great  weakness,  from  which  they  emerge  with  difficulty,  and  which  some- 
times continues  for  several  months.  It  is  likewise  after  these  dangerous 
form-  of  dothinenteria  that  we  meet  with  the  paralytic  affections  now  under 

consideration. 

The,  paralysis  is  sometimes  general,  affecting  not  only  motion  and  sensi- 
bility,   hut    also   the   senses,  the    patients    being   deaf  and    blind,  as  Well  as 

unable  to  move:  sometimes  also,  it  is  localized,  in  which  case  it  is  generally 
seated  in  the  lower  extremities ;  at  the  same  time  implicating  the  bladder, 


DOTHINENTERIA.  285 

so  as  to  cause  retention  or  incontinence  of  urine,  micturition  being  either  an 
overflow  of  the  bladder,  or  the  result  of  the  inability  of  the  paralyzed 

sphincter  to  retain  the  urine:  there  is  also  sometimes  paralysis  of  the  rectum, 
the  patients  involuntarily  passing  their  stools.  You  must  beware  of  being 
misled  as  to  the  nature  of  these  cases:  you  will  often  meet  with  patients 
who  seem  to  have  this  description  of  paralysis  of  the  sphincters,  when  it 
really  does  not  exist.  You  remember  in  bed  No.  4  of  St.  Agnes'.-  Ward, 
a  young  man  who  for  several  days  soiled  his  personal  linen  and  the  sheets. 
In  him,  as  in  others,  this  proceeded  from  mental  debility,  or,  more  correctly 
speaking,  from  the  laziness  resulting  from  that  debility.  It  is  sufficient  in 
such  eases  to  make  the  patients  ashamed  of  their  dirty  habits,  and  to 
threaten  them  with  low  diet  in  the  event  of  their  not  discontinuing  them: 
you  will  particularly  observe  cases  of  this  kind  in  children.  Finally,  pa- 
ralysis may  locate  itself  exclusively  in  the  organs  of  the  senses,  producing 
a  longer  or  shorter  continuance  of  blindness  or  deafness.  A  restorative 
regimen  and  tonics  are  the  only  means  by  which  we  can  get  rid  of  these 
untoward  symptoms. 

The  diagnosis  of  these  paralytic  affections  seems  so  simple,  as  to  preclude 
the  necessity  of  saying  a  word  on  the  subject;  but  nevertheless,  cases  occur 
in  which  you  might  And  yourselves  at  fault.  The  case  of  our  patient  in 
bed  No.  4  is  a  proof  that  one  has  to  distinguish  between  a  true  and  apparent 
paralysis.  The  following  history,  communicated  to  me  by  a  physician  in 
town,  will  show  you  how  much  complexity  there  may  be  in  this  diagnosis. 

A  girl,  twelve  years  of  age,  had  a  serious  attack  of  putrid  fever:  during 
convalescence,  she  was  absolutely  unable  to  walk.  Her  physician  having 
recommended  exercise  in  the  open  air,  she  was  taken  out  in  a  little  carriage, 
but  as  no  improvement  occurred  under  this  treatment,  she  was  sent  into  the 
country.  No  amendment  had  taken  place  in  her  condition,  when  by  mis- 
take, she  was  one  day  left  alone  locked  up  in  her  room.  Great  was  the 
surprise  of  her  attendants,  when,  on  their  return,  they  found  the  door  open, 
and  the  patient  on  her  feet :  to  liberate  herself  from  confinement,  she  had 
walked.  The  relations  exclaimed  that  a  miracle  had  been  wrought ;  but 
unfortunately,  the  miracle  Avas  not  a  complete  cure,  for  on  the  following 
day,  the  paralysis  returned,  and  at  present,  according  to  the  information 
which  I  received  from  the  attending  physician,  the  patient  is  still  unable  to 
walk. 

In  this  case,  gentlemen,  the  paralysis  was  certainly  not  a  consequence  of 
the  fever :  paralytic  affections  consequent  on  fevers  do  not  terminate  so  sud- 
denly, and  when  they  have  ceased,  do  not  so  quickly  return.  Though  I 
did  not  see  the  patient,  I  think  I  may  say  that  her  affection  was  hvsterieal 
paralysis,  for  paralysis  is  often  simulated  by  one  of  those  strange  whims 
which  get  into  the  heads  of  that  singular  class  of  patients  called  hysterical. 
If,  as  an  objection  to  this  opinion,  it  be  said  that  the  youth  of  the  girl  hardly 
allows  us  to  suppose  that  her  case  was  of  this  class,  that  at  her  age  there  is 
unfeigned  lightheadedness,  while  the  affection  condemned  her  to  long- 
continued  rest  and  prevented  all  participation  in  the  games  which  constitute 
so  large  a  part  of  the  occupation  of  childhood,  I  reply,  that  hysteria  is  not 
a  rare  disease,  even  in  children  of  twelve  years  of  age.  In  cases  of  this 
kind,  we  must  have  recourse  to  moral  more  than  to  what  are  considered 
strictly  medical  means  of  cure. 

I  have  recently  been  studying,  in  a  convalescent  dothinenteric  patient, 
a  form  of  paralysis  which  may  occur  as  a  sequel  to  any  severe  disease,  but 
which  is  most  frequently  observed  after  fevers.  It  is  the  consequence  of 
the  disease  itself — of  its  duration  and  severity.  There  is  in  small-pox,  as 
you  know,  a  form  of  paralysis,  which,  on  the  contrary,  is  a  concomitant  of 


286  DOTHINENTERIA. 

the  rachialgia,  of  the  invasion-period  of  the  disease.  This  form  of  paralysis, 
occurring  at  the  beginning  of  a  fever,  is  a  very  important  element  in  the 
diagnosis :  and  I  am  not  aware  that  it  has  hitherto  been  observed  at  the 
commencement  of  any  pyrexia  except  small-pox.  I  have,  however,  just 
seen  an  occurrence  of  this  kind  in  a  young  woman,  occupying  bed  No.  11 
of  St.  Bernard's  Ward,  who,  some  days  after  her  admission,  presented  all 
the  symptoms  of  typhoid  fever.     Here,  in  a  few  words,  is  this  case. 

Some  years  previously,  the  patient,  on  the  rapid  disappearance  of  eczema 
of  the  lower  extremities,  became  affected  with  paraplegia,  which  continued 
ft>r  a  whole  year.  She  became  pregnant,  and  from  that  time  the  paralysis 
gradually  diminished.  Her  pregnancy  was  not  attended  by  any  serious 
symptoms  ;  but  her  confinement  took  place  at  the  seventh  month.  For  the 
six  following  years,  she  had  very  satisfactory  health,  till  eight  clays  before 
she  came  into  hospital,  when  she  complained  of  fever,  lassitude,  pains  in 
the  limbs,  loss  of  appetite,  and  nausea,  but  no  diarrhoea:  she  made  special 
complaint  of  inability  to  stand.  On  examining  the  patient,  I  found  that 
she  moved  the  lower  extremities  very  feebly,  and  said  that  they  were  the 
seat  of  lancinating  pains:  she  also  complained  of  pain  in  the  dorsal  region 
of  the  vertebral  column,  upon  percussing  or  making  pressure  over  it.  I 
thought  that  there  was  myelitis,  and  that  it  was  the  cause  of  the  rheuma- 
tism. There  was  nothing  to  lead  me  to  suppose  that  it  was  a  case  of  vario- 
lous paraplegia,  as  the  patient  had  none  of  the  symptoms  of  the  invasion- 
period  of  small-pox,  and  had  had  the  paraplegia  for  eight  days  when  I  saw 
her.  There  was  neither  stupor  nor  diarrhoea,  and  the  pulse  was  not  bound- 
ing. It  was,  therefore,  to  my  great  surprise  that  three  days  after  the 
patient  came  into  our  wards,  that  is  to  say,  eleven  days  from  the  com- 
mencement of  the  paraplegia,  I  observed  an  eruption  of  rosy  lenticular 
spots  on  the  abdomen.  The  paralysis  soon  disappeared,  and  did  not  return 
in  the  course  of  the  disease,  nor  during  convalescence.  The  typhoid  fever, 
which  was  mild,  pursued  its  normal  course,  and  its  duration  was  not  more 
than  three  weeks. 

Here,  then,  is  an  example  of  paraplegia  occurring  at  the  commencement 
of  typhoid  fever.  It  is  true,  certainly,  that  the  paraplegia  occurred  in  a 
subject  who  had  previously  suffered  from  it  for  a  whole  year:  still,  the  case 
deserves  to  be  mentioned  as  one  of  clinical  importance:  it  is  an  example  of 
the  "spinal"  form  of  the  disease,  more  particularly  described  by  G.  Fritz, 
and  of  which  I  have  already  spoken. 

It  is  important  to  distinguish  these  forms  of  paralysis  from  that  muscular 
debility  which  is  always  observed  in  convalescents  from  dothineuteria,  and 
which  ia  partly  dependent  on  nervous  exhaustion,  and  partly  on  that  altera- 
tion of  the  muscular  tissue  which  I  have  already  described.  1  told  you* 
that  the  contractile  tissue  of  very  many,  if  not  of  all,  muscles  underwent, 
to  a  greater  or  less  extent,  granular  or  waxy  degeneration:  and  that  some 
weeks  are  required  for  the  absorption  of  the  degenerated  tissue,  and  the 
formation  of  new  contractile  tissue  in  its  stead.  During  this  period,  there 
is  necessarily  greal  embarrassment  in  the  muscular  movements. 

The  forms  of  dropsy  which  sometimes  supervene  during,  and  in  conva- 
lescence from,  typhoid  fever,  as  Well  as  in  C lection  wilh  all  serious  fevers. 

are  symptoms  of  the  same  class  as  those  we  have  just  been  passing  under 

review.      Like  the  nervous  symptoms,  they  are   all    dependent   upon   a    had 

general  state  of  the  economy,  upon  the  adynamia  into  which  organic  life 

has  fallen,  but  more  particularly  upon    the   special  alteration   of  the  blood, 

which  singularly  favors  Berous  effusion  into  the  cellular  tissue  and  Berous 


See  page  249,  ot  scq. 


DOTHINENTERIA.  287 

cavities.  When  we  recollect  the  frequency  with  which  albundmena  ifi  mel 
with  in  the  course  of  typhoid  fever,  one  might  be  induced  to  believe  that 
the  dropsies  of  which  I  am  now  speaking  were  associated  with  an  albu- 
minuria symptomatic  of  disease  of  the  kidney.  But  the  albuminuria  met 
with  is  either  quite  transient  and  purely  functional,  in  no  way  connected 
with  any  real  or  permanent  change  of  structure  in  the  kidney,  or  it  is  coin- 
cident with  the  renal  lesion  characteristic  of  Bright's  disease,  as  in  cases 
observed  by  Kayer,  Barthez,  and  Rilliet,  Christison,  Gregory,  and  others. 
But  in  the  consecutive  dropsies  of  typhoid  fever,  no  trace  of  albumen  is 
found  in  the  urine. 

A  fact,  not  less  remarkable,  to  which  the  attention  of  physicians  has 
been  called  by  that  laborious  observer,  Dr.  Leudet  of  Rouen*  is,  that  the 
dropsies  consecutive  to  dothinenteria  occur  much  more  frequently  in  some 
localities  than  in  others,  and  that  the  influence  of  the  prevailing  medical 
constitution  has  something  to  do  with  their  production.  At  Paris,  for  ex- 
ample, we  rarely  see  them,  while  foreign  physicians  meet  with  them  fre- 
quently, and  describe  them  with  great  minuteness.  During  ten  years  which 
Dr.  Leudet  studied  in  the  hospitals  of  Paris,  and  was  constantly  in  the 
habit  of  taking  down  the  particulars  of  numerous  cases  of  typhoid  fever, 
he  never  once  saw  dropsy  following  that  disease,  but  after  having  been  for 
a  much  shorter  period  a  physician  to  the  Hotel-Dieu  of  Rouen  he  there 
collected  eight  examples. 

These  dropsical  effusions,  occupying  almost  exclusively  the  subcutaneous 
cellular  tissue,  are  generally  limited  to  the  lower  extremities,  where  the 
oedema  is  greatest  on  the  most  depending  parts,  around  the  malleoli,  and 
on  the  posterior  aspect  of  the  feet,  and  posterior  aspect  of  the  thighs.  But 
sometimes  there  are  partial  effusions  into  the  subcutaneous  cellular  tissue 
of  the  upper  extremities :  and  sometimes  also,  there  is  oedema  of  the  face, 
limited  occasionally  to  one  side,  as  in  a  case  recorded  by  Virchow,  in  which 
it  was  associated  with  obliteration  of  the  internal  jugular  vein.  Ascites 
sometimes  occurs.  Finally,  the  anasarca  may  be  general :  either  appear- 
ing simultaneously  in  the  different  parts  of  the  body,  or  being  at  first  local- 
ized, and  then  spreading. 

The  oedema  is  generally  moderate  in  degree :  in  exceptional  cases  it  is 
considerable,  and  may  be  compared  to  that  which  supervenes  when  there  is 
organic  disease  of  the  heart.  It  bears  no  relation  to  the  severity  of  the 
dothinenteria ;  and  causes  of  debility,  such  as  profuse  evacuations  and  in- 
testinal hemorrhages,  do  not  seem  to  have  any  effect  in  producing  it.  Trans- 
itions from  heat  to  cold,  which  are  such  marked  causes  of  scarlatinous  ana- 
sarca, do  not  here  seem  to  possess  a  similar  influence. 

Though  the  appearance  of  the  dropsical  affections  which  come  on  pas- 
sively towards  the  second  or  third  week  of  the  fever,  without  any  initiatory 
symptoms,  is  sometimes  coincident  with  a  febrile  exacerbation,  a  copious 
eruption  of  sudamina,  or  an  acute  bronchitis,  they  generally  disappear  in 
fifteen  or  twenty  days.  When  they  continue  long,  they  retard  convalescence, 
but  in  other  respects  are  not  serious.  They  yield  to  dietetic  management, 
and  a  purely  tonic  treatment,  demanded  by  the  state  of  general  debility 
under  which  they  have  arisen. 

Gentlemen,  the  cedema  of  which  I  have  been  speaking  is  seen  unassociated 
with  albuminuria  in  some  other  pyrexia?.  I  have  often  observed  it  in 
measles,  and  on  examination  the  urine  has  generally  been  found  to  contain 
no  albumen.  But  another  kind  of  oedema  which  I  have  observed  in  doth- 
inenteria, is  that  which  is  connected  with  obliteration  of  a  vein  ;  it  is  a  real 

*  Leudkt:  Archives  Generules  de  M6decine.     Oct.,  1858. 


288  DOTHINENTERIA. 

phlegmasia  alba  dolens.  I  very  recently  met  with  a  case  of  this  kind  in  one 
of  my  nieces  aged  twenty-four.  She  was  seized  with  painful  oedema  about 
the  fortieth  day  from  the  beginning  of  the  fever.  Virchow's  case,  which  I 
have  just  mentioned,  is  of  the  same  description. 


Local  Complications  which  supervene  During  and  at  the  Decline  of 
Dothinenteria. 

1.  Softening  of  the  Cornea. 

A  woman,  suffering  from  a  very  severe  form  of  putrid  fever,  was  ad- 
mitted to  bed  Xo.  8  of  St.  Bernard's  Ward.  During  the  third  week,  when 
the  nervous  symptoms  were  very  severe,  the  eyelids  were  incompletely  closed 
during  sleep,  leaving  the  inferior  segment  of  both  cornea?  exposed.  After 
some  days,  the  conjunctiva  was  injected,  and  the  eyes  became  bleared  : 
twenty-four  hours  later,  there  was  real  catarrhal  ophthalmia.  On  carefully 
examining  the  globes  of  the  eyes,  it  was  easy  to  see  that  the  cornea?  were 
swollen,  and  had  a  whitish,  macerated  appearance :  there  was  also  intense 
photophobia,  and  the  patient,  though  in  a  state  of  stupor,  complained  of 
her  eyes,  even  when  not  obliged  to  raise  the  eyelids.  Her  sight  was  very 
much  affected.  It  seemed  evident  to  me,  and  to  all  who  went  round  with 
me  at  the  visit,  that  the  cornea?  were  completely  softened,  and  vision  hope- 
lessly lost. 

This  softening  of  the  cornea?,  which,  gentlemen,  you  have  frequently  ob- 
served, not  only  in  the  course  of  dothinenteria,  but  also  in  all  diseases  ac- 
companied by  cerebral  disturbance,  is  one  of  the  most  serious  complications ; 
and  one  of  which  I  was  for  a  long  time  unable  to  understand  the  mechanism. 
I  have  at  last,  I  believe,  found  it  out :  and,  what  is  more  important,  I  think 
I  have  discovered  a  very  simple  means  of  curing  the  affection.  It  is  quire 
possible  that  others  may  claim  along  with  me  the  honor  of  this  little  dis- 
covery. fShould  what  I  am  about  to  bring  under  your  notice  in  a  few  words 
have  been  previously  observed  by  others,  I  shall  in  that  circumstance  find 
a  cause  of  congratulating  myself  on  having  given  my  sanction  to  a  little- 
known  practical  fact.  We  see,  every  day,  our  professional  brethren  claim- 
ing the  honor  of  priority  with  a  zeal  which  excites  in  me  very  little  desire 
to  follow  their  example.  Let  it  be  understood,  then,  that  I  will  surrender, 
whenever  it  is  necessary,  all  my  rights  over  the  treatment  of  softening  of 
the  cornea  in  bad  fevers. 

But  before  telling  you  what  my  treatment  is,  before  following  out  the 
history  of  the  woman  to  whose  case  I  have  recalled  your  attention,  I  am 
anxious  to  explain  to  you  the  mechanism  by  which,  in  my  opinion,  soften- 
ing of  the  cornea  takes  place. 

You  have  often  observed  in  putrid  fevers,  that  patients  sleep  with  their 
eyes  half  open  :  under  such  circumstances,  it  almost  always  happens  that 
the  globe  of  the  eye  is  turned  upwards,  and  the  cornea  entirely  concealed. 
No  other  inconvenience  results  from  this  condition  of  the  eyelids,  except  an 
inflammatory  affection  of  the  conjunctiva',  and  if  this  conjunctiva]  inflamma- 
tion be,  which  1  willingly  admit  it  is,  dependent  upon  the  general  state  of  the 
patient,  as  is  the  inflammation  of  the  bronchial  tubes  and  back  part  of  the 
mouth,  I  cannot  but  also  admit  that  it  is  aggravated  by  the  inability  to  wink, 
as  is  seen  in  persons  suffering  from  paralysis  of  the  facial  uerve.  You  all 
know  that  patients  with  paralysis  of  the  seventh  pair  of  nerves,  being  unable 
to  shut  the  eye  or  to  wink,  have  always  more  or  Less  irritation  of  the  mucous 
membrane  of  the  eye;  and  in  some  cases,  this  irritation  proceeds  to  inflam- 


DOTIIINENTERIA.  289 

ination,  and  even  to  softening  of  the  cornea.  The  patients  themselves 
know  how  to  ward  off  these  consequences,  by  moving  their  eyelids  with  the 
assistance  of  the  finger  sufficiently  often  to  supply  the  place  of  winking; 
hut  during  sleep,  unless  they  take  special  precautions,  the  globe  of  the  eye 
is  left  exposed  to  the  air,  and  in  the  morning  they  awake  with  irritative 
congestion,  pain,  and  blearedness  of  the  eye. 

In  all  severe  fevers,  the  eyes  remain  partially  open,  and  if  the  stupor 
continue  sufficiently  long,  or  be  excessive,  they  are  night  and  day  in  the 
condition'  similar  to  that  of  persons  affected  with  paralysis  of  the  seventh 
pair.  Recollect  also  the  fact,  that  in  putrid  fevers  the  sensibility  is  blunted, 
and  that  the  irritation  caused  by  the  contact  of  the  air  with  the  conjunc- 
tiva is  not  felt,  so  that  the  necessity  for  winking  is  not  experienced.  The 
same  thing  takes  places  with  the  eye  which  occurs  in  respect  of  the  nostrils, 
which  become  filled  with  dust  and  other  foreign  bodies  floating  in  the  air, 
because,  from  the  parts  not  being  sensitive  to  the  presence  of  foreign  bodies, 
the  patient  does  nothing  to  get  rid  of  them. 

Reflect  for  a  moment  on  the  theory  of  winking,  and  you  will  perceive 
the  reason  of  the  frequency  of  the  symptoms  of  which  I  have  been  speak- 
ing. There  are  three  pairs  of  nerves  concerned  in  winking.  In  the  first 
place,  there  is  the  fifth  pair — the  sensitive  pair — which  transmits  to  the 
brain  the  impression  of  pain  caused  by  continuous  contact  of  the  air,  and 
drying  of  the  cornea — the  impression  which  imparts  the  necessity  of  wink- 
ing. In  the  second  place,  there  is  the  seventh  pair — a  motor  pair — which 
conveys  to  the  sphincter  of  the  eyelids  the  command  to  wink.  Finally, 
there  is  the  third  pair  of  nerves — also  a  motor  pair — which  sends  a  branch 
to  the  levator  palpebrce,  and  which  consequently  presides  over  the  elevation 
of  the  upper  eyelid.  But  there  is  still  another  nerve  which  I  have  to  men- 
tion, and  that  is  the  lachrymal,  which  comes  from  the  ophthalmic  branch 
of  the  fifth  pair,  and  presides  over  the  secretion  of  the  tears,  which  serve 
more  than  the  ocular  mucus  to  accomplish  the  ultimate  object  of  winking, — 
lubrication  of  the  conjunctiva. 

You  can  now  understand  that  the  performance  of  an  act  so  complicated 
as  that  of  winking,  an  act  which  requires  the  agency  of  so  many  nerves, 
should  be  disturbed,  or  even  suspended,  during  such  a  disease  as  dothinen- 
teria,  which  in  so  high  a  degree  impairs  the  action  of  the  whole  nervous 
system. 

You  must  also  bear  in  mind  that  in  severe  fevers,  there  are  other  special 
conditions  quite  independent  of  the  causes  (to  a  certain  extent  physical)  of 
which  I  have  been  speaking.  In  virtue  of  causes,  very  imperfectly  under- 
stood, but  essentially  connected  with  the  nature  of  septic  diseases,  the  mu- 
cous membranes  become  the  seat  of  congestions,  which  may  be  somewhat 
active  or  somewhat  passive,  and  which  easily  proceed  to  inflammation  and 
even  to  sphacelus.  In  the  ordinary  train  of  symptoms  in  septic  fevers, 
we  also  meet  with  ophthalmia,  coryza,  sore  throat  and  laryngitis,  and  in- 
flammatory affections  of  the  genitals  of  young  girls,  upon  which  latter  class 
of  affections  I  shall  afterwards  have  to  make  some  special  remarks.  You 
will  then  better  understand  how  inflammation  of  the  cornea,  caused  by 
absence  of  winking,  easily  passes  into  a  state  of  softening,  which  is  really 
a  kind  of  gangrene. 

Let  us  now  revert  to  the  clinical  facts. 

Along  with  Dr.  Grenat,  I  attended  a  young  man  suffering  from  a  ner- 
vous disease,  which  was  deficient  in  distinctive  characters,  but  presented 
symptoms  indicating  that  it  wras  a  connecting  link  between  brain  fever  and 
putrid  or  common  typhoid  fever.     There  was  slight  congestion  of  the  con- 
vol.  i. — 19 


290  DOTHIXEXTERIA. 

junctiva,  arising  as  much  from  the  fever  itself  as  from  the  want  of  wink- 
ing.    One  of  the  cornea?  became  softened,  and  the  patient  lost  the  eye. 

This  unfortunate  occurrence  having  made  me  reflect,  it  occurred  to  me 
that  if  the  greatest  part  of  the  evil  originated  in  the  fever,  the  constant 
exposure  of  the  eye  to  the  air  from  want  of  power  to  wink  was  an  im- 
portant, and  perhaps  the  principal,  cause  of  the  ultimate  mischief.  I 
forthwith  took  steps  to  be  able  to  accomplish  that  which  in  point  of  fact  I 
afterwards  put  in  practice  with  great  success  in  our  patient  of  No.  8  St. 
Bernard's  Ward. 

It  seemed  to  me,  as  well  as  to  those  who  were  present  at  my  clinical  visits 
when  I  examined  this  case,  that  the  woman  must  inevitably  lose  her  sight. 
To  me  the  case  appeared  as  hopeless  as  it  appeared  to  others ;  but  I  never- 
theless resolved  to  try  the  plan  which  I  had  settled  in  my  own  mind  was 
the  proper  treatment.  Having  completely  closed  the  eyelids  of  the  patient, 
I  placed  on  them  two  pledgets  of  soft  cotton,  which  I  kept  in  their  places 
by  means  of  a  moderately  tight  bandage.  This  little  apparatus  was  ar- 
ranged at  the  morning  visit.  During  the  day,  the  pain  was  less  severe, 
and  it  altogether  disappeared  during  the  night.  When  I  examined  the 
state  of  matters  next  morning,  I  found  to  my  great  satisfaction  that  the 
cornea?  had  their  normal  color,  and  excepting  that  the  conjunctiva?  were  a 
good  deal  bloodshot,  the  eyes  had  completely  returned  to  their  natural  con- 
dition. There  was  still  some  imperfection  of  vision  ;  but  the  photophobia 
was  gone.  The  treatment  was  continued  for  three  days,  at  the  end  of  which 
period  the  apparatus  was  removed.  The  general  nervous  symptoms  had 
somewhat  subsided  :  the  stupor  had  nearly  quite  disappeared  ;  and  from 
that  time  the  eyes  were  closed  during  sleep.  Although  during  convales- 
cence a  severe  attack  of  cholera  supervened,  and  although  that  was  suc- 
ceeded by  colitis,  presenting  some  of  the  characters  of  epidemic  dysentery, 
there  was  no  return  of  the  ocular  symptoms. 

The  following  case  was  observed  by  my  friend  and  colleague  Dr.  Am- 
broise  Tardieu :  A  man  took  scarlatina  ;  and  from  the  beginning  of  tin- 
attack  had  septic  symptoms.  The  eyelids  remained  in  a  state  of  partial 
closure,  and  the  lower  segment  of  the  cornea  became  softened,  precisely  as 
in  our  patient.  Already,  there  was  acute  pain,  photophobia,  and  a  con- 
siderable affection  of  the  sight.  Suddenly,  erysipelas  of  the  face  super- 
vened, and  simultaneously  took  possession  of  both  eyelids,  causing  com- 
plete occlusion  of  both  eyes  for  four  days.  Upon  the  erysipelas  subsiding, 
the  patient  opened  his  eyes,  when  Dr.  Tardieu  was  very  pleased  to  find 
that  the  eyes,  which  he  supposed  lost,  were  perfectly  restored  to  their  natu- 
ral state. 

Although  in  this  case,  gentlemen,  the  disease  was  not  the  same  as  that 
now  under  our  consideration,  the  complications  were  identical,  as  were 
likewise  the  means  employed  to  subdue  them — means,  however,  which  in 
Dr.  Tardieu's  case,  nature  herself  applied.  The  treatment  consisted  in 
the  occlusion  of  the  eyelids,  a  measure  simple  and  of  easy  application, 
which  1  beseech  you  not  to  forget. 


2.  Affections  of  the  Larynx. — Necrosis  <>f  t/i><  GartUages  <>/  the  Nose. — 
(Edema  of  the  Qlottie  supervening  during  Dothinenteria,  and  necessitating 
Tracheotomy. 

Gentlemen,  early  in  March,  1858,  a  young  man  of  eighteen,  sen  1  to  Paris 
by  a  physician  of  Aix,  was  placed  in  our  wards,  to  lie  treated  for  an  affec- 
tion of. the  larynx,  which  had  necessitated  tracheotomy.     <  >n  admission, 


DOTHINENTERIA.  291 

lie  was  still  using  the  tracheal  tube,  which  he  could  not  discontinue  with- 
out being  immediately  seized  with  violent  suffocative  paroxysms. 

The  laryngeal  affection  was  stated  to  have  commenced  eight  months 
previously  in  the  course  of  severe  typhoid  fever,  which,  according  to  the 
written  statement  forwarded  by  my  colleague,  had  assumed  the  adynamic 
form,  and  had  lasted  for  thirty  days.  Towards  the  end  of  the  attack,  the 
patient  was  seized  with  almost  .complete  aphonia,  which  not  only  continued, 
but  became  aggravated  at  the  commencement  of  convalescence.  Respira- 
tion at  the  same  time  became  more  difficult :  expiration  was  performed 
with  sufficient  freedom,  but  inspiration  was  laborious  and  accompanied  by 
snoring  and  whistling  sounds.  There  was  no  pain  occasioned  by  making 
pressure  over  the  larynx  ;  and  no  oedematous  swelling  could  be  detected 
at  the  upper  orifice  of  the  air-passage,  by  introducing  the  finger  far  back 
into  the  throat.  The  dyspnoea  was  to  a  certain  extent  intermittent,  or  I 
should  rather  say  was  remittent,  for  it  never  quite  ceased,  although  it 
diminished  during  the  day,  and  increased  during  the  night  in  severity. 

The  parts  at  the  entrance  of  the  larynx  were  cauterized,  and  two  setons 
were  inserted  over  the  thyroid  cartilage ;  but  no  benefit  resulted  from  these 
measures.  Eighteen  days  after  the  commencement  of  the  laryngeal  symp- 
toms, asphyxia  being  threatened,  it  became  imperative  to  perform  trache- 
otomy to  save  the  man's  life.  From  the  date  of  the  operation,  the  patient's 
health  became  completely  re-established,  so  that  he  came  to  Paris  to  get 
rid  of  the  tracheal  fistula,  which  he  regarded  as  an  irksome  infirmity  rather 
than  as  a  malady.  However,  on  his  arrival  at  the  Hotel-Dieu,  he  was  still 
complaining  of  some  embarrassment  in  his  respiration ;  but  this  ceased 
from  the  time  of  our'  substituting  a  wider  tube  for  the  tube  which  he  had 
been  wearing. 

I  made  several  attempts  to  relieve  him  entirely  from  the  necessity  of 
using  the  tube,  with  a  view  to  closing  the  wound  in  the  trachea,  and  restor- 
ing entrance  for  the  air  by  the  upper  orifice  of  the  larynx  ;  but  on  each 
occasion  the  excitation  of  suffocative  paroxysms  showed  me  that  the  air- 
passages  were  not  free.  After  having  been  six  weeks  in  our  wards  the 
patient,  discouraged,  left  the  Hotel-Dieu,  that  he  might  apply  to  others 
from  whom  he  had  better  hopes. 

Several  of  you  may  remember  a  case  similar  to,  if  not  identical  with, 
that  now  narrated,  which  came  under  our  observation  during  last  year.  In 
it,  however,  you  had  the  opportunity  of  following  the  laryngeal  affection 
step  by  step,  so  to  speak,  through  all  its  phases.  The  patient  was  a  young 
man  of  twenty.  He  was  placed  in  bed  No.  4  of  St.  Agnes's  Ward,  laboring 
under  one  of  the  severest  forms  of  dothinenteria,  in  which  ataxo-adynamic 
symptoms  predominated,  and  left  behind  them  long-continued  disturbance 
of  the  cerebral  functions  :  during  convalescence  he  was  in  a  sort  of  imbecile 
state. 

During  the  third  week  of  this  young  man's  illness  I  observed  symptoms 
involving  the  respiratory  organs :  there  was  dyspnoea,  but  the  most  charac- 
teristic indications  were  hoarseness  and  cough.  On  examining  the  back 
part  of  the  throat  I  was  enabled  to  ascertain  that  there  was  undoubtedly 
swelling  of  the  epiglottis,  and  was  led  to  suspect  that  it  extended  to  the 
aryteno-epiglottidean  folds — perhaps  even  to  the  mucous  membrane  of  the 
larynx  and  the  vocal  cords.  By  means  of  regular  insufflation  several  times 
a  day  of  alum  and  tannin  there  was  a  great  amelioration,  but  not  a  complete 
cessation  of  the  symptoms :  under  these  circumstances  he  asked,  and  was 
granted,  his  dismissal.  Believing,  however,  that  there  was  deepseated  mis- 
chief, localized  probably  in  the  cartilages  of  the  larynx,  I  told  you  that 
there  was  necrosis  of  one  of  the  cartilages,  and  stated  my  fears  as  to  the 


292  DOTHINENTERIA. 

fate  of  this  young  man  :  my  impression  was  that  in  a  few  days  he  would 
return  to  the  hospital  in  a  worse  condition,  and  requiring  serious  surgical 
intervention. 

In  point  of  fact,  ten  days  afterwards,  he  did  return.  My  prediction  was 
fulfilled:  the  symptoms  had  assumed  a  formidable  severity.  Respiration 
was  oppressed :  expiration,  which  was  whistling,  was  less  laborious  than 
inspiration :  the  cough  was  exceedingly  hoarse,  there  was  an  almost  total 
absence  of  voice,  and  it  was  only  by  very  great  exertions  that  this  unfortu- 
nate young  man  could  make  himself  understood.  Nevertheless,  the  oppres- 
sion not  having  proceeded  to  the  last  degree,  and  there  being  no  threatening 
suffocation,  I  made  a  new  attempt  to  subdue  the  symptoms,  using  the  same 
means  which  had  at  first  been  successfully  employed.  I  prescribed  insuffla- 
tions of  alum  and  tannin,  but  no  abatement  of  the  symptoms  resulted  from 
that  treatment.  With  a  view  to  give  him  a  last  chance  before  resorting  to 
tracheotomy,  I  looked  on  the  case  as  possibly  one  of  syphilitic  laryngitis, 
although  only  too  well  convinced  of  the  accuracy  of  my  diagnosis,  and 
although  I  had  hardly  any  hope  of  obtaining  more  favorable  results.  Profit- 
ing, therefore,  by  the  time  granted  me,  by  the  want  of  urgency  in  the  symp- 
toms, I  administered  preparations  of  iodine ;  but  under  this  treatment  the 
oedema  of  the  glottis  increased,  and,  on  the  18th  July,  there  was  a  renewal 
of  the  threatening  of  suffocation ;  and,  from  asphyxia  being  imminent,  it 
became  imperative  to  resort  to  tracheotomy.  The  operation  was  performed 
late  in  the  evening  by  the  interne  on  duty,  M.  Warmont,  a  distinguished 
hospital  pupil,  and  next  morning,  at  the  visit,  I  found  our  patient  in  good 
spirits,  and  asking  food. 

Some  weeks  afterwards  he  finally  left  the  hospital,  breathing  freely  by 
the  wound  in  the  trachea,  thanks  to  a  tube  of  very  large  calibre  which  had 
been  inserted.  When  he  wished  to  speak  he  closed  the  tracheal  opening,  and 
though  his  voice  was  still  very  hoarse,  it  was  easily  heard.  He  afterwards 
came  to  see  us  occasionally,  and  from  time  to  time  we  have  had  accounts 
of  him.  Two  years  after  the  operation  he  was  still  breathing  through  the 
tube,  which  he  could  not  close  completely  without  being  threatened  with 
suffocation.  His  general  health  was  excellent:  at  his  last  visit  we  found 
that  he  had  gained  a  considerable  amount  of  flesh.  He  had  resumed  work 
as  a  coppersmith.  To  render  his  infirmity  more  supportable,  and  for  the 
purpose  of  concealing  it  as  much  as  possible,  he  had  invented  a  somewhat 
ingenious  apparatus:  he  had  adapted  to  his  tracheal  cauula  a  long  caout- 
chouc tube,  which,  passing  under  his  neckerchief  and  descending  along  his 
body,  opened  in  the  side  pocket  of  his  trousers.  When  he  wished  to  speak 
he  put  his  hand  into  his  fob,  without,  as  formerly,  having  to  put  his  finger 
to  his  neck.  He.  was,  however,  obliged  to  renounce  this  contrivance,  as  it 
interfered  with  the  freedom  of  his  breathing.  Some  days  ago  I  learned 
that  he  continued  in  the  same  state  of  health,  but  was  still  wearing  the 
tracheal  cauula. 

Cases  of  oedema  of  the  glottis,  similar  to  those  now  related,  occur  not 
unfrequentry  in  the  course  of,  and  during  convalescence  from,  severe  con- 
tinued level's.  I  say  severe  fever*,  because  they  are  observed  not  in  dolhin- 
enteria  only,  but  likewise  in  scarlatina  and  small-pox.  A.t  present,  to  speak 
only  of  what  occurs  in  putrid  fever,  I  may  mention  that  my  lamented  col- 
league  Sestier,  ill    274   cases  which    he  collected,   gives    10   cases    in  which 

oedema  of  the  glottis  supervened  during  convalescence  from  typhoid  fever. 
These  cases  were  Qot  encouraging,  for  they  all  proved  fatal;  in  five  of  them, 
tracheotomy  was  resorted  to. 


-;-iiii::    La   Bronchotomie  dana   le  cas   d'Angine    Laryngle  (Edlmateuse. 
[Archives  G6n6rales  de  M6decine,  1850] 


DOTHINENTERIA.  293 

In  contrast  with  these  unfortunate  cases,  I  can  quote  others  of  a  more 
favorable  character,  in  addition  to  the  two  which  I  have  already  related. 
In  the  Gazette  Hebdomadmre,  for  August,  1859,  you  will  find  a  report  in 
relation  to  this  subject,  by  Dr.  Charcot,  of  cases  published  in  Germany,  in 
which  the  proportion  of  successful  cases  was  great, — seven  in  nineteen. 

What  ought  most  to  surprise  you,  gentlemen,  is  that  cases  of  oedema 
of  the  glottis  consecutive  to  dothinenteria  are  not  more  numerous,  seeing 
the  frequency  of  the  lesions  under  the  influence  of  which  this  affection  may 
be  produced. 

I  have  related  to  you  the  only  two  cases  of  this  affection  which  I  have 
met  with  as  sequels  of  dothinenteria  since  I  have  occupied  this  clinical 
chair;  so  that  I  have  had  no  opportunity  of  verifying  by  dissection  the 
appearances  which  others  have  seen  in  similar  cases.  But  that  I  may 
make  my  remarks  on  this  subject  as  complete  as  possible,  I  will  quote  three 
cases,  the  first  from  my  former  pupil,  Dr.  Louis  Genouville,  the  other  two 
from  Dr.  Second-Ferreol.* 

Dr.  Genouville's  case  was  that  of  a  person  admitted  to  the  Hospital  of 
St.  Anthony,  to  the  wards  of  my  colleague,  Dr.  Bergeron.  The  patient 
was  at  the  end  of  a  severe  attack  of  adynamic  putrid  fever,  when,  a  few 
days  after  his  arrival,  he  was  seized  with  a  suffocative  paroxysm  which 
imperatively  demanded  tracheotomy.  On  the  second  day  after  the  oper- 
ation, when  he  seemed  sufficiently  well  to  be  allowed,  at  his  own  request, 
to  discontinue  the  tracheal  tube,  he  was  suddenly  carried  oft1  by  a  suffocative 
attack.  On  opening  the  body,  the  mucous  membrane  of  the  larynx  was 
found  to  be  gangrenous,  and  this  condition  extended  back  to  behind  the 
ventricles ;  the  arytenoid  cartilage  was  entirely  destroyed  ;  the  inferior 
constrictor  muscles  of  the  pharynx  and  the  crico-arytenoid  muscles  were 
sphacelated.  The  bronchial  glands  were  black,  and  exhaled  the  character- 
istic odor  of  gangrene.  In  the  situation  of  the  ileo-caacal  valve  were  seen 
the  morbid  appearances  which  belong  to  dothinenteria. 

In  this  history,  there  is  nothing  said  of  oedema  of  the  glottis ;  but  I 
nevertheless  deem  the  case  deserving  of  mention,  for  gangrene  of  the 
larynx  and  necrosis  of  the  cartilages  are  lesions  associated  with  oedema  of 
the  glottis,  although  gangrene  is  not  so  commonly  met  with  as  other  morbid 
alterations,  of  which  there  are  notices  in  the  cases  reported  by  Dr.  Second- 
Ferreol,  which  I  am  now  going  to  relate. 

One  of  his  patients,  a  man  of  twenty-two  years  of  age,  had  had  a  seriously 
complicated  attack  of  ataxo-adynamic  putrid  fever:  he  had  gangrenous 
sloughs  over  the  sacrum,  and  the  surfaces  to  which  blisters  had  been  ap- 
plied on  the  calves  of  the  legs  were  sphacelated.  On  the  22d  December 
he  went  into  La  Pitie  Hospital,  under  the  care  of  my  excellent  friend  and 
colleague,  Dr.  Noel  Gueneau  de  Mussy,  and  at  the  end  of  January  was 
convalescent;  his  wounds,  however,  were  not  cicatrizing,  and  numerous 
subcutaneous  purulent  collections  formed,  which  had  to  be  opened.  He  had 
been  subject  to  loss  of  voice  before  his  typhoid  fever,  and  had  a  return  of 
this  affection  during  the  convalescence.  He  was  not  only  voiceless,  but 
had  likewise  difficult  respiration,  and  the  inspiration  was  whistling,  par- 
ticularly during  sleep.  By  cauterizing  the  superior  orifice  of  the  larynx 
with  nitrate  of  silver  these  symptoms  were  temporarily  moderated,  but 
again  increased  when  speaking  was  attempted.  They  soon  became  of  such 
a  character  that  suffocation  was  imminent,  and  tracheotomy  necessary. 
The  patient  died  during  the  operation. 

The  autopsy  showed  a  slight   oedematous  infiltration  of  the  aryteno- 

*  Bulletins  de  la  SocieUe  Anatomique,  for  1857  and  1858. 


294  DOTHINENTERIA. 

epiglottidean  folds ;  both  vocal  cords  were  swollen,  and  presented  slight 
superficial  erosions.  The  larynx  contained  a  large  quantity  of  muco-pur- 
ulent  fluid,  which,  when  pressure  was  made  on  the  cricoid  cartilage,  flowed 
out  through  a  fistulous  opening,  situated  posteriorly  and  a  little  to  the  left 
side  of  the  cricoid  cartilage.  This  opening  communicated  with  a  collection 
of  pus,  bounded  on  one  side  by  the  sterno-thyroid,  and  crico-thyroid  muscles, 
and  on  the  other  by  the  mucous  membrane  of  the  larynx.  A  great  part 
of  the  left  half  of  the  cricoid  cartilage  had  disappeared.  There  was  a  loss 
of  substance,  very  irregular  in  shape,  constituted  by  the  destruction  of  the 
superior  circumference  of  the  ring,  and  involving  three-fourths  of  its  height. 
On  each  vocal  cord  there  was  observed  a  small  club-shaped  polypus  with 
a  slight  pedicle,  and  about  the  size  of  a  lentil.  These  two  small  polypi,  at- 
tached, opposite  to  each  other,  were  floating  loose  ;  and  by  falling  down  over 
the  orifice  of  the  glottis  they  could  very  well  close  it  completely.  These 
polypi  may  not  have  much  complicated  the  necrosis  of  the  larynx,  but  they 
accounted  for  the  aphonia  to  which  the  patient  was  liable  prior  to  his  attack 
of  typhoid  fever. 

The  subject  of  the  second  case  was  a  young  man  of  seventeen  years  of  age, 
who  likewise  was  received  into  Dr.  N.  Gueneau  de  Mussy's  wards  with 
typhoid  fever.  The  attack,  apparently  slight  at  first,  was  marked,  during 
the  second  week,  by  adynamic  symptoms  of,  however,  no  great  severity. 
On  the  morning  of  the  eleventh  day  after  his  being  received  into  hospital, 
he  showed  signs  of  excitement ;  the  voice  was  hoarse,  and  sounded  as  if  it 
were  stifled  :  inspiration  was  noisy  and  whistling,  while  expiration  was 
more  easy.  Frictions  with  croton  oil  on  the  neck,  cauterizations  of  the 
superior  orifice  of  the  larynx  with  a  solution  of  nitrate  of  silver  in  three 
times  its  weight  of  water,  applied  by  means  of  a  sponge,  did  not  stop  the 
symptoms,  which  indeed,  by  the  evening,  had  become  considerably  aggra- 
vated. Redness  was  then  visible  on  the  isthmus  faucium,  and  when  the 
finger  was  directed  to  the  orifice  of  the  larynx,  the  epiglottis  was  distinctly 
felt  to  be  swollen,  so  as  in  shape  to  resemble  a  round  cushion  with  a  cen- 
tral hole,  and  to  extend  towards  the  aryteno-epiglottidean  folds.  The 
patient  died  during  the  night. 

At  the  autopsy,  the  isthmus  faucium  had  a  permanent  bright  red  color, 
and  the  glands  in  that  situation  were  swollen,  as  were  likewise  the  papillae 
circumvallata?  of  the  tongue.  There  was  a  large  cedematous  infiltration, 
with  vascularity  of  the  submucous  cellular  tissue,  situated  at  the  orifice  of 
the  larynx,  around  the  epiglottis:  in  form  somewhat  spherical  and  resem- 
bling a  cherry,  it  extended  into  the  interior  of  the  larynx,  and  over  the 
vocal  cords,  which  were  eroded  at  their  free  margins.  At  the  anterior 
horn  of  the  left  arytenoid  cartilage,  at  the  insertion  of  thevocal  cord  of  the 
same  side,  there  was  a  small,  oval,  grayish  erosion,  with  fringed  irregular 
edges,  which  led  to  a  deposit  of  concrete  pus  in  the  submucous  cellular 
tissue  of  the  gouitii-n-  <!<.-<  boissons  from  two  to  three  centimetres  long  by  one 
and  a  half  broad.  The  arytenoid  cartilage  presented  to  the  eye  do  appre- 
ciable alteration,  but  its  anterior  apophysis  was  found  denuded  at  the 
bottom  of  the  erosion  already  described. 

The  necroses  of  the  larynx,  which  in  the  cases  now  detailed  gave  rise  to 
the  affection  improperly  termed  (edema  of  the  glottis,  have  (following  a 
mechanism  which  I  will  afterwards  explain)  as  their  starting-poinl  ulcera- 
tions which  are  almost  always  met  with  in  this  region  in  dothinenteria,  as 
has  been  pointed  out  by  Chomel.  The  term  oedema  of  the  glottis,  I  call 
improper,  because  the  affection  really  occupies  the  glottis  itself  less  than 
the  aryteno-epiglottidean  ligaments,  that  is  to  say,  than  the  superior  orifice 

of  the  larynx.      I  will  afterwards  return  to  this  point,  when  I  come  to  con- 


DOTHINENTERIA.  295 

sider  in  a  special  manner  the  history  of  oedema  of  the  glottis.  These  laryn- 
geal affections,  described  with  the  greatest  possible  care  by  Louis,  exist  so 
constantly,  that  that  physician  gives  ulceration  and  partial  destruction  of 
the  epiglottis  as  one  of  the  secondary  anatomical  characters  of  dothinen- 
teric  fevers,  placing  them  in  that  category  along  with  ulcerations  of  the 
pharynx  and  esophagus.  So  characteristic  arc  these  appearances  in  his 
opinion  that  he  says  :  "  If  found  on  examining  the  body  of  one  who  has  died 
from  an  acute  disease,  they  will  establish  with  nearly  perfect  certainty,  and 
without  going  any  farther,  that  the  affection  was  typhoid  fever."* 

The  cartilages  of  the  nose  may  be  affected  by  dothinenteric  necrosis. 
We  are  indebted  to  one  of  our  accomplished  hospital  colleagues  Dr.  Henri 
Roger  for  the  account  of  a  very  curious  case  of  necrosis  of  the  cartilage  of 
the  septum.  It  occurred  in  a  young  man,  who,  when  convalescent  from 
very  severe  typhoid  fever,  attracted  the  attention  of  his  physicians  by  an 
unusual  phenomenon ;  he  had  a  perforation  of  the  nasal  septum,  through 
which  he  could  make  his  two  fingers  meet.  There  was  shown  to  exist,  in 
fact,  an  ulceration  with  perfectly  rounded  edges,  bleeding  at  some  points, 
and  at  others  covered  with  crusts  which  circumscribed  a  complete  destruc- 
tion of  part  of  the  septum,  which  wjas  found  to  present  a  perforation  of  the 
size  of  a  five  centime  piece.  The  cicatrization  of  the  ulcerated  soft  parts 
was  soon  completed,  but  the  perforation  of  the  septum  remained.  It  was 
of  an  oval  form,  and  situated  three  millimetres  above  the  orifice  of  the 
nostrils.  The  only  functional  disturbance  which  it  occasioned  was  a  snuf- 
fling sound  of  the  voice,  which  at  first  was  considerable,  and  then  gradually 
diminished.  Dr.  Henri  Roger  very  properly  classes  this  case  with  those  of 
necrosis  of  the  larynx.  It  is,  however,  much  more  rare,  for  neither  Roki- 
tansky  nor  Griesinger  mention  it.  There  is  no  example  of  it  quoted  by 
Cruveilhier ;  and  I  have  never  seen  one.f 

These  lesions  admit  of  explanation,  without  the  necessity  of  supposing 
a  special  localization  of  the  disease  analogous  to  that  which  takes  place 
in  the  intestinal  canal.  There  always  exists  in  dothinenteria,  in  a  degree 
more  or  less  marked,  that  irritation,  that  catarrhal  condition  of  the  respi- 
ratory passages  to  which  I  have  called  your  attention  :  and  on  the  other 
hand,  it  is  known  how  much  in  this  fever  the  tendency  to  ulceration  shows 
itself,  wherever  there  is  inflammation  or  even  mere  irritation  of  the  mucous 
membranes.  You  have  not  forgotten,  I  presume,  what  I  told  you,  to  the 
effect,  that  in  septic  diseases  the  mucous  membranes  become  the  seat  of 
half  active,  half  jDassive  congestions,  which  readily  proceed  to  inflammation 
and  even  to  sphacelus,  a  fact  which  explains  the  ophthalmic  affections  of 
which  I  have  spoken — the  coryzas,  sore  throats,  inflammations  of  the  geni- 
tals, and  laryngitic  attacks,  which,  in  fact,  all  belong  to  the  common  cor- 
tege of  septic  fevers.  With  this  fact  in  your  minds,  you  will  not  be  aston- 
ished to  meet  with  a  tendency  to  ulceration,  a  tendency  which  is  sometimes 
found  where  it  would  hardly  be  looked  for.  For  example,  Dr.  Charcot 
had  a  case  in  which  there  was  ulceration  of  the  gall-bladcler. 

It  may,  therefore,  be  said  that  there  is  a  sort  of  ulcerous  diathesis  in 
dothinenteria  ;  but  independent  of  this  diathesis,  of  this  dyscrasia  of  the 
blood,  which  constitutes  one  of  the  characters  of  putridity,  ulceration  is  one 
of  the  consecpuences  of  inanition,  as  has  been  demonstrated  by  the  beautiful 
experiments  of  Chossat.| 

*  Louis  :  Keeherches  sur  la  Fievre  Typhoi'de,  p.  321.     Paris,  1841. 
f  H.  Soger  :  Bulletin  de  la  Societe  M6dicale  des  Hopitaux  de  Paris.     T.  iv, 
p.  427. 

X  Chossat  :  Keeherches  Experimentales  sur  l'lnanition.     Paris,   1843. 


296  D0TH1NENTERIA. 

Likewise,  there  are  no  circumstances  under  which  ulcerations  of  the 
larynx,  nose,  pharynx,  oesophagus,  &c,  are  more  common  than  when  the 
dothinenteria  has  been  of  the  putrid  form,  adynamic,  or  when  the  course 
of  the  disease  has  been  protracted,  or  when  the  diet  of  the  patient  has  been 
kept  too  rigorously  low.  I  intend,  as  I  have  already  said,  to  reserve  my 
remarks  on  the  mechanism  of  oedema  of  the  glottis,  as  I  propose  to  devote 
an  entire  lecture  to  the  consideration  of  that  affection. 

There  still  remains  a  question  for  our  consideration.  When  once  oedema 
of  the  glottis  has  been  ascertained  to  exist,  ought  tracheotomy  to  be  imme- 
diately performed  ?  Ought  we  to  wait  for  violent  suffocative  paroxysms? 
Ought  we  to  wait  till  asphyxia  is  imminent? 

You  have  seen,  gentlemen,  what  I  did  in  the  case  which  came  under 
your  own  observation.  At  the  first  examination,  I  diagnosed  oedema  of  the 
glottis :  paroxysms  of  suffocation  occurred,  but  I  still  postponed  opening 
the  trachea,  and  instituted  treatment,  which,  although  I  was  not  sanguine 
as  to  its  success,  nevertheless  gave  a  chance  of  obviating  the  necessity  of 
operating.  I  held  myself  in  readiness  for  every  eventuality  :  I  caused  the 
patient  to  be  closely  watched,  resolving  to  perform  tracheotomy  whenever, 
from  the  suffocative  fits  becoming  frequent  and  violent,  asphyxia  should 
become  imminent.  The  young  man  was  not  operated  on  till  it  would  have 
been  dangerous  to  have  waited  longer.  Such  in  my  opinion  is  the  proper 
course  to  follow  ;  for  after  balancing  the  indications  for  and  against  open- 
ing the  trachea  in  oedema  of  the  glottis,  I  would  say  that  it  is  wrong  to 
wait  till  asphyxia  has  proceeded  so  far  as  to  render  death  imminent.  To 
wait  the  arrival  of  that  critical  moment  would  be  to  run  the  risk  of  failure 
from  the  patient  sinking  during  or  immediately  after  the  operation,  in  con- 
sequence of  his  having  fallen  into  a  state  of  stupor  and  collapse,  from  which 
it  might  be  difficult  to  rouse  him.  On  the  other  hand,  it  would  be  equally 
wrong  to  be  in  a  hurry  to  operate  as  soon  as  severe  and  well-marked  attacks 
of  suffocation  had  occurred,  and  it  would  be  equally  objectionable  to  oper- 
ate as  soon  as  oedema  of  the  glottis  had  declared  itself;  for  under  both  of 
these  conditions,  there  are  cases  in  which  recovery  takes  place  without 
tracheotomy.  These  recoveries  seldom  occur  when  the  oedema  depends 
upon  necrosis  of  the  cartilages  of  the  larynx,  because  the  necrosed  portions, 
with  hardly  an  exception,  absolutely  require  to  be  eliminated,  and  this 
elimination  cannot  take  place  till  repeated  inflammations  have  been  excited; 
and  under  their  influence  infiltration  of  the  aryteno-epiglottidean  folds  is 
produced.  Sometimes,  also,  the  vocal  cords  are  infiltrated,  as  I  will  after- 
wards explain  to  you. 

Nevertheless,  gentlemen,  it  is  quite  possible  for  this  elimination  to  take 
place  without  involving  these  consequences.  When  this  occurs,  recovery 
is  the  result  of  the  unaided  efforts  of  nature,  as  is  exempli  lied  by  the  fol- 
lowing case,  which  occurred  in  the  practice  of  my  colleague  Dr.  Ilerard, 
physician  to  the  Lariboisiere  Hospital. 

A  young  woman  of  twenty-tWO  had  a  very  tedious  convalescence  from 
typhoid  fever.  After  the  lapse  of  about  three  months,  she  was  suddenly 
seized  with  severe  dyspnoea  accompanied  by  loss  of  voice.  Prom  thai  time 
she  had  hud  occasional  attacks  of  suffocation,  during  which  the  inspiration 
in  particular  was  exceedingly  painful.      Six  months   later,  the  aphonia  was 

almosl  absolute.  The  few  sounds  emitted  by  the  patient  were  hoarse,  gut- 
tural, and  accompanied  by  a  little  hissing  noise.     Respiration  was  very 

much  oppressed:  inspiration,  which  was  noisy  and  somewhat  wheezing, 
brought  the  muscles  of  the  chest  into  strong  action,  'flic  patient  hail  at 
the  same  time  a  frequent  and  very  distressing  COUgh,  but  it  did  not  come 
in  fits:   the  sound    of  the   COUgh  was    very   deep.      There  Was   a    little  sero- 


DOTIIINENTERIA.  297 

mucous  expectoration  slightly  streaked  with  blood.     The  patient's  general 
condition  was  good;  her  countenance  had  a  natural  appearance;  she  was 

plump;  and  had  regained  her  strength. 

Examination  of  the  respiratory  apparatus  only  furnished  negative  signs. 
On  applying  the  stethoscope  over  the  larynx,  a  very  decided  whistling 
sound  was  heard:  it  was  very  rough  during  both  inspiration  and  expiration, 
but  particularly  during  inspiration.  Externally,  there  was  no  sign  of  si  ruc- 
tural  change  in  the  larynx — no  cicatrix,  no  fistula,  no  crepitation  on  pres- 
sure— nothing  to  indicate  lesion  of  the  cartilages.  On  introducing  the  finger 
into  the  throat,  it  was  impossible  to  detect  any  increased  volume  of  the 
aryteno-epiglottidean  folds;  and  a  sound  Was  easily  introduced  into  the 
larynx.  Some  days  later,  the  patient  experienced  more  discomfort  in  the 
larynx :  she  thought  that  she  felt  a  movable  body  which  occasionally  got 
across  the  throat.  All  at  once,  during  the  evening,  she  was  seized  with  a 
real  and  very  severe  paroxysm  of  suffocation  ;  and  after  a  violent  fit  of 
coughing,  she  ejected  by  the  mouth  two  small  osseous  sequestra. 

On  the  immediately  following  days,  the  aphonia  remained  as  before. 
The  cough  was  distressing,  and  had  all  the  characters  of  laryngeal  cough. 
The  larynx,  when  pressed,  was  slightly  painful,  but  unless  pressure  was 
made,  there  was  no  sensation  of  pain  in  it  worth  noticing.  At  the  end  of 
a  month,  slight  improvement  showed  itself.  There  was  less  cough;  and  the 
vocal  sounds,  though  still  very  incomplete,  were  uttered  with  more  ease. 

At  the  end  of  a  residence  of  seven  months,  the  patient  left  the  hospital. 
Her  general  health  was  then  unexceptionable:  utterance  was  nearly  natural, 
though  the  voice  was  still  rather  hoarse,  guttural,  and  deep.  There  was  no 
cough,  and  no  pain  in  the  larynx,  even  on  pressure.  The  state  of  the  chest 
continued  satisfactory. 

In  conclusion,  wThen  oedema  of  the  glottis  supervenes  during  convalescence 
from,  or  in  the  course  of,  dothinenteria,  after  trial  has  been  made  of  the 
available  therapeutic  resources  of  medicine,  such  as  insufflation  of  alum  or 
tannin,  cauterizations  with  nitrate  of  silver,  and,  when  practicable,  scarifi- 
cation of  the  cedematous  aryteno-epiglottidean  folds,  we  must  be  ready  to 
perform  tracheotomy — and  that  early  rather  than  late — that  is  to  say,  when 
the  suffocative  paroxysms  have  become  frequent  and  of  increased  severity 
and  duration,  and  the  respiration  more  embarrassed  in  the  intervals  between 
the  fits.  The  more  the  patient  has  been  reduced  by  the  antecedent  malady, 
the  less  delay  ought  there  to  be  in  operating. 


3.  Sloughs. — Erysipelas. —  Colliquative  Suppurations. — Paraplegia  Consecu- 
tive to  Infiltration  of  Pus  into  the  Spinal  Canal  producing  Inflammation  and 
Suppuration  of  the  Spinal  Marrow. 

Gentlemen,  the  tendency  to  sphacelus,  which  is  one  of  the  characters  of 
the  condition  to  which  the  name  putridity  has  been  given  in  severe  fevers, 
is  never  more  decided  than  in  adynamic  dothinenteria.  It  is  the  principal 
cause  of  the  sloughs  which  you  have  so  often  observed  in  our  patients. 
They  occur  chiefly  in  parts  subjected  to  continuous  pressure,  such  as  over 
the  sacrum,  great  trochanters,  and,  as  Chomel  has  noted,  sometimes  even, 
over  the  occiput.  Continuous  pressure,  then,  contributes  its  share  in  causing 
mortification  of  tissues :  the  contact  of  faeces,  and  urine,  by  constantly  soil- 
ing the  parts,  undoubtedly  also  assists  in  producing  that  result.  It  is  neces- 
sary, therefore,  that  the  patients  should  be  kept  exceedingly  clean,  and  that 
their  position  should  be  frequently  changed,  so  as  to  prevent  the  injurious 
consequences  of  pressure  continued  too  long  on  the  same  part  of  the  body. 


298  DOTHINENTERIA. 

With  a  view  to  obviate  the  inconveniences  which  arise  from  the  roughness 
occasioned  by  folds  in  the  sheets  on  which  the  patient  lies,  napkins  of  vul- 
canized india-rubber  have  been  invented  for  placing  under  the  seat :  they 
are  stretched  across,  and  fixed  at  each  side  of  the  bed.  By  this  contri- 
vance, a  perfectly  smooth  and  soft  surface  is  obtained :  and  these  napkins 
have,  moreover,  the  advantage  of  being  easily  kept  clean,  as  that  can  be 
accomplished  by  wiping  them  with  a  wet  sponge.  When  one  has  not  at 
command  an  apparatus  of  this  description,  the  pelvis  of  the  patient  may  be 
wrapped  up  in  a  chamois  skin,  such  as  is  used  for  washing  carriages :  it  is 
fixed  in  front,  so  that  whatever  position  the  patients  get  into,  they  are 
always  in  contact  with  a  smooth,  soft  surface.  These  chamois  skins  can  be 
obtained  anywhere  ;  and  they  are  very  easily  washed.  Another  plan  sug- 
gested— a  plan  you  saw  me  put  in  practice  with  one  of  our  male  patients — 
consists  in  making  the  patients  sleep  on  straw,  in  accordance  with  the  sys- 
tem adopted  with  the  gateux*  of  the  Bicetre  and  Salpetriere.  The  straw 
absorbs  the  fluid  part  of  the  excrementitious  matters,  which  by  their  contact 
would  have  irritated  the  skin;  and  in  this  way  one  of  the  causes  of  gangrene 
is  removed. 

Unfortunately,  these  different  measures  often  prove  insufficient ;  for,  as  I 
told  you,  the  principal  cause  of  sloughing  in  dothiuenteric  patients  is  the 
tendency  to  mortification  which  belongs  to  the  disease.  How  great  this 
tendency  is  is  seen  by  the  facility  with  which  surfaces  to  which  blisters 
have  been  applied  become  gangrenous,  even  when  the  blisters  have  been 
applied  to  the  front  of  the  chest  and  insides  of  the  thighs,  surfaces  on  which 
there  can  be  neither  pressure,  nor  soiling  by  urine  or  feces.  It  also  often 
happens  that  pustules  of  ecthyma  in  different  parts  of  the  body  and  the 
bites  of  leeches  become  the  starting-point  of  sloughs  of  greater  or  less  size, 
and  of  more  or  less  depth,  irrespective  of  pressure  or  irritation  from  excre- 
mentitious matter,  causes  to  which  some  physicians — as  I  think  erroneously 
— attach  very  great  importance. 

The  sloughs  which  occur  so  frequently  in  dothinenteria  sometimes  become 
exceedingly  serious  complications. 

They  may  occasion  erysipelas,  which,  developing  itself  around  a  slough, 
may  spread  widely,  invading  a  great  part  of  the  skin,  or  exciting  febrile 
action,  which  exhausts  the  patient,  already  much  reduced  by  the  long  dura- 
tion of  the  putrid  fever. 

From  their  number,  extent,  and  depth,  the  sloughs  are  in  themselves 
serious  complications;  for  when  they  do  not  lead  to  a  fatal  termination, 
they  exceedingly  retard  convalescence.  Gangreue  often  proceeds  from  the 
skin  to  the  cellular  tissue,  then  reaches  the  muscles,  and  destroys  them.  Its 
destructive  power  affects  even  the  bones,  which  it  leaves  denuded  and  ne- 
crosed. Under  these  circumstances,  there  are  large  deep  ulcerations  yield- 
ing a  pin  rid  -anguinolent  discharge ;  and  ere  long,  lite  is  terminated  by  the 
vain  attempt  of  the  organism  to  struggle  againsl  profuse  ami  constant  sup- 
puration. 

Moreover,  the  extensive  ulcerations  of  the  skin  produced  by  the  doughs 
— as  well  as  boils,  carbuncles,  and  buboes — may  lead  to  the  absorption  of 
putrid  or  purulent  matter.  Professor  Andral  mentions  a  casein  which  nu- 
merous metastatic  abscesses  supervened  after  an  attack  of  small-pox.f 


*  See  p.  '2l">.  The  g&teux  of  the  Bicetre,  una"  the  g&tetisea  of  the  Salpetridrc  are 
the  patients  in  tin'  respective  hospitals,  who,  from  mental  imbecility,  or  paralj  Bis  Df 
tin'  sphincters,  pass  their  excrements  either  without  regard  to  decency,  or  involun- 
tarily — TRANStATOR. 

f  Anhkai.  :  Clinique,  t.  i.,  p.  '278 :  8me  6dit. 


DOTHINENTERIA.  299 

It  is  natural  to  suppose  that  in  some  eases  the  dothinenteric  ulcerations 
of  the  intestines  may  become  the  starting-point  of  purulent  fever. 
On  the  16th  December,  1861,  a  case  of  this  description  was  observed  at 

the  anatomical  theatre  of  the  Hotel-Dieu.  The  autopsy  to  which  I  refer 
was  that  of  a  man  of  twenty-seven,  who  died,  in  the  wards  of  my  colleague, 
Dr.  Horteloup,  during  the  seventh  week  of  typhoid  fever.  The  symptoms 
which  the  man  had  latterly  presented  were  such  as  are  frequently  observed 
in  the  last  week  of  dothinenteria,  just  when  convalescence  ought  to  he  begi  li- 
ning, and  which  consist  in  an  exacerbation  of  symptoms,  and  the  appear- 
ance of  new  typhoid  and  ataxic  complications. 

When  the  intestines  were  being  removed  from  the  body,  that  they  might 
be  opened,  it  was  observed  that  the  most  fleshy  part  of  the  left  psoas  muscle 
was  swollen  out  into  a  tumor.  When  this  was  cut  into,  chocolate-colored 
pus  spurted  out,  the  quantity  evacuated  being  estimated  at  nearly  100 
grammes.  Dr.  Horteloup's  interne,  who  made  the  autopsy,  informed  us 
that  the  patient  had  never  presented  the  signs  usually  attributed  to  psoitis. 
I  at  once  remarked  that  the  psoas  abscess  must  be  metastatic,  and  that 
from  appearances  there  were  numerous  similar  abscesses  in  the  lungs.  The 
lungs  were  in  fact  studded  with  small  purulent  collections,  such  as  are  com- 
monly seen  in  the  fever  dependent  upon  the  absorption  of  pus:  similar  puru- 
lent collections  were  found  in  the  liver.  We  discovered  nothing  to  explain 
the  fact  of  purulent  absorption,  except  extensive  dothinenteric  ulcerations 
in  the  lower  part  of  the  ileum. 

A  similar  case,  in  which  recovery  took  place,  is  reported  by  MM.  Castel- 
nau  and  Ducrest.* 

There  is  still  another  complication  of  dothinenteria  which,  although  I 
have  not  seen  it,  may  be  met  with.  I  allude  to  an  inflammation  of  the 
spinal  marrow  and  its  membranes,  which  has  a  slough  over  the  sacrum  as 
its  starting-point.  You  have  seen  a  case  of  this  description,  though  not  in 
connection  with  putrid  fever.  The  case,  however,  naturally  claims  notice 
in  relation  to  the  point  now  before  us.  Similar  cases  are  also  described  in 
classical  works. 

My  colleague,  Professor  ISTelaton,  remarks,  in  his  "Elements  de  Patholo- 
gie  Chirurgicale,"  that,  as  a  consequence  of  the  sloughs  which  form  over 
the  sacrum,  "there  sometimes  occurs  an  exceedingly  serious  complication, 
easily  explained  by  the  anatomical  relations  of  the  parts.  The  lower  outlet 
of  the  sacral  canal  is  closed  by  a  fibrous  band  extending  from  the  sacrum 
to  the  coccyx,  and  this  band  is  itself  involved  in  the  mortification.  The 
spinal  dura  mater  and  arachnoid  are  also  pei'forated,  and  a  putrid  sanies 
flows  into  the  arachnoid  cavity,  producing  all  the  symptoms  of  spinal  men- 
ingitis, and  ere  long  causing  death." 

This  statement  is  quite  a  description  of  the  case  of  the  patient  whom  you 
lately  saw  in  bed  No.  8  of  St.  Agnes's  Ward.  Having  presented  the  signs 
of  acute  myelitis,  with  sloughs  over  the  sacrum,  and  typhoid  symptoms,  she 
sank  delirious  after  an  illness  of  six  weeks.  On  examination  after  death, 
the  entire  posterior  aspect  of  the  space  between  the  trochanters  was  found 
to  be  occupied  by  a  slough.  The  sacro-coccygeal  ligament  was  destroyed: 
the  vertebrae  were  to  a  considerable  extent  denuded,  and  a  probe  could  be 
introduced  into  the  sacral  canal.  The  membranes  within  the  sacral  canal 
were  reduced  to  a  greenish  pulp,  and  it  was  impossible  to  recognize  the 
arachnoid.  There  was  a  great  quantity  of  pus  as  high  up  as  the  .seventh 
dorsal  vertebra :  it  seemed  to  have  originated  in  the  slough  of  the  integu- 

*  Castelnau  et  Ducrest  :  Kecherches  sur  les  Abces  Multiples  compares  sous 
leurs  difterents  rapports.     Paris,  1846. 


300  DOTHINENTERIA. 

ments.  Up  to  the  seventh  dorsal  vertebra  the  membranes  of  the  spinal 
cord  were  thickened,  but  above  that  they  were  in  a  normal  condition. 
Down  to  four  centimetres  above  its  termination  in  the  cauda  equina,  the 
spinal  cord,  throughout  its  whole  extent,  was  unaltered  by  any  morbid 
affection.  There  it  was  in  a  softened  condition,  and  under  a  jet  of  water  it 
became  disintegrated.     There  was  no  lesion  of  the  encephalon. 

This  was  evidently  not  a  case  of  dothinenteria :  but  you  can  very  well 
understand  that  consequences  similar  to  those  now  described  might  follow 
from  sloughs  arising  in  connection  with  dothinenteria,  and  it  is  on  that 
account  that  I  have  related  this  history. 

4.  Spontaneous  Gangrene  of  the  Limbs. 

Among  the  local  complications  which  may  supervene  during  the  course, 
and  in  the  decline,  of  dothinenteria,  one  remains  to  be  mentioned,  which  is 
very  much  rarer  than  any  of  those  to  which  I  have  as  yet  directed  your 
attention.  I  refer  to  spontaneous  gangrene  of  the  limbs,  an  affection  to 
which  in  recent  times  particular  attention  has  been  paid.  I  have  not  seen 
any  cases  of  this  complication  ;  but  you  will  find  some  reported  by  most 
trustworthy  physicians.  Among  others  I  would  mention  those  which  Dr. 
Gigon  of  Angouleme  has  made  the  subject  of  a  paper  entitled,  "  Note  sur 
le  Sphacele  et  la  Gangrene  Spontanes  dans  la  Fievre  Typhoide  ;"*  and  two 
cases  read,  on  the  14th  January,  1857,  before  the  Hospitals  Medical  Society, 
by  Dr.  Bourgeois  of  Etampes.f  To  them  I  will  add  the  following  case,  com- 
municated to  me  by  my  chef  cle  clinique,  Dr.  Leon  Blondeau,  who  saw  it 
when  interne  at  the  Children's  Hospital. 

A  boy,  of  ten  years  of  age,  was  admitted,  on  the  3d  December,  1847,  to 
the  wards  of  Baudelocque.  He  fell  ill  at  the  beginning  of  November ;  and, 
from  the  accounts  of  his  illness  given  by  his  family,  there  could  be  no  doubt 
that  he  had  had  adynamic  putrid  fever. 

On  admission,  that  of  which  the  little  patient  most  complained,  was  great 
pain  in  the  right  leg,  in  which,  however,  neither  change  of  color  nor 
swelling  could  be  seen.  Baudelocque  had  the  idea  that  the  pain  was  caused 
by  the  formation  of  one  of'those  deepseated  phlegmons  which  are  sometimes 
met  with  in  severe  fevers  :  he,  therefore,  prescribed  mercurial  inunction  over 
the  seat  of  pain.  Ten  days  afterwards,  however,  gangrene  began  to  shew 
itself  in  the  foot.  The  boy  was  then  taken  into  the  surgical  wards  of  M. 
Paul  Guersant. 

The  entire  surface  of  the  right  foot  was  of  a  purple  color,  which  was 
deeper  on  the  internal  aspect,  from  the  tip  of  the  great  toe  to  the  first  line 
of  tarsal  bones.  This  violet  hue,  which  might  he  compared  to  that  of  a 
nasvus,  extended  to  the  third  interosseous  space  of  the  metatarsus.  Upon 
the  ankle  and  internal  malleolus,  the  veins  were  marked  by  greenish-brown 
subcutaneous  lines,  like  those  seen  in  putrefying  dead  bodies.  The  feeble 
heat  still  retained  by  the  parts  in  this  mortified  condition  was  more  attribu- 
table to  precautions  taken  to  keep  the  tout  wrapped  up  in  flannel  and  wad- 
ding, than  to  the  temperature  of  the  foot  itself. 

There  was  complete  absence  of  pulsation  in  the  righl  tibial  artery.  On 
the  internal  and  posterior  surface  of  the  righl  leg,  at  the  junction  of  ii- 
upper  and  middle  thirds,  ami  in  the  course  of  the  artery,  a  large  hard 
cord  was  felt  :    it  was  felt    most    distinctly  at  (he  tibial  insertion  of  the  gas- 


•:  Gigon:  See  Union  Mldictile for  24  nnd  28  September,  ism. 

t  Bourgeois:  See  Archives  Ge*n6rales  de  M6decine  for  August,  1857. 


DOTHJNENTERIA.  301 

trocnemius  interims.  The  slightest  pressure  over  that  place  occasioned 
acute  pain.  On  that  side  of  the  limb,  the  pulsations  of  the  popliteal  artery 
could  not  be  detected,  but  the  pulsations  of  the  crural  artery  had  the  same 
force,  frequency,  and  rhythm  as  in  the  left  thigh. 

The  inguinal  glands  were  swollen  :  those  of  the  right  side  were  the 
largest,  and  the  most  painful  on  pressure  ;  and  over  them  the  skin  was  of 
a  pale  red  color. 

The  pulse  at  the  wrist  was  small,  very  compressible,  and  100  in  the 
minute.  The  patient  was  in  a  state  of  great  excitement,  and  seemed  to  be 
suffering  much  pain. 

Six  leeches  were  applied  to  the  seat  of  pain  in  the  leg,  with  apparently 
the  result  of  giving  some  relief,  by  diminishing  the  acuteness  of  the  con- 
stant pain  :  but  the  sphacelus  went  on  increasing,  the  livid  color  of  the 
skin  became  of  a  deeper  shade,  and  spread  itself  over  a  larger  surface. 

Tonic  regimen  aud  tonic  medicines  (including  cinchona  as  the  chief) 
were  prescribed.  The  limb  was  at  the  same  time  kept  enveloped  in  opiated 
poultices. 

On  the  16th  December,  three  days  after  the  boy's  admission  into  M. 
Guersant's  ward,  there  was  a  complete  demarcation  between  the  gangren- 
ous and  non-gangrenous  parts.  Next  day,  the  vascular  cord  could  not  be 
felt ;  and  the  fever  had  subsided.  On  the  29th  December,  the  gangrene 
seemed  to  be  perfectly  circumscribed  in  the  region  which  I  have  just 
described  :  it  appeared  to  be  very  superficial,  and  not  to  go  deeper  than  the 
skin.  Over  the  malleoli,  and  in  particular  over  the  malleolus  extemus, 
some  brownish  lines  were  visible,  formed  by  veins  gorged  with  stagnant 
blood.  The  boy  complained  of  very  acute  pains  in  the  affected  parts, 
which  were,  in  general,  most  severe  at  night.  The  pains  in  the  legs  had 
completely  ceased.  The  general  condition  of  the  patient  was  very  satis- 
factory. Notwithstanding  the  severity  of  the  lesions,  the  boy — after  having 
had  his  foot  amputated — perfectly  recovered,  and  left  the  hospital  on  the 
17th  May,  1848. 

In  this  case,  gentlemen,  the  gangrene,  which  supervened  in  the  wrane  of 
an  attack  of  dothinenteria,  undoubtedly  originated  in  obliteration  of  an 
artery.  The  question,  however,  still  remains,  whether  the  arterial  oblitera- 
tion was  the  consequence  or  the  cause  of  arteritis,  the  existence  of  which 
arteritis  was  characterized  by  the  presence,  in  the  course  of  the  artery,  of 
an  indurated  cord,  painful  to  pressure.  My  own  opinion  is  that  in  this 
case,  as  well  as  in  the  two  cases  of  Dr.  Bourgeois  of  Etampes  which  I  am 
about  to  relate,  as  likewise  in  cases  published  by  Dr.  Gigon  of  Angouleme, 
and  Dr.  Patry  of  St.  Maure,  the  primaiy  cause  of  the  gangrene  was  the 
formation  of  a  clot-plug,  this  clot  having  been  either  formed  in  situ,  consti- 
tuting the  thrombus  of  Virchow,  or  being  a  migi'atory  clot,  the  embolus  of 
the  German  professor.  This  clot,  acting  as  a  foreign  body  on  the  inner 
surface  of  the  vessel,  had  excited  inflammation  in  it,  which  inflammation  in 
its  turn  had  produced  plastic  products,  and  in  this  way  the  stoppage  in  the 
artery  had  been  increased,  and  its  obliteration  had  at  last  been  completed. 
The  subject  of  the  obliteration  of  vessels  by  self-made  clots  [caillots  autoch- 
thones]— to  use  the  current  term  of  the  day — is  of  so  much  importance  that 
I  must  devote  one  or  more  of  our  meetings  to  its  consideration.  It  is, 
moreover,  so  often  met  with  in  practice,  that  we  shall  certainly  have  an 
opportunity  of  returning  to  it;  and  I,  therefore,  reserve  our  special  study 
of  it  and  its  bearings  upon  clinical  instruction. 

Let  us  now  return  to  the  subject  more  immediately  before  us.  The  cases 
of  Dr.  J.  Bourgeois  of  Etampes  are  even  more  interesting  than  the  case  I 
have  just  related  to  you,  from  the  circumstance  that  in  them  the  sphacelus 


302  DOTHIXENTERIA. 

was  deeper  and  more  extensive,  in  one  case  involving  the  whole  of  the  leg, 
and  in  another  case  involving  both  legs,  causing  in  both  instances  ampu- 
tation  of  limbs  by  the  unaided  efforts  of  nature. 

In  the  young  girl,  the  subject  of  his  first  case,  there  came  on,  in  the 
wane  of  a  mild  attack  of  dothinenteria,  acute  pain  in  the  /ight  leg,  which 
was  neither  red  nor  swollen,  but  in  which  there  was  a  notable  diminution 
of  motor  power  and  sensibility,  and  a  reduction  in  temperature  :  after  a 
few  days,  the  leg  was  quite  cold.  The  skin  soon  assumed  a  color  which  at 
first  was  dark  gray,  then  copper-red  or  brick-red,  and  quickly  afterwards 
became  clear  violet  with  numerous  streaks.  The  physiological  sensibility 
of  the  leg  was  so  completely  extinct  that  a  pin  could  be  pushed  in  its 
whole  length  without  causing  any  annoyance.  An  irregularly  fringed 
line,  separating  the  obviously  mortified  from  the  still  living  parts,  extended 
from  the  tuberosity  of  the  tibia  to  the  upper  third  of  the  calf,  and  encircled 
the  leg.  The  integuments  losing  their  violet  hue,  became  more  and  more 
slate-colored.  At  the  point  of  contact  of  the  healthy  and  diseased  parts 
a  deep  ulceration  formed,  from  which  there  was  every  day  a  flow  of  gray- 
ish, very  fetid  pus.  The  knee  was  slightly  painful :  in  the  thigh,  there  was 
no  pain.  The  toes  and  the  foot  dried  up,  but  the  leg,  well  nourished,  long 
retained  its  natural  size.  The  patient's  condition,  however,  improved  from 
day  to  day.  She  was  kept  on  restorative  diet,  and -tonic  medicines.  The 
leg  was  covered  with  powders  of  an  absorbent  aromatic  and  septic  char- 
acter. The  soft  parts  very  soon  separated :  the  living  flesh  retracted, 
leaving  between  the  healthy  and  modified  parts  a  space  of  from  four  to  five 
centimetres,  in  which  were  seen  the  two  bones  of  the  leg,  perfectly  denuded, 
dry,  and  almost  white.  To  rid  the  patient  of  a  fatiguing  weight,  and  a 
source  of  exhalations  more  or  less  injurious,  the  bones  were  sawn  through 
at  two  centimetres  from  the  wound,  which  had  a  sound  red  appearance, 
and  was  even  beginning  to  cicatrize  at  its  edges,  and  to  contract. 

Twenty  days  afterwards,  two  small  rings  of  bone  were  detached ;  and 
then  cicatrization  was  soon  completed.  The  girl  left  the  hospital,  having 
regained  her  fresh  looks  and  plump  appearance.  The  stump  was  exactly 
similar  to  stumps  obtained  after  amputations  performed  at  a  selected  spot, 
and  in  the  best  possible  manner,  according  to  the  rules  of  art. 

Dr.  Bourgeois  states  that  he  did  not  find  any  swelling  in  the  course  of 
the  great  vessels.  It  is  probable,  however,  that  in  this,  as  in  the  other  case 
I  related,  the  gangrene  was  the  consequence  of  obliteration  of  the  popliteal 
artery.  This  remark  is  applicable  also  to  Dr.  Bourgeois's  other  case,  which 
I  am  now  going  to  narrate.  No  painful  cord  caused  by  the  obliterated 
artery  was  observed,  although  it  was  noted  that  there  was  entire  absence 
of  pulsation  in  the  arteries  of  the  mortified  limb.  Here  is  an  abstract  of 
the  case. 

The  patient  was  a  boy  of  twelve  years  of  age.  At  about  the  third  week 
of  a  moderate  attack  of  mucous  fever,  and  just  when  convalescence  seemed 
to  be  beginning,  he  was  seized  in  both  legs  with  very  acute  pain,  which 
was  mo-t  severe  in  the  right  :  the  pain  was  increased  on  pressure,  DU1  was 
unaccompanied  by  any  swelling.      There  was  a  decrease  of  temperature  in 

the  legs:  the  thighs  presented  nothing  abnormal.  After  two  or  three  days, 
the  surface  of  the  right  limb  assumed  a  grayish  tint,  which  passed  into  a 
copper-red,  traversed  by  numerous  streak-.  The  pain  was  most  intense 
below  the  tibio-femoral  articulation.  The  integuments  had  lost  their  sen- 
sibility, and  the  paralysis  was  complete. 

A  deeply-indented  line  had  separated  the  living  from  the  sphacelated 
part-.     Scarcely  a  week  later,  similar  changes  were  occurring  in  the  left 


DOTIIINENTEHIA.  303 

leg.  The  patient  was  admitted  to  the  hospital  at  Etampes,  where  Dr.  J. 
Bourgeois  observed  the  progress  of*  the  malady  from  day  to  day. 

The  boy  died  after  nine  months  of  dreadful  suffering.  The  natural 
separation  of  the  dead  parts  was,  you  observe,  waited  for.  Although  it 
was  obvious  that  there  were  some  objections  to  thus  allowing  the  dead 
parts  to  remain,  it  was  supposed  that  as  they  were  perfectly  dry,  and  far 
separated  from  the  stump,  the  evil  consequences  could  only  be  very  slight. 
It  is  to  be  regretted  that  there  was  no  autopsy.  Had  an  examination  of 
the  body  been  made  after  death,  there  would  probably  have  been  found 
not  only  an  obliteration  of  the  vessels  of  the  thigh,  the  pulsations  of  which 
were  felt  during  life,  but  of  the  popliteal  arteries  ;  and  thus  a  complete 
explanation  would  have  been  afforded  of  the  spontaneous  gangrene  of  the 
limbs,  without  the  necessity  of  having  recourse  to  the  very  questionable 
hypothesis  of  disturbance  of  the  functions  of  the  nervous  system,  or  with- 
out requiring  to  invoke,  with  Dr.  Bourgeois,  a  metastasis,  of  which  really 
I  can  form  no  conception. 

Two  of  the  cases  observed  by  Dr.  Gigon  of  Angouleme  presented  a 
remarkable  similarity  to  those  which  I  have  already  laid  before  you,  with 
these  differences,  however,  that  it  was  not  an  inferior  extremity  which  was 
sphacelated,  but  the  right  superior  extremity,  and  that  the  gangrene  was 
moist  and  not  dry.  This  latter  difference  is  explained  by  the  affected  part 
being  different,  and— as  the  autopsy  showed — by  the  vascular  obliteration 
being  in  the  veins  and  not  in  the  arteries. 

"In  two  patients,"  says  Dr.  Gigon,  "suffering  from  very  severe  typhoid 
fever  with  symptoms  of  putridity  of  the  humors,  there  arose  in  the  right 
arm  considerable  swelling,  which  was  greatest  in  the  neighborhood  of  the 
axilla.  The  hand  and  forearm  were  least  swollen.  The  arm  was  at  first 
red,  and  painful  to  the  touch,  and  then  it  swelled  to  twice  its  natural  size : 
its  skin  became  purple,  its  temperature  fell,  its  sensibility  became  obtuse, 
numerous  phlyctama?  (filled  with  a  yellow  or  reddish  fluid)  showed  them- 
selves, and  some  brown  patches  appeared  below  the  shoulder  and  towards 
the  elbow.  Incisions,  large  and  deep,  made  both  before  and  behind, 
throughout  a  great  part  of  the  length  of  the  arm,  were  hardly  felt  by  the 
patient:  the  subcutaneous  cellular  tissue  was  deeply  gangrenous,  and  infil- 
trated with  pus.  Shreds  of  gangrenous  cellular  tissue  became  detached, 
along  with  portions  of  aponeurosis,  and  there  was  a  discharge  of  sanious, 
reddish,  putrid  purulent  matter.  The  symptoms  of  general  prostration  in- 
creased greatly  at  the  same  time  ;  and  led  to  speedy  death.  In  one  case, 
eight  days,  and  in  the  other  nine  days,  elapsed  between  the  appearance  of 
the  swelling  and  the  fatal  issue.  The  gangrenous  affection  seemed  to  be 
much  more  serious  in  the  superior  than  in  the  inferior  extremity.  The 
autopsy  showed  that  in  both  cases  there  had  been  inflammation  of  the  su- 
perior portion  of  the  subclavian  vein,  with  formation  of  a  complete  clot- 
plug,  which  adhered  to  the  inside  of  the  vein :  the  clot  was  of  pretty  firm 
consistence,  of  a  rose  color,  and  acted  as  a  stopper.  Less  tenacious  rami- 
fications of  the  clot  extended  into  neighboring  veins,  such  as  the  superior 
scapular,  the  axillary,  the  cephalic,  and  external  mammary :  in  the  sub- 
clavian vein,  the  internal  surface  was  of  a  very  deep  red,  this  color,  as  the 
vessel  advanced,  diminishing  towards  the  ramifications :  the  venous  coats 
were  more  friable  than  natural,  and  thickened.  The  mechanical  obstacle 
to  the  circulation  was,  in  my  opinion,  the  cause  of  the  moist  gangrene  of 
the  arm." 

Dr.  Patry  of  St.  Maure*  reports  the  case  of  a  patient  who  had  simul- 

*  Patry:  Gangrene  des  Membres  dans  la  Fievre  Typhoi'de.  [Archive*  Generates 
de  Medeeine,  fevrier  et  mai,  1861.] 


304  DOTHINENTERIA. 

taneously  dry  and  moist  gangrene  in  different  parts  of  the  same  inferior 
extremity.  The  dry  gangrene  occupied  the  foot  and  leg,  which  were  black, 
dried  up,  and  shrunken  :  the  moist  gangrene  was  spread  over  the  whole 
thigh,  which  was  purple,  swollen,  and  denuded  of  epithelium  in  several 
places.  On  examination  after  death,  the  crural  artery  was  found  to  be  in- 
creased in  size,  and  completely  obliterated  at  its  upper  part  by  black  clots, 
which  broke  down  easily,  and  were  not  adherent  to  the  interior  of  the  ar- 
tery :  in  the  popliteal  portion  of  the  vessel,  the  clots  were  friable  and  harder, 
and  some  of  them  were  adherent  to  its  inner  surface :  the  arterial  coats 
were  red,  injected,  thickened,  and  had  lost  their  elasticity.  The  crural  vein 
was  obliterated  by  consistent  black  clots,  which,  however,  did  not  adhere 
to  the  internal  tunic  :  its  coats  were  thickened,  injected,  of  a  deep  red  color, 
and  did  not  collapse  when  cut.  The  dry  gaugrene  of  the  foot  and  leg  is 
evidently  explained  by  the  obliteration  of  the  popliteal  artery,  which  took 
place  before  the  obliteration  of  the  crural  artery,  in  which  the  clots  were 
more  recent,  softer,  and  non-adherent.  The  moist  gangrene  of  the  thigh 
was  equally  the  result  of  the  obliteration  of  the  crural  artery  and  the 
crural  vein:  there  was  a  combination  of  gangrene  arising  from  suspension 
of  the  arterial  circulation,  and  of  oedema  from  arrest  of  the  venous  circu- 
lation. 

Dr.  Patry  has  also  given  the  very  curious  history  of  a  young  man  who, 
at  the  twentieth  day  of  an  adynamic  dothinenteria,  suddenly  felt  a  very 
acute  pain,  proceeding  from  the  left  angle  of  the  inferior  maxilla  to  the 
parotid  and  temporal  regions.  In  forty-eight  hours  from  the  commence- 
ment of  this  pain,  the  left  ear  sphacelated.  Subsequently,  the  parotid  and 
temporal  regions  became  cold,  and  assumed  a  purple  color,  while  bulla1, 
filled  with  a  blackish  fetid  fluid,  appeared  on  their  surface.  Four  days 
latter,  the  sphacelus  had  extended  to  the  forehead,  to  both  eyelids,  and  to 
the  cheek,  as  far  as  the  commissure  of  the  lips.  In  spite  of  these  frightful 
disorders,  the  patient  survived  twelve  days.  At  the  autopsy,  the  external 
carotid  artery  was  found  to  be  obliterated  by  two  clots,  one  of  which,  situa- 
ted in  the  upper  part  of  the  vessel,  was  hard,  friable,  colorless,  and  adhe- 
rent; and  the  other,  more  recent,  and  striated  lower  down,  was  of  a  deep 
black  color,  and  tolerably  consistent.  In  the  situation  of  the  upper  clot, 
the  arterial  canal  was  injected,  thickened,  and  more  easily  torn  than  nat- 
ural :  the  inner  coat  had  lost  its  smoothness  and  transparency.  The  jugular 
veins  were  in  a  normal  state. 

In  connection  with  this  case,  Dr.  Patry  mentions  that  he  saw,  in  1843, 
in  the  hospital  practice  of  Dr.  Charccllay  of  Tours,  a.  man  who  was,  dur- 
ing dothinenteria,  attacked  with  gangrene  of  the  whole  of  the  left  side  of 
the  face,  and  who  was  for  five  months  a  sufferer  from  this  complication. 
Both  the  right  and  KTt  superior  alveolar  arches  were  destroyed,  and  the 
patient  was  obliged  to  wear  a  bandage  over  the  left  side  of  the  face,  so  as 
to  conceal  the  hideous  enlargement  of  the  mouth. 

To  complete  this  scries  of  abridged  eases,  it  is  necessary  t<>  add,  that  the 
typhoid  fever  in  which  the  complications  arose  was  characterized  by  find- 
ing, during  life  and  after  death  respectively,  the  symptoms  and  lesions 
peculiar  to  that  disease — a  fact  which  both  Dr.  Gigon  ami  Dr.  Patry  are 
careful  to  state.  I  i'  obliteration  of  an  artery  or  vein  is  the  undoubted  cause 
of  sphacelus  of  an  entire  limb,  or  of  a  greal  part  of  a  limb,  arising  in  the 
course  or  at  the  end  of  dothinenteria  ;  if  this  obliteration  of  vessels,  if  the 
arteritis  or  phlebitis  which  have  been  active  agents  in  producing  it,  have  for 
a  starting-point  a  sanguineous  clot,  the  formation  of  which  (as  1  remarked 
when  speaking  of  embolism)  ought  to  be  attributed  to  a  peculiar  dyecrasia 

of  the    blood  met,  with  in    other  diseases  verv  ditliiviil   in  their  nature  from 


TYPHUS.  305 

typhoid  fever — it  is  also  indisputable  that  the  mechanical  cause  acts  much 
more  energetically  in  dothinenteria,  from  the  circumstance  that  a  notable 
tendency  to  mortification  of  tissues  is  one  of  the  characteristics  of  the 
putridity  at  times  so  strongly  marked  in  that  fever. 


LECTURE    XVI. 

TYPHUS. 

An  Infectious  Disease  like  Dothinenteria. — Differs  from  Dothinenteria  in  the 
Absence  of  Intestinal  Lesions. —  The  two  Fevers  are  distinguished  from 
each  other  by  the  Aggregate  of  the  Symptoms,  and  their  Thermal  Varia- 
tions. 

Gentlemen  :  Although,  from  the  nature  of  the  instruction  which  it  is 
my  duty  to  impart  to  you,  there  is  a  propriety  in  confining  myself  to  the 
consideration  of  the  clinical  cases  which  come  under  your  observation,  and 
to  their  elucidation  from  the  results  of  my  personal  experience,  I  still  think 
that  I  may  to-day  speak  to  you  about  a  disease  which  we  have  never  had 
an  opportunity  of  seeing  in  our  wards,  but  which  is  certainly  well  known 
to  you  by  name.  I  speak  of  typhus,  which,  at  least  in  the  totality  of  its 
general  symptoms,  presents  so  great  a  resemblance  to  dothinenteria  that 
the  question  of  the  identity  of  the  two  diseases,  after  having  been  for  a  long 
time  under  discussion,  is  still  far  from  being  settled,  although  the  partisans 
of  non-identity  seem  now  to  be  the  majority. 

Epidemic  in  some  countries — notably  so  in  the  Britannic  Isles — where 
after  having  reigned  exclusively,  first  in  Ireland,  and  then  in  Scotland,  it 
seems  now  to  be  permanently  installed  in  some  of  the  manufacturing  towns 
of  England,  particularly  in  London,  where,  in  recent  years,  it  has  com- 
mitted great  ravages.  From  the  accounts  of  the  disease — described  under 
very  various  names* — furnished  by  old  and  modern  authors,  it  appears 
that  epidemics  of  typhus,  originating  under  the  influence  of  the  same 
causes,  and  propagated  by  contagion,  have  in  all  periods  of  history  ap- 
peared at  various  epochs,  in  the  Old  World  and  in  North  America. 

France,  though  not  exempt  from  epidemics  of  typhus,  has  suffered  less 
from  them  than  other  countries.  Without  going  back  to  remote  periods,  it 
will  be  sufficient  to  remind  you  that  during  the  first  fifteen  years  of  the 
present  century,  typhus,  following  the  armies  which  were  then  overrun- 
ning Europe,  broke  out  on  several  occasions  in  a  considerable  number  of 
places  in  France  ;  and  that  it  has  since  reappeared,  for  example,  at  Toulon 
in  1820,  1829, 1833,  1845,  and  1851  :f  at  Rheims  in  1839 :%  at  Strasbourg 

*  Fievre  Pestilentielle,  Febris  Pestilens  :  [Fracasto?-,  1546.]  Typhus  des  Camps, 
Typhus  des  Prisons:  [Sauvages,  1759.]  Fjevre  Petechiale,  Febris  Petechials: 
[Sennertus,  1641:  Selle,  1770,  Borsieri,  1785.]  Typhus  Exanthematicus  :  [German 
authors.]     Spotted  Fever,  Typhus  Fever:   [English  authors."] 

f  Keratidren  :  Typhus  dans  les  Bagnes  de  Toulon.  [Arch.  Gen.  de  Medecine, 
T.  iii,  1833.] 

Fleury  :  Histoire  M6dicale  de  la  Maladie  qui  a  regne  parmi  les  condamnes  du 
Bagne  de  Toulon,  1829.      [Mem   de  V Acad,  de  Medecine,  T.  iii,  1853.] 

Barraillier:  Du  Typhus  Epidemique  a,  Toulon.     Paris,  1861. 

%  Landouzy  :  Arch.  Gen.  de  Medicine,  1842. 
vol.  i. — 20 


306  TYPHUS. 

in  1854:*  and  that  in  1856,  imported  from  the  Crimea,  where  our  soldiers 
imbibed  its  germ  during  the  war  in  the  East,  it  declared  itself  in  several 
other  towns,  among  which  were  Marseilles,  Avignon,  and  even  Paris,  where 
as  you  know,  in  the  military  hospital  of  Val- de-Grace,  it  prevailed  as  an 
epidemic  from  January  to  May  of  this  year  1856.f 

I  have  said  that  typhus  seems  always  to  arise  under  the  influence  of  the 
same  causes.  This  is  a  point  upon  which  all  physicians  are  agreed.  All 
admit  that  the  morbific  matter,  the  poison,  the  miasm  which  engenders  the 
disease,  can  be  spontaneously  developed  wherever  great  masses  of  human 
beings  are  accumulated,  as  in  the  great  centres  of  population,  in  armies  con- 
centrated within  a  space  too  small  in  relation  to  the  number  of  persons,  in 
prisons,  and  in  ships.  This  is  particularly  the  case  in  ships  used  as  penal 
hulks,  if  the  men  are  exposed  to  bodily  fatigue,  mental  anxiety,  moral  suf- 
fering, and  dieted  with  food  bad  in  quality,  and  insufficient  in  quantity. 
But  I  also  stated,  that  when  typhus  is  once  developed  in  a  locality,  it  often 
spreads  by  contagion,  when  one  cannot  point  to  any  other  cause  for  this 
propagation  taking  place.  Bear  also  in  mind,  that  in  respect  of  typhus,  as 
in  respect  of  all  other  contagious  diseases,  it  is  not  necessary  that  the  con- 
tagion be  transmitted  by  persons  who  have  the  disease  :  it  may  be  carried 
by  individuals  who  have  not,  and  who  have  never  had,  the  malady,  the 
morbific  germ  of  which  they  are  the  means  of  transmitting. 

This  fact — an  incontestable  acquisition  of  science — sugge-ts  the  fear  that 
from  the  constantly  increasing  intercourse  between  the  two  countries,  typhus, 
at  present  in  permanence  in  England  both  in  the  epidemic  and  sporadic 
form,  will  pass  over  into  France,  and  establish  itself  among  us  for  a  longer 
or  shorter  period.  It  is,  therefore,  my  duty,  gentlemen,  to  give,  regarding 
this  disease  some  information,  which  you  may  soon,  perhaps,  have  to  make 
use  of  in  practice.  This  information  I  will  take  from  a  work  published  by 
Dr.  Murchison,  physician  to  the  Fever  Hospital  of  London.? 

Dr.  Murchison  discusses  the  question  of  the  identity  or  non-identity  of 
typhoid  fever  and  typhus,  and  declares  himself  a  believer  in  their  noii-ideu- 
tity.  This  is  a  subject  to  which  I  shall  have  to  return.  Dr.  Murchison 
states  in  the  preface  to  his  book,  that  after  having  been  brought  up  in  the 
opposite  belief,  he  was  led  by  his  own  observations  to  adopt  the  views  of 
Drs.  Stewart  and  Jenner,  and  that  therefore  his  present  opinion  cannot  be 
attributed  to  preconceived  ideas. 

Tie  invasion  of  typhus  is  usually  sudden,  but  it  may  lie  preceded  by  a 
slight  indisposition  of  one  or  several  days'  duration,  characterized  by  gen- 
eral lassitude,  vertigo,  a  little  headache,  and  loss  of  appetite. 

Without  premonitory  symptoms,  the  patient  i.-  seized  with  transient, 
irregular  rigors,  followed  by  moderate  perspiration:  he  complain-  of  frontal 
headache,  prostration,  and  a  bruised  feeling  rendering  every  kind  of  move- 
ment painful,  of  pains  in  the  loins  and  limbs  l  particularly  the  thighs  ,  and 
of  loss  of  appetite.  During  the  first  two  or  three  days,  although  the  skin  is 
hot.  even  burning  hot.  he  constantly  complains  of  cold,  and  place-  himself 
close  to  tli"  lire.  The  tongue  is  large,  pale,  covered  with  a  fur  which  is  at 
first  white,  and  BOOH  becomes  yellow  or  brown.      The  taste  is  vitiated  :   there 

is  thirst,  more  or  less  uri:' nt,  which  causes  the  patient  \<<  desire  every  kind 


*  Forget:   Preuves  Cliniques  de  la  non-identite*  du  Typhus  et  de  la  Fievi 
phold  '  Rendu*  d»  I' Acad  S        tes,  9  Octobre,  ]-s-">4.] 

I  idelier:   Biemoirc  sur  le  Typhu9  observes  au   Vnl-de-Grace.     [Bulletin  dt 

Mi  351    T.  xxi,  p.  88 

sables  Bl itbchison  :  Treatise  on  the  Continued   Fevers  of  Great   Britain. 
i),  1862. 


TYPHUS.  307 

of  drink,  but  he  soon  loathes  them  all  except  cold  water.  Sometimes,  there 
is  nausea,  and  much  more  rarely,  vomiting  of  bilious  matters.  The  abdo- 
ni'ii,  generally  supple,  and  sunk  rather  than  distended,  is  neither  the  seat 
of  the  slightest  pain,  nor  is  even  sensitive  to  pressure.  The  bowels  are  gen- 
erallv  constipated.  The  urine  is  thick  and  high-colored.  Usually,  the 
pulse  is  full,  but  compressible:  in  some  cases,  it  is  hard  and  bounding, 
while  in  others,  it  is  irregular  and  intermittent.  There  is  a  notable  variety 
in  its  frequency:  it  sometimes  rises  to  120,  and  may  afterwards  go  up  to 
150,  which  is  one  of  the  most  threatening  symptoms  which  can  occur  ;  or  it 
may,  on  the  contrary,  remain  below  the  normal  standard,  even  falling  so 
low  as  28.  This  is  frequently  an  indication  of  feeble  action  of  the  heart, 
which  in  such  circumstances  contracts  twice  for  each  arterial  pulsation. 
Respiration  is  more  or  less  accelerated :  and  there  is  frequently  decided 
oppression  of  the  breathing  accompanied  by  cough  and  mucous  expectora- 
tion, under  which  circumstances  there  are  heard  on  auscultation  sonorous 
'rales,  indicating  the  existence  of  bronchial  catarrh.  The  face  is  red:  the 
margins  of  the  eyelids  are  swollen,  the  conjunctivse  injected,  and  the  eyes 
suffused  with  tears.  At  first,  the  expression  of  the  countenance  indicates 
languor  and  fatigue,  but  it  soon  becomes  sad,  heavy,  and  stupid.  From 
the  beginning  of  the  attack,  there  is  vertigo,  singing  in  the  ears,  restlessness, 
and  often  complete  insomnia,  while  it  also  happens  that  the  patient  says 
that  he  has  not  slept,  although  his  attendants  have  seen  that  he  had  been 
asleep  for  hours.  This  sleep,  however,  is  disturbed  by  distressing  dreams, 
and  by  awakings  with  a  sudden  start:  after  three  or  four  nights,  the  patient 
speaks  in  his  sleep  or  in  a  semi-delirious  state  between  sleeping  and  waking. 
When  he  awakens,  he  is  conscious  of  what  is  passing  around  him,  although 
his  memory  and  intelligence  are  a  little  confused.  From  an  early  period, 
and  rapidly,  the  prostration  of  the  muscular  force  goes  on  increasing.  He 
walks  with  tottering  gait :  when  asked  to  hold  out  the  hand,  it  is  seen  to 
tremble :  this  tremulous  movement  is  also  observed  in  the  tongue,  w7hen  an 
attempt  is  made  to  protrude  it  beyond  the  mouth.  The  feeling  of  debility 
and  exhaustion  soon  becomes  so  great  that  about  the  third  day  from  the 
beginning  of  the  disease,  the  patient  is  unable  to  leave  his  bed. 

Between  the  fourth  and  seventh  day — generally  about  the  fourth  or  fifth 
day — the  eruption  appears  on  the  skin.  It  consists  of  numerous  irregularly 
shaped  spots,  varying  in  diameter  from  a  mere  point  to  three  or  four  lines. 
The  spots  are  either  isolated,  or  they  are  grouped  like  pieces  of  marquetry 
in  irregular  forms,  often  recalling  the  appearance  of  the  eruption  of  measles. 
At  first,  they  are  of  a  dirty  rose  color,  or  they  present  a  sort  of  bloom,  and 
are  slightly  elevated  above  the  skin  :  they  disappear  when  pressed  by  the 
finger :  from  the  first  or  second  day,  they  become  of  a  darker  brown  shade, 
no  longer  disappear,  but  only  become  pale  when  pressed  by  the  finger. 
Their  margins  are  ill-defined,  and  blend  insensibly  with  the  general  hyper- 
semic  hue  of  the  skin.  They  usually  appear  first  on  the  abdomen,  then  on 
the  chest,  back,  shoulders,  and  thighs  ;  in  some  cases,  their  first  appearance 
is  on  the  backs  of  the  hands.  They  are  most  frequently  met  with  on  the 
trunk  and  arms,  and  are  rarely  seen  on  the  neck  or  face.  They  are  always 
most  obvious  on  the  dependent  parts  of  the  body;  and  in  doubtful  cases,  it 
is  on  the  posterior  parts  and  the  back  that  they  ought  to  be  looked  for. 
Besides  the  superficial  spots,  there  are  others  paler,  and  less  distinct  from 
one  another,  which,  from  their  being  apparently  situated  under  the  epider- 
mis, are  called  subepidermic.  When  these  subepidermic  spots  are  abun- 
dant, they  give  the  skin  a  wavy  marbled  aspect,  in  contrast  with  the  darker 
and  better  defined  spots  formerly  described,  although  sometimes  both  spots 
seem  to  be  blended  together.     There  is  great  variety  in  the  appearance  of 


308  TYPHUS. 

the  eruption  of  typhus,  according  to  the  relative  abundance  of  the  wavy 
or  distinct  spots.  In  some  cases  there  is  a  profusion  of  both  kinds,  and  in 
other  cases  there  are  not  many  of  either.  There  is  also  a  diversity  in  the 
appearance  of  the  eruption,  dependent  upon  the  greater  or  less  degree  in 
which  it  is  confluent.  The  marble-like  spots  constitute  what  Jenner  has 
described  under  the  name  of  the  mulberry  rash,  and  which  other  physicians 
have  called  measly  or  rubeolou*.  In  two  or  three  days  the  eruption  is  com- 
plete ;  or,  at  least,  if  new  spots  appear  at  a  later  date,  they  do  not  attain 
a  full  development.  The  severity  and  duration  of  the  malady  are  propor- 
tionate to  the  quantity  of  the  eruption  and  the  darkness  of  its  hue.  Such 
is  typhus  during  its  first  six  or  seven  days. 

Towards  the  end  of  the  first  week  the  headache  ceases,  and  delirium 
supervenes.  The  delirium  varies  in  its  character  ;  occasionally  it  is,  at  first, 
acute,  the  patient  screaming,  talking  incoherently,  and  being  more  or  less 
violent.  He  will,  unless  placed  under  restraint,  get  out  of  bed,  walk  up 
and  down  the  room,  or  even  jump  out  at  the  window.  This  state  of  violence 
is  generally  followed  by  a  period  of  collapse,  during  which  the  patient  is 
calm,  and  speaks  mutteringly  in  a  low  voice.  As  a  rule  the  delirium  is  not 
violent,  even  at  its  commencement.  Whatever  may  be  its  form,  it  is  ac- 
companied by  insomnia,  and  its  manifestations  are  excited  by  speaking  to 
the  patient.  The  expression  of  the  countenance  becomes  more  sombre, 
sadder,  and  more  stupid,  the  prostration  at  the  same  time  increasing  from 
hour  to  hour.  The  symptoms  of  nervous  excitement  are  generally  most 
severe  in  the  evening  and  daring  the  night,  while  the  prostration  is  greatest 
in  the  morning.  At  this  period  of  the  disease,  the  tongue  is  tremulous,  dry, 
brown,  and  rough  in  the  centre ;  sordes  accumulate  on  the  teeth  and  lips  ; 
the  bowels  remain  confined.  The  pulse  ranges  between  100  and  120;  it  i.s 
sometimes  full  and  soft,  but  more  frequently  is  small  and  feeble.  In 
respect  of  the  respiratory  movements,  there  is  also  a  great  variation  ;  the 
inspirations  vary  from  twenty  to  thirty  in  the  minute,  but  they  may  retain 
their  normal  frequency,  or  they  may  fall  as  low  as  eight,  when  the  pulse  is 
small,  and  the  action  of  the  heart  exceedingly  disturbed.  Again,  respira- 
tion may  be  spasmodic  or  jerking:  this  is  the  case  when  the  cerebral  symp- 
toms are  very  severe,  as  when  there  is  delirium  followed  by  coma.  Finally, 
respiration  may  also  be  irregular,  the  inspirations  succeeding  one  another 
with  extreme  rapidity;  and  also,  it  may  be  purely  diaphragmatic,  the 
muscles  of  the  chest  being  seemingly  paralyzed.  This  nervous  respiration 
does  not  depend  on  any  affection  of  the  respiratory  apparatus,  and  i>  an 
extremely  serious  symptom.  The  breath  of  the  patient  is  fetid.  The  skin, 
colder  than  during  the  first  week,  dry,  or  slightly  glutinous,  exhales  a  pe- 
culiar odor,  which  may  be  compared  to  the  smell  of  rotten  straw,  of  deer, 
or  of  mice,  but  which  is  really  a  smell  mi  generis.  The  color  of  the  erup- 
tion becomes  darker;  and  towards  the  middle  of  the  second  week,  there 
appear  true  petechia'  of  a  purple  or  bluish  tint,  which  may  be  developed  in 
the  centre  of*  many  spots,  with  the  brownish-red  of  which  the  margins  of 
the  petechia  become  gradually  blended. 

After  three  or  four  days,  consequently  about  the  tenth  or  eleventh  day 
from  I  he  beginning  of  the  malady,  cerebral  oppression,  or  stupor,  lake-  I  he 

place  of  nervous  excitement.  The  stupor  at  lir.-i  alternates  with  the  delirium, 
which  is  greatest  during  the  night.  There  is  extreme  prostration  :  the  patient 
lies  on  the  bach,  groaning  and  muttering  incoherently,  or  he  remains  quiet 
and  at  rest,  Imi  showing  a  tendency  to  gel  down  to  the  bottom  of  the  bed. 
He  is  quite  unable  to  raise  himself  up, or  even  to  turn  on  his  side:  he  is  raised 
with  very  great  difficulty,  and  is  wholly  indifferent  to  surrounding  persona 
and  things.    At  this  stage  there  are  often  tremors, startings  of  the  tendons, 


TYPHUS.  309 

and  picking  of  the  bedclothes:  the  look  is  haggard,  and  there  is  an  expres- 
sion of  stupidity  in  the  countenance:  the  conjunctivae  are  injected,  the  eye- 
lids are  nearly  closed,  and  the  pupils  are  contracted.  Deafness  is  common. 
When  addressed  in  a  loud  voice  the  patient  looks  around  him  with  an  as- 
tonished  gaze,  and  when  told  to  put  out  his  tongue,  he  opens  his  mouth, 
and  keeps  it  half  open  till  ordered  to  shut  it.  These  are  the  only  indica- 
tions of  consciousness  which  he  gives,  and  they,  even,  are  sometimes  wanting. 
His  mind,  however,  is  far  from  being  inactive  :  he  dreams  the  most  frightful 
dreams,  which  he  implicitly  accepts  as  realities,  and  of  which  he  retains  a 
complete  recollection  after  his  recovery.  His  thoughts  turn  upon  the  events 
of  his  past  life.  He  fancies  that  he  is  persecuted  by  the  persons  around 
him,  even  by  his  dearest  relations:  he  compresses  years  into  hours,  and  in 
a  few  hours  imagines  that  he  has  lived  a  lifetime.  Those  only  who  have 
experienced  this  mental  suffering  can  form  an  idea  of  its  intensity.  The 
teeth  and  lips  are  covered  with  sordes :  the  tongue  is  hard,  dry,  brownish- 
black,  gathered  up  into  a  sort  of  ball,  and  is  either  protruded  with  difficulty 
or  not  at  all.  The  abdomen  is  flaccid,  or  sometimes  tympanitic.  The  bowels 
are  confined,  or,  two  or  three  times  a  day,  stools  of  rather  diarrhoeal  char- 
acter are  passed  involuntarily.  There  is  an  increase  in  the  quantity  of 
urine,  but  it  is  paler  than  natural,  and  below  the  normal  specific  gravity : 
it  is  passed  involuntarily,  or  there  is  retention,  necessitating  the  use  of  the 
catheter.  The  skin  becomes  still  colder,  and  is  occasionally  somewhat 
moist.  There  is  an  increase  in  the  number  of  petechial  spots.  The  parts 
of  the  body  subject  to  pressure,  particularly  the  sacral  region,  become  red 
and  soft,  and  are  apt  to  ulcerate.  The  pulse  is  rapid,  ranging  between  120 
and  140,  small,  often  of  an  intermittent  character,  irregular,  and  scarcely 
perceptible :  the  cardiac  impulse,  and  the  sounds  of  the  heart,  have  either 
become  diminished  in  intensity,  or  have  ceased  to  be  audible. 

The  patient  may  remain  in  this  condition,  with  life  in  the  balance,  for 
some  hours  or  several  days,  till  at  last  stupor  merges  into  profound  and 
fatal  coma  :  or,  he  dies  from  asphyxia,  consecutive  upon  sudden  engorge- 
ment of  the  lungs :  or,  the  pulse  becomes  imperceptible,  the  skin  being  cold, 
livid,  and  bathed  in  profuse  sweat,  death  generally  taking  place  without  a 
return  to  consciousness,  but  without  stertor  occurring,  and  being  apparently 
the  result  of  syncope  rather  than  of  coma. 

The  issue  is  not,  however,  always  fatal.  Towards  the  fourteenth  day  of 
the  disease,  a  more  or  less  sudden  amelioration  may  occur.  The  patient 
falls  into  a  calm  sleep,  which  lasts  for  several  hours,  and  from  which  he 
awakes  a  new  man.  At  first,  he  is  bewildered,  and  does  not  know  where  he 
is:  by  and  by,  he  recognizes  his  attendants  and  friends, and  becomes  aware 
of  his  extreme  weakness.  His  extremities  retain  their  sensibility,  but  when 
he  attempts  to  move  them,  they  seem  as  if  they  did  not  belong  to  his  body. 
The  pulse  has  become  stronger  and  less  rapid  :  the  tongue  is  clean,  and  at 
the  edges  is  moist :  there  is  some  desire  for  food.  These  symptoms  of  amend- 
ment are  often  accompanied  by  slight  perspiration,  diarrhoea,  or  sediment 
in  the  urine.  After  two  or  three  days,  the  tongue  becomes  quite  clean,  the 
appetite  insatiable,  and  the  pulse  normal,  or  even,  it  may  be,  very  slow. 
There  is  a  rapid  return  of  strength.     Convalescence,  in  fact,  is  complete. 

Gentlemen,  this  picture,  drawn  by  Dr.  Murchison,  represents  to  you  a 
case  of  uncomplicated  typhus.  The  disease,  however,  presents  great  va- 
rieties in  respect  of  severity,  and  the  relative  predominance  of  adynamic  or 
ataxic  symptoms.  In  cases  of  average  severity,  the  tongue  is  never  dry  nor 
brown,  the  pulse  is  never  above  100,  and  the  eruption  is  never  petechial. 
A  slight  confusion  of  memory  and  the  intellectual  faculties,  with  disturbed 
sleep,  seem  to  be  the  only  cerebral  symptoms  which  show  themselves.  Local 


310  TYPHUS. 

complications,  however,  may  modify  the  progr&ss  and  character  of  the 
attack. 

Of  these  complications,  which  vary  with  the  epidemic  and  the  locality, 
the  most  common  are  affections  of  the  respiratory  organs.  Chest  complica- 
tions generally  supervene  insidiously,  the  usual  symptoms  of  cough  and  ex- 
pectoration being  insignificant  or  wholly  wanting,  and  the  patient  making 
no  complaint  of  pain.  Under  such  circumstances,  the  rapid  breathing, and 
lividity  of  the  countenance,  are  the  only  signs  indicative  of  a  pulmonary 
affection  ;  but  rapid  breathing  is  not  in  itself  a  conclusive  sign,  because,  as 
I  have  already  said,  it  is  a  frequent  accompaniment  of  fever,  and  may  exist 
in  a  very  aggravated  form  irrespective  of  any  important  lesion  of  the  respi- 
ratory organs.  Moreover,  if  dyspnoea  dependent  on  an  important  lesion 
declares  itself  by  lividity  of  the  face  and  hands,  that  lividity  does  not  ap- 
pear till  the  complication  on  which  it  depends  is  far  advanced,  and  often 
not  till  it  is  irremediable.  When,  therefore,  there  is  the  least  doubt  as  to 
the  nature  of  the  affection,  the  chest  ought  to  be  examined  by  auscultation 
and  percussion. 

Bronchitis  is  perhaps  the  most  common  of  all  the  complications  of  typhus. 
In  some  epidemics,  it  is  met  with  in  the  majority  of  cases.  In  Ireland, 
bronchitis  is  so  usual  a  complication,  that  the  typhus  of  that  country  has 
been  called  catarrhal  typhus;  and  German  physicians,  including  Rokitansky, 
who  have  derived  their  knowledge  of  typhus  from  descriptions  of  it  as  seen 
in  Ireland,  believe  that  it  is  nothing  more  than  a  thoracic  form  of  dothin- 
euteria.  Bronchitis  may  be  the  first  symptom  of  typhus,  or  it  may  come 
on  during  the  course  of  the  disease,  and  continue  during  its  decline.  It  is 
necessary  to  watch  carefully  all  cases  in  which  there  are  bronchitic  symp- 
toms. There  is  no  immediate  danger,  when  the  only  signs  of  pulmonary 
affection  are  an  occasional  cough  and  some  scattered  sibilant  rales :  but 
when  the  prostration  increases,  the  thoracic  inflammation  is  liable  to  extend 
suddenly,  and  at  the  same  time  insidiously,  and  to  become  more  or  less  as- 
sociated with  hypostatic  engorgement.  Under  these  circumstances,  cough- 
ing and  expectoration  being  impossible  in  consequence  of  paralysis  of  the 
bronchial  muscles,  the  catarrhal  secretion  accumulates  in  the  bronchial 
tubes,  and  induces  asphyxia. 

I  have  thought  it  best  to  give  you  a  nearly  exact  translation  of  Dr. 
Murchison's  description  of  this  complication,  on  account  of  the  frequency 
of  its  occurrence;  but  it  will  suffice  merely  to  enumerate  the  others. 

Hypostatic  engorgement  of  the  lungs  is  described  as  a  complication  of 
typhus.  Coming  on  generally  at  a  more  or  less  advanced  period,  about  the 
eleventh  or  fourteenth  day,  sometimes  earlier — as  early  sometimes  as  the 
seventh  day — and  being  usually  associated  with  bronchial  catarrh,  it  is  the 
most  common  cause  of  death  in  English  typhus.  Hypostatic  engorgement 
must  not  be  confounded  with  that  acute  pneumonia,  in  which  there  is  exu- 
dation of  plastic  lymph  into  the  pulmonary  cells  and  intervening  cellular 
tissui — a  form  of  pneumonia  which  is  very  rare.  Hypostatic  engorgement 
sometimes  terminates  in  pulmonary  gangrene,  particularly  in  persons,  who, 
prior  to  their  attack,  have  been  ill-fed.  Pleurisy  is  another  bul  a  rare  com- 
plication of  typhus.      Winn  it  does  OCCUr,  il  is  latent. 

Phlegmasia  alba  dolemt  often  supervenes  in  the  decline  of  typhus,  bul  less 
frequently  than  in  the  decline  of  typhoid  fever.  Purulent  infection  with 
articular  abscesses  is  rarer  Btill.  When  it  does  occur,  it  proves  rapidly 
mortal.  Scorbutus  is  a  complication  met  with  in  some  epidemics.  The 
symptoms  by  which  it  show.-  itself  are  a  great  tendency  to  syncope,  spots  of 
purpura,  and  hemorrhages  by  the  nose,  bronchial  tubes,  stomach,  intestines, 

and  bladder. 


TYPHUS.  311 

Imbecility,  and  sometimes  mania  (as  in  typhoid  fever),  occur  as  sequels 
to,  but  not  as  complications  of,  typhus.  The  same  remark  applies  to  pa- 
ralysis, which  may  be  general,  or  partial.  There  may  be  hemiplegia,  para- 
plegia, or  paralysis  of  the  bladder,  or  paralysis  affecting  the  instruments  of 
motion  or  sensation,  or  both  at  once.  The  paralysis  may  also  affect  the  or- 
gans of  the  senses — of  hearing,  for  example,  leading  to  deafness,  which  fre- 
quently comes  on  in  the  course  of  typhus,  continues  after  convalescence, 
and  is  often  associated  with  otorrhea  and  inflammation  of  the  external 
ear; — and  of  sight,  occasioning  a  certain  degree  of  amaurosis.  These  par- 
alytic affections  of  typhus  are  generally  transitory,  but  sometimes  they 
continue  for  life. 

Erysipelas  of  the  face,  erysipelas  of  the  hairy  scalp  ;  oedema  of  the  inferior 
extremities,  in  some  cases  anasarca,  at  times  dependent  on  renal  disease ; 
gangrenous  affections  of  parts  subjected  to  constant  pi*essure,  and  gangrene 
of  the  limbs  similar  to  that  which  we  have  seen  in  dothinenteria  ;  coma; 
eruptions  of  furuncular  or  pemphigoid  character ;  inflammations  of  the  cel- 
lular tissue;  parotitis;  buboes; — such  are  the  principal  complications  which 
have  been  described  as  rendering  unfavorable  the  prognosis  of  typhus. 

The  inflammatory  form  of  typhus  is  characterized  by  the  intensity  of  the 
febrile  action,  and  acute  delirium.  It  is  most  commonly  met  with  in  the 
young  and  vigorous,  and  chiefly  among  those  in  comfortable  circumstances. 
The  ataxic  form  is  characterized  by  the  predominance  of  nervous  symptoms, 
such  as  delirium,  somnolence,  and  subsultus  tendinum.  The  fever  is  said  to 
be  adynamic,  when  there  is  great  prostration,  involuntary  evacuations,  a 
tendency  to  syncope,  coldness  of  skin,  and  a  slow  pulse.  It  is  said  to  be 
ataxo-adynamic  or  congestive,  when  the  symptoms  are  those  of  congestion. 

Typhus  has  been  called  siderant  [i.  e.,  influenced  by  the  stars],  when  it 
proves  fatal  within  a  few  hours  or  days.  It  is  said  to  be  mild,  when,  as 
generally  happens  in  sporadic  cases,  it  runs  through  its  stages  without  show- 
ing any  serious  symptoms.  The  disease  is  sometimes  so  mild,  that,  were  it 
not  for  the  presence  of  the  characteristic  eruption,  one  might  suppose  that 
the  affection  was  a  simple  synocha. 

Under  the  name  of  typhisation  a  petites  doses,  Dr.  Felix  Jacquot,  a  French 
physician  often  quoted  by  Dr.  Murchison,  has  described  an  aggregate  of 
symptoms  met  with  in  persons  constantly  exposed  to  the  contagion  of  typhus, 
and  who  are  not  otherwise  affected  by  the  poison.  These  symptoms  are 
general  discomfort,  slight  fever,  loss  of  appetite,  sleeplessness,  occasional 
confusion  of  ideas,  and  a  feeling  of  general  fatigue.  Real  typhus  sometimes 
declares  itself  in  this  way  under  the  circumstances  referred  to;  but  in 
general,  only  the  symptoms  now  enumerated  occur,  and  they  disappear  on 
the  patient  leaving  the  poisoned  atmosphere. 

The  diagnosis  of  typhus  presents  no  difficulty,  when  the  characteristic 
cutaneous  eruption  exists.  When  this  is  absent,  typhus  may  be  confounded 
with  dothineuteria  and  other  diseases  characterized  at  some  periods  of  their 
course  by  typhic  symptoms.  However,  independently  even  of  this  specific 
eruption,  typhus  can  be  distinguished  from  typhoid  fever  by  an  aggregate 
of  symptoms  which  I  shall  have  to  bring  under  your  notice  when  I  discuss 
the  question  of  the  identity  or  non-identity  of  the  two  pyrexiae.  As  to  the 
diseases  in  which  the  occurrence  of  typhoid  symptoms  may  lead  to  difficulty 
of  diagnosis,  an  attentive  observation  of  the  phenomena  will  prevent  mis- 
takes. 

Hitherto,  gentlemen,  I  have  said  nothing  regarding  the  researches  which 
have  been  made  into  the  temperature  of  typhus.  I  reserved  my  remarks  on 
that  point,  that  I  might  make  them  in  connection  with  the  subject  of  diag- 
nosis.    Thermometrical  investigation  furnished  valuable  indications  which 


312  TYPHUS. 

enabled  me  to  form  a  definite  opinion  in  respect  of  a  case  which  you  had  an 
opportunity  of  observing  in  our  wards,  and  the  particulars  of  which  I  am 
now  going  to  lay  before  you,  from  notes  taken  down  by  one  of  niv  worthy 
pupils,  Dr.  Alfred  Duclos  of  St.  Quentin.* 

On  Saturday,  11th  June,  there  came  into  my  wardsva  man,  aged  27,  of 
good  constitution,  who  had  lived  in  Paris  for  three  years  and  had  from 
January  last  been  treated  for  pulmonary  inflammation.  On  the  Thursday, 
the  patient  had  been  suddenly  seized  with  very  intense  headache,  raehialgia, 
feebleness  of  the  legs,  particularly  of  the  right  leg,  in  which,  from  that  date, 
he  complained  of  lancinating  pains.  Eespiration  was  difficult  and  sighing, 
but  he  had  neither  cough  nor  haemoptysis.  On  the  Wednesday,  there  was 
neither  vomiting,  diarrhoea,  nor  epistaxis.  On  the  day  of  his  admission 
into  hospital — the  fourth  day  of  the  fever — we  found  a  considerable  num- 
ber of  papular  spots.  Xext  day — June  12th — the  eruption  was  confluent 
on  the  trunk  and  forearms,  sibilant  rales  were  heard  in  the  chest,  and  there 
was  stupor.     There  was  no  diarrhoea. 

On  the  13th  June,  the  sixth  day  of  the  fever — there  were  vomiting,  epis- 
taxis, and  fine  subcrepitant  rales  at  the  base  of  both  lungs.  Dry  cupping 
was  ordered,  but  by  mistake  the  cupper  scarified.  On  the  14th,  there  were 
stupor,  delirium,  subcrepitant  rales,  and  gurgling  in  the  right  iliac  fossa. 
The  eruption  was  very  confluent,  and  so  great  was  the  confluence  that  on 
the  forearms,  the  eruption  was  so  like  that  of  measles,  as  to  lead  me  to 
think  that  the  case  might  be  one  of  anomalous  measles  notwithstanding 
the  symptoms  of  dothinenteria  which  existed.  On  the  15th,  the  eruption 
was  gone,  but  the  general  condition  of  the  patient,  including  the  delirium 
and  stupor,  remained  as  before.  On  the  16th,  the  patient  passed  his  urine 
involuntarily  :  he  had  no  diarrhoea  :  but  he  had  hemiplegia,  an  unusual 
occurrence  in  dothinenteria — there  was  a  very  decided  want  of  power  in 
the  right  arm  and  leg,  as  well  as  distortion  of  the  features.  He  was  cupped 
at  the  nape  of  the  neck  ;  and  a  draught  was  administered  containing  twen- 
ty-five centigrammes  of  musk.  The  delirium  and  stupor  disappeared  :  the 
patient  answered  with  precision  the  questions  which  were  addressed  to  him, 
and  from  that  day  took  his  full  share  in  conversation.  Two  days  later,  he 
was  able  to  leave  his  bed,  but  there  was  still  a  manifest  remaining  feeble- 
ness of  the  right  side.  He  remained  permanently  hemiplegic,  an  occur- 
rence which  sometimes  follows  typhus,  but  is  never  a  sequel  of  dothinen- 
teria. 

In  this  ease,  in  which  I  long  hesitated  in  my  diagnosis,  examination  of 
the  thermal  index  enabled  me  to  affirm  that  the  disease  was  typhus.  This 
is  what  I  observed  :  on  the  fifth  day  of  the  disease',  the  thermometer  in  the 
evening  indicated  40.4°  :  next  day — the  sixth  day  of  the  malady — there 
was  a  slight  remission  in  the  fever,  and  the  thermometer  fell  to  39.8  ,  to 
rise  again  in  the  evening  to  the  same  point  whence  it  had  fallen  in  the 
morning.  On  the  seventh  day.  there  was  a  somewhat  remarkable  fall  in 
the  evening  temperature  :  it  had  fallen  to  40°,  a  circumstance  attributable 
to  the  abstraction  of  blood  by  cupping.  On  the  eighth  day.  the  evening 
temperature  was  40.6  :  it  fell  again  on  the  morning  of  the  ninth  day  to 
■'i!u''  .  rose  in  the  evening  to  40.4°;  fell  one  degree  on  the  morning  <A'  the 
tenth  day,  and  in  place  of  rising  six-  or  eight-tenths  of  a  degree  in  the 
evening,  as  it  had  usually  done,  it  only  rose  four-tenths,  or  in  other  words, 
it  was  39.8  on  the  evening  of  the  tenth  day.  Tin-  remission  was  like  the 
former,  due  to  cupping.     ( >n  the  eleventh,  twelfth,  and  thirteenth  days, 

Duclos:  Q  tel  |nea  Recbercbes  Bur  l'.'tat  de  la  Temperature  dans  lea  Maladies. 
Inaugurate.     Paris,  1864. 


TYPHUS.  313 

there  was  observed  the  same  regularity  in  the  evening  ascent  and  morning 
descenl  of  the  pulse  which  had  at  iirst  been  observed;  bul  on  the  morning 

of  the  fourteenth  day,  the  temperature  fell  abruptly  to  o7.2°.  That  is  to 
say,  between  the  evening  of  the  thirteenth  and  the  morning  of  the  four- 
teenth day,  within  the  space  of  a  few  hours,  there  was  a  fall  in  the  tem- 
perature of  the  patient  of  two  degrees  and  four-tenths.  The  temperature, 
therefore,  suddenly  became  normal  and  convalescence  began  exactly  at  the 
end  of  the  second  week.  An  abrupt  defervescence  of  this  kind  never  occurs 
in  dothinenteria,  nor  does  defervescence  ever  take  place  in  that  fever  at  the 
end  of  the  second  week.  It  consequently  follows,  that  our  case  was  not 
one  of  dothinenteria. 

But  the  eruption,  which  reminded  one  of  measles,  or  rather,  I  should 
>ay,  of  the  measly  rash  of  dothinenteria,  might  be  attributed  to  typhus 
fever.  Certainly  the  thermal  changes  in  our  patient  were  exactly  those 
which  occur  in  that  disease.  Here  is  what  takes  place  in  respect  of  tem- 
perature in  typhus  patients.  The  temperature  continues  to  rise  before  the 
exanthematous  spots  come  out,  and  for  five  or  six  days,  or  it  may  even  be 
for  ten  days  after  it  appears ;  this  is  a  characteristic  which  at  once  distin- 
guishes typhus  from  the  eruptive  fevers.  Again,  in  typhoid  fever,  defer- 
vescence takes  place  by  a  regularly  decreasing  temperature,  whereas  in 
typhus,  the  decline  of  temperature  is  rapid,  continuous,  and  without  evening 
exacerbation.  By  means,  then,  of  observing  the  temperature  in  the  case 
which  I  have  been  referring  to,  we -were  enabled  at  the  beginning  of  the 
attack  to  avoid  mistaking  the  disease  for  measles,  and  at  the  close  for 
dothinenteria. 

My  object  in  now  describing  this  case  is  to  demonstrate  to  you  the  clin- 
ical value  of  the  thermometer.  In  conclusion  let  me  add,  that  the  thermal 
diagram  is  so  characteristic,  that  Dr.  Hiibler,  clinical  assistant  of  Dr.  Wal- 
ther  of  Dresden,  whenever  he  sees  it,  at  once  makes  a  diagnosis,  even  in 
circumstances  which  in  this  case  caused  me  to  hesitate  for  several  days. 

Generally  speaking,  typhus  is  a  very  serious  disease.  According  to  Dr. 
Murchison's  statistics,  the  average  mortality  in  the  Irish  and  Scottish  epi- 
demics, has  been  as  high  as  one-fifth  of  those  seized.  In  London,  between 
1856  and  1860,  a  period,  however,  during  which  the  cases  were  not  numer- 
ous, the  mortality  reached  the  enormous  proportion  of  forty-two  in  the 
hundred.  In  general,  the  mortality  is  greatest  at  the  beginning  and  at  the 
height,  and  lowest  during  the  decline,  of  an  epidemic. 

There  are  a  certain  number  of  other  circumstances  which  affect  the 
prognosis.  Thus,  for  example,  the  disease  is  more  severe  in  men  than  in 
women,  a  fact  which  Dr.  Murchison  explains  by  stating  that  typhus  princi- 
pally attacks  men  debilitated  by  the  privations  incident  to  extreme  poverty, 
or  by  intemperance.  This  fever  is  also  more  dangerous  in  adults  and  old 
people  than  in  young  subjects.  It  is  a  more  serious  disease  among  the 
poor  than  the  rich.  In  a  word,  typhus  is  most  serious  when  it  attacks 
persons  of  enfeebled  constitution.  The  state  of  the  mind  of  the  patient  has 
an  important  influence  on  the  disease.  Dread  of  some  misfortune,  the  fear 
of  death,  or  any  mental  anxiety,  increases  the  danger.  A  pulse  above  120, 
nervoug  respiration,  and  the  early  occurrence  of  cerebral  symptoms,  are 
prognostics  of  the  worst  augury.  All  other  conditions  being  equal,  it  may 
be  said,  the  more  profuse  the  exanthematous  eruption  and  the  darker  its 
color,  the  greater  is  the  danger.  Even  in  the  worst  cases,  however,  the 
physician  must  not  despair:  for  in  no  disease  so  often  as  in  typhus  is 
recovery  seen  to  take  place  after  the  position  of  the  patient  has  become 
apparently  desperate.     Recovery  is  sometimes  abrupt :  and  as  a  general 


314  TYPHUS. 

rule,  convalescence  is  very  rapid  in  typhus,  a  circumstance  which  consti- 
tutes a  differential  character  between  it  and  typhoid  fever. 

We  have  now  to  come  to  the  question  of  the  identity  or  non-identity  of 
typhus  and  typhoid  fever.  It  is  a  question  which  has  been  long  under  dis- 
cussion, and  is  still  debated.  Not  having  had  sufficient  opportunities  of 
studying  typhus  at  the  bedside  of  the  patient,  I  ought,  perhaps,  on  the  plea 
of  incompetence,  to  decline  giving  an  opinion.  I  may,  nevertheless,  say 
that  from  the  perusal  of  the  works  of  those  who  have  treated  this  subject, 
I  have  formed  an  opinion  in  unison  with  that  of  those  French,  English, 
and  American  physicians  who  maintain  that  the  two  diseases  are  not  iden- 
tical. 

Those  who  hold  with  Stokes,  Magnus  Huss,*  and  Lindwurnf  that  typhus 
fever  and  typhoid  fever  are  only  different  forms  of  one  and  the  same 
pyrexia,  and  not  two  distinct  nosological  species,  still  recognize  the  exist- 
ence of  two  absolutely  distinct  types,  the  one  corresponding  to  our  dothin- 
enteria,— the  "typhus  abdominalis"  of  the  Germans,  the  "abdominal," 
"ileo-typhus,"  and  "enteritic  fever"  of  the  English, — and  the  other 
being  "petechial  fever,"  the  "typhus  petechialis,"  the  "typhus  exanthe- 
maticus,"  or  "  typhus  fever,"  characterized  by  a  specific  exanthematous 
eruption,  very  different  from  the  rosy  lenticular  spots  of  typhoid  fever,  and 
which  after  a  series  of  changes  becomes  petechial — the  mulberry  rash:  this 
form  of  fever  is  characterized  still  more  by  the  absence  of  the  intestinal 
lesion  peculiar  to  dothinenteria. 

Although  these  two  forms  of  typhus  can,  in  well-marked  cases,  be  per- 
fectly distinguished  from  one  another,  there  are,  according  to  the  physicians 
who  believe  in  the  identity  of  the  two  fevers,  intermediate  cases  coming 
more  or  less  near  the  primitive  types,  but  blending  and  combining  in  such 
a  way  as  to  make  it  impossible  to  perceive  sharply-marked  distinctive  char- 
acters. These  mixed  forms  are  looked  upon,  by  the  supporters  of  the  doc- 
trine of  identity,  as  the  links  of  a  chain,  the  two  extremities  of  which  are 
the  two  typical  forms. 

Two  principal  considerations  upon  which  is  based  the  doctrine  of  the 
identity  of  typhus  and  typhoid  fever  are,  that  both  seem  to  be  produced  by 
the  same  causes,  and  that  during  the  prevalence  of  the  same  epidemic  con- 
stitution, the  two  extreme  forms  may  prevail  simultaneously  or  predomi- 
nate alternately  ;  but  the  doctrine  chiefly  rests  upon  the  capital  allega- 
tions that  the  contagion  of  typhus  is  capable  of  producing  typhoid  fever, 
and  that  also  from  the  contagion  of  typhoid  fever,  typhus  may  originate. 

According  to  those  by  whom  the  doctrine  of  identity  is  maintained,  the 
explanation  of  the  transformations  which  seem  to  negative  their  views,  is 
to  be  found  partly  in  the  cliraatological  differences  of  countries,  and  partly 
in  the  hygienic  conditions  and  diverse  modes  of  living  of  differenl  peoples; 

The  advocates  of  the  non-identity  doctrine  say,  that  apart  from  the 
absence  of  specific  anatomical  lesions,  typhus  generally  presents  symptoms 
sufficiently  characteristic  to  distinguish  it  from  typhoid  lever.  Thus,  in 
typhus,  the  invasion  is  sudden  :  most  of  the  symptoms,  Such  as  lever,  stupor, 
and  delirium  appear  rapidly,  and  with  great  intensity.  The  abdominal 
symptoms,  such  as  diarrhoea, gurgling  in  the  iliac  fossa,  and  meteorism, are 

generally,  nay,  are  almosl  always,  alisent  :  ami  when  they  do  supervene,  it 
is  only  towards  the  close  of  the  attack.  The  total  duration  of  typhus,  as  I 
have  said   on    the  authority  of   Dr.  Murchison,  and   as    you    have   had    an 

*  Magnus  Buss:  Statistique  el  Traitemenl  du  Typhus  el  de  In  Fidvre  Typhoide 
— Observations  Recueillies  &  L'hdpital  S6raphin  de  Stockholm,     Paris,  L855. 
f  Liindwuhn  :  Du  Typhus  en  [rlande,     L852. 


COMMON    MEMBRANOUS    SORE    THROAT.  315 

opportunity  of  seeing  in  the  case  of  our  patient  in  the  clinical  wards,  is 
less  than  thai  of  typhoid  fever,  being  fourteen  days  iii  cases  free  from  com- 
plication. Ets  favorable  termination  takes  place  more  abruptly,  and  con- 
valescence proceeds  more  quickly,  than  in  typhoid  lever. 

In  reply  to  the  capital  argument  of  their  opponents,  the  physicians  on 
whose  side  1  range  myself  deny  that  the  contagium  of  typhus  can  engender 
typhoid  fever.  They  maintain  that  the  having  had  one  of  these  fevers  does 
not  prevent  a  person  from  taking  the  other,  hut  that  persons  who  have'  had 
either  typhus  or  typhoid  fever  are  found  generally  to  have  acquired  immu- 
nity respectively  from  a  second  attack. 

The  remarks  which  I  made  upon  the  treatment  of  typhoid  fever  are  also 
applicable  to  the  treatment  of  typhus.  We  cannot  cure  the  disease :  we 
cannot  even  shorten  its  course:  all  that  we  can  do  is  to  be  on  the  watch  to 
assist  nature.  I  repeat  to  you  in  the  words  of  Stokes  of  Duhlin,  that  the 
disease  cures  itself.  If  you  keep  up  the  patient  to  the  fourteenth,  nine- 
teenth, or  twenty-first  day,  he  will  recover.  The  leading  indication  always 
is  to  sustain  the  vital  powers  by  food  suited  to  the  digestive  capacity  of  the 
individual,  by  stimulating  and  tonic  beverages,  and  by  wine  and  spirits 
measured  out  in  exact  quantities. 


LECTURE  XVII. 

MEMBRANOUS    SORE   THROAT, 

And  in  Particular  Herpes  or  the  Pharynx.      [Common  Membranous 

Sore  Throat.] 

Many  different  kinds  of  Membranous  Sore  Throat  might  be  enumerated. — 
Common  Membranous  Sore  Throat  often  Originates  in  Herpes  of  the 
Pharynx. —  Often  Difficult,  especially  during  an  Epidemic,  to  form  a 
good  Differential  Diagnosis  between  it  and  Diphtheritic  Sore  Throat. — 
In  these  Doubtful  Cases  we  must  act  as  if  the  malady  were  of  a  bad  char- 
acter.— Recovery  from  Common  Membranous  Sore  Throat  is  Spontaneous. 

Gentlemen  :  It  is  only  by  recognizing  the  existence  of  morbific  causes, 
as  I  shall  more  fully  show  when  I  come  to  discuss  the  subject  of  specificity, 
that  we  hecome  justified  in  constituting  species  in  pathology.  We  could 
not  establish  species  upon  an  acquaintance  with  symptoms,  they  being 
essentially  changeable  and  fleeting,  as  well  as  common  to  numerous  mala- 
dies ;  nor  could  we  base  it  upon  lesions,  although  they  certainly  present 
more  stable  and  less  equivocal  grounds  of  distinctiveness.  Sometimes, 
indeed,  a  lesion  seems  to  characterize,  I  had  almost  said  to  constitute,  a 
disease :  but  often  we  cannot  name  any  lesion  as  the  essential  characteristic 
of  a  malady.  There  may,  on  the  one  hand,  be  a  complete  absence  of  char- 
acteristic lesion,  as  when  scarlatina,  measles,  and  small-pox  occur  without 
eruption  ;  so,  on  the  other  hand,  we  may  meet  in  the  same  disease  with 
many  lesions  of  different  kinds;  as,  for  example,  in  syphilis;  or  again,  simi- 
lar organic  alterations  may  occur  in  the  course  of  diseases  which  are  essen- 
tially different  from  one  another.  This  is  what  takes  place  in  membranous 
sore  throat. 

Under  the  exceedingly  vague  name  of  membranous  sore  throats  [angines 


316  COMMON    MEMBRANOUS    SORE    THROAT. 

couenneuses]  are  included  a  number  of  affections  possessing  as  a  character 
in  common  plastic  exudation  into  the  pharynx.  The  exudation,  whatever 
may  be  its  cause,  consists  of  fibrin  nearly  pure.  In  it,  with  the  assistance 
of  the  microscope,  we  find  small  molecular  corpuscles,  detritus  of  epithelial 
cells,  some  globules  of  pus,  and  some  globules  of  blood.  These  bodies  vary, 
no  doubt,  in  form,  appearance,  and  consistence,  but  it  is  useless  to  attempt 
to  distinguish  different  species  of  sore  throat  by  an  appeal  to  these  varia- 
tions. 

At  the  same  time,  if  we  only  take  into  account  the  character  which  these 
affections  possess  in  common,  we  shall  confound  with  one  another  maladies 
which  are  quite  different  in  their  nature.  "We  shall,  for  instance,  confound 
inflammatory  sore  throat  with  erysipelas  of  the  pharynx,  and  affections, 
generally  speaking,  not  at  all  serious,  in  which  whitish  pseudo-membranous 
concretions  appear  sometimes  on  the  tonsils  and  veil  of  the  palate,  with  other 
kinds  of  sore  throat,  which  are  often  frightfully  dangerous,  and  for  which 
the  name  of  diphtheritic  sore  throat  has  been  more  specially  reserved.  I 
propose  to  speak  of  the  latter  in  future  lectures. 

Membranous  sore  throat,  then,  constitutes  a  nosological  genus  which  in- 
cludes many  species.  It  is  evident  that  it  would  be  easy  to  multiply  exam- 
ples, when  we  consider  that  mucous  surfaces  are  not  only  seldom  excoriated 
without  the  excoriations  becoming  covered  with  fibrinous  exudations,  and 
still  more  when  we  consider  that  when  the  inflammation  of  these  surfaces 
is  somewhat  active,  there  is  a  remarkable  tendency  to  the  formation  of 
plastic  deposits.  Thus,  cauterization  of  the  pharynx  with  nitrate  < if  silver, 
ammonia,  or  hydrochloric  acid,  immediately  excites  inflammations,  which 
are  followed  by  the  formation  of  pseudo-membranous  deposits.  These  tran- 
sient affections  may  lead  to  a  mistaken  belief  in  the  existence  of  diphther- 
itic sore  throat. 

The  effects  produced  by  the  application  of  cantharides  to  mucous  mem- 
branes is  still  more  remarkable,  and  deserves  more  special  consideration 
than  it  receives,  because  cantharidic  pellicular  inflammation  is  in  appear- 
ance similar  to  diphtheria:  there  are,  however,  well-marked  characters  by 
which  the  one  affection  can  be  distinguished  from  the  other.  As  Breton- 
neau  has  said  in  his  account  of  his  experiments  on  animals,  the  cantharidic 
inflammation,  limited  to  the  surface  to  which  the  vesicant  has  been  applied, 
soon  becomes  circumscribed  and  disappears,  but  the  diphtheritic  inflamma- 
tion extends  and  persists. 

Along  with  affections  which,  when  they  occupy  the  pharynx,  constitute 
forms  of  membranous  sore  throat,  I  place  mercurial,  too  often  confounded 
with  syphilitic  membranous  sore  throat. 

In  describing  scarlatina,  I  mentioned  scarlatino-merabranous  sore  throat, 
and  pointed  out  the  differences  between  it  and  diphtheritic  sure  throat  I 
said  then  thai  the  scarlatinous  deposit  has  a  pultaceous  aspect,  is  less  ad- 
herent to  the  tonsil  which  it  covers,  and  hears  less  resemblance  to  the  false 
membrane  of  diphtheria,  than  to  the  secretion  from  the  surface  of  ill-con- 
ditioned ulcers.  I  believe  thai  I  dwelt  sufficiently  on  the  subject  to  obviate 
the  necessity  of  now  returning  to  it." 

But  when  speaking  of  the  complications  of  dothinenteria,  I  omitted  to 
speak  of  the  pultaceous  sore  throat  winch  sometimes  supervenes  in  that  dis- 
ease.  I  do  not  refer  to  thrush  [muguet']  which,  as  you  know,  and  as  I  shall 
have  occasion  to  repeal  to  you,  appears  rather  frequently  as  an  e'piphe- 
QOmenon  in  the  course  of,  and  particularly  at  the  end  of.  <t'\-rrr  fevers,  as 
well  as  in  the  wane  of  phthisis  ami  other  chronic  diseases  :  I  refer  to  pulta- 

*  See  p.  l  i'.'. 


COMMON    MEMBRANOUS    SORE    THROAT.  317 

ceous  sore  throat  [<tiit/iu<  puitacSe],  a  complication  which  is  not  very  serious, 
hut  is  sometimes  mistaken  for  diphtheritic  sore  throat. 

Common  membranous  sore  throat  [angine  couenneuse,  dite  commune]  \>  of 
all  the  membranous  affections  of  the  throat  that  which  has  given  ami  does 
give  rise  most  frequently  to  errors  in  diagnosis.  Bretonneau  did  not  fail  to 
perceive  the  nature  of  this  affection.  It  is  true  that  in  his  treatise  on  diph- 
theria lie  was  not  very  explicit  on  the  point,  and  was  satisfied  to  mention 
the  coincidence  of  common  membranous  sore  throat  with  herpes,  which,  he 
says,  "  appears  around  the  mouth  and  nasal  orifices,  while  at  the  same  time 
a  membranous  exudation  occupies  the  surface  of  one  of  the  tonsils."  But 
my  illustrious  master  often  enunciated  to  his  pupils  that  this  common  rnern- 
branous  sore  throat  was  simply  herpes  of  the  pharynx:  he  compared  what 
takes  place  in  the  mucous  membrane  of  the  mouth  and  pharynx  with  what 
occurs  in  the  conjunctiva  when  it  is  the  seat  of  herpetic  eruption.  This  is 
an  idea  which  I  have  often  expatiated  upon  in  my  clinical  lectures,  both  in 
the  Necker  Hospital  and  in  this  theatre:  but  it  is  to  Dr.  Gubler,  formerly 
my  pupil,  now  my  colleague  at  the  Beaujon  Hospital,  that  the  merit  is  due 
of  having  specially  called  general  attention  to  this  important  subject,  by 
the  publication  of  his  excellent  memoir  on  herpes  of  the  throat  [herpes  gut- 
tural].* Now  that  the  affection  has  been  sufficiently  made  known,  there 
are  few  physicians  who  have  not  had  opportunities  of  observing  cases  of  it. 

A  person  when  in  enjoyment  of  perfect  health,  after  a  chill  or  some  other 
cause,  is  seized  with  general  discomfort,  lassitude,  and  pains  in  the  limbs, 
symptoms  which  are  soon  accompanied  by  febrile  reaction.  These  symp- 
toms are  of  variable  intensity,  and  are  sometimes  combined  with  disorders 
of  the  digestive  canal,  such  as  want  of  appetite,  nausea,  and  vomiting.  The 
general  discomfort  continues  for  about  twenty-four  or  thirty  hours,  when 
all  at  once  the  patient  complains  of  sore  throat.  The  pain,  generally  limited 
to  one  side  of  the  pharynx,  sometimes  (though  rarely),  occupying  both  sides, 
extends  to  that  part  of  the  cervical  region  which  corresponds  with  the  angle 
of  the  maxilla.  There  is  difficulty  in  swallowing,  a  feeling  of  acridity  and 
burning  heat  in  the  throat,  which  extends  sometimes  to  the  larynx,  but 
oftener  to  the  nasal  fossae,  and  still  more  frequently  to  the  Eustachian  tube. 
The  submaxillary  glands  are  swollen,  but  not  severely;  and  the  amount  of 
glandular  swelling  is  far  short  of  what  is  seen  in  diphtheritic  sore  throat, 
in  which  it  is  sometimes  extensive.  In  common  membranous  sore  throat 
enlargement  of  the  glands  cannot  be  recognized  without  having  recourse  to 
palpation.  Care  must  be  taken  not  to  mistake  for  engorged  glands  the 
tumefied  tonsils  which  we  may  come  upon  with  our  exploring  fingers. 

If  the  practitioner  is  not  called  in  till  some  time  after  the  beginning  of 
the  affection,  he  will  find,  on  examining  the  throat,  one  or  sometimes  both 
tonsils  red,  swollen,  and  covered  with  membranous  exudation  of  a  yellow- 
ish-white color,  and  slightly  adherent  to  the  subjacent  tissues. 

Let  me  suppose,  gentlemen  (and  the  circumstances  will  often  occur  to 
you  in  practice),  that  you  encounter  this  affection  in  a  form  presenting  none 
of  the  lesions  I  am  about  to  mention,  and  the  presence  of  which  would 
exceedingly  facilitate  the  diagnosis — in  the  absence  of  these  pathological 
lesions,  and  of  precise  information  regarding  the  previous  course  of  the 
disease,  your  first  idea  would  be  that  the  case  was  one  of  diphtheria.  This 
is  particularly  likely  to  occur  with  children  who  cannot  give  an  account 
of  what  they  feel,  and  in  whom  the  examination  of  the  throat  is  rendered 
difficult  by  the  resistance  offered ;  in  such  circumstances  your  embarrass- 
ment will  be  great.     The  embarrassment  is  still  greater  both  in  adults  and 

*  Bulletins  de  la  Societe  de  Medecine  des  Hopitaux ;  and  Union  Medicale,  1858. 


318  COMMON    MEMBRANOUS    SORE    THROAT. 

in  children,  when,  as  often  occurs,  the  characters  which  distinguish  diph- 
theritic from  herpetic  membranous  sore  throat  are  not  unmistakably  clear. 
As  Bretonneau  has  justly  remarked,  the  question  can  sometimes  only  be 
solved  by  the  dangerous  tendency  of  the  diphtheritic  affection  to  extend  to 
the  tonsils,  pharynx,  and  respiratory  passages.  During  an  epidemic,  when 
the  diagnosis  is  undecided,  we  ought  in  every  case  to  be  as  prompt  to  act 
as  if  we  bad  real  diphtheria  to  combat;  for  it  is  better  to  treat  energeticallv 
a  malady  which  is  not  serious,  than  to  run  the  risk  of  allowing  one  of  an 
essentially  malignant  character  to  gain  ground. 

When  you  have  obtained  a  history  of  the  case  from  its  commencement, 
when  you  have  learned  that  an  acute,  burning  pain  in  the  throat  was  pre- 
ceded some  days  by  general  symptoms  of  illness,  by  febrile  discomfort  and 
disorder  of  the  stomach,  you  may  conclude  that  the  case  is  one  of  common 
membranous  sore  throat;  for,  as  a  general  rule,  diphtheria  does  not  an- 
nounce itself  in  that  way.  It,  in  general,  begins  insidiously.  Hardly 
has  the  patient  become  a  little  feverish,  when  he  complains  of  sore  throat. 
Nevertheless,  I  hold  that  we  cannot  rest  a  solid  diagnosis  upon  distinc- 
tions so  devoid  of  precision. 

How  are  the  membranous  deposits  formed  ?  When  we  are  enabled  to 
follow  step  by  step,  so  to  speak,  the  development  of  the  pharyngeal  affection, 
we  see  on  the  tonsils,  after  some  time — after  a  few  hours  or  two  or  three 
days  from  the  appearance  of  the  first  general  symptoms  of  illness — a  more 
or  less  confluent  eruption  of  red  spots,  which  soon  become  excoriated. 
These  superficial  ulcerations  are  covered  almost  immediately  with  a  gray- 
ish-white plastic  exudation,  which,  spreading  beyond  the  limits  of  the 
ulceration,  may  become  united  to  ulcerations  originating  in  other  herpetic 
vesicles,  so  as  to  form  more  or  less  extensive  membranous  patches.  But  if, 
as  Dr.  Gubler  has  satisfactorily  proved,  this  extension  of  the  membranous 
deposit  partly  explains  the  formation  of  large  membranous  patches  on  the 
pharynx,  it  does  not  completely  explain  it:  there  is  another  cause  likewise 
in  operation.  The  local  inflammation  which  has  preceded,  which  accom- 
panies, and  which  follows  the  development  of  the  herpetic  vesicle,  docs  not 
remain  confined  exactly  to  the  original  space  :  it  extends  to  the  surrounding 
parts,  where  it  manifests  itself  by  redness,  swelling,  and  oedematous  indu- 
ration :  this  inflammation,  though  not  ulcerous,  does  not  the  less  give  rise 
to  an  exudation  of  plastic  products  similar  to  those  secreted  by  the  ulcerated 
surface.  On  raising  this  deposit,  which  is  easily  detached  by  using  a  pledget 
of  charpie,  there  is  found  below  it  an  ulceration  more  or  less  extensive: 
perhaps  there  may  be  only  a  small  ulcerous  point  remaining,  or  the  mucous 
membrane  may  be  entirely  cicatrized,  and  present  no  trace  of  the  primitive 
lesion. 

When  the  herpetic  vesicles  are  more  apart  from  one  another,  it  is  easier 
to  perceive  the  nature  of  the  affection.  We  then  see  white  patches,  mii- 
rounded  by  a  pretty  extensive  inflammatory  areola,  and  varying  from  the 
Bize  of  a  millet-seed  to  that  of  a  pea.  These  spots  leave  in  their  place 
Superficial  ulcerations,  which  may  have  raised  edges,  the  result  of  (edema- 
tous swelling:-  of  the  neighboring  inflamed  tissues.  When  ulcerations  of 
the  same  nature  arc  situated  in  the  skin,  they  soon  hecoinc  covered  with  a 
brownish  crusl  ;  but  nothing  of  this  kind  occurs  when  their  sea!  is  on  the 
mucous  membranes.     The  plastic  exudation  from  the  denuded  Burface  of 

tie-  dermis  may  be,  as  I  have  already  said,  in  sullieient  quantity  to  cover 
the  ulceration  and  spread  beyond  it  ;  or  it  may  be  so  scanty  as  to  be  re- 
moved by  the  movements  of  deglutition  as  soon  as  it   is  exuded,  in  which 

Case  the  ulcerations    are  very  soon    cicatrized,  so   thai     in    point    of  fad    no 

membranous  deposit  is  formed.     This  is  the  aphthous  Bore  throat  of  the 


COMMON    MEMBRANOUS    SORE    THROAT.  310 

English  physicians,  and  is  the  only  affection  of  this  class  which  they  de- 
scribe. M.  Feron  has  considered  it  as  a  special  form  of  the  disease.*  The 
older  authors  knew  it:  and  it  was  probably  this  affection  which  A.retseus 
called  benign,  common  ulcers  of  the  tonsils — ulcera  mitia,  familiaria. 

But  I  do  not  wish  to  leave  a  false  impression  on  your  minds.  The  ex- 
coriations which  proceed  from  pharyngeal  herpes  are  very  different  from 
true  aphthae  of  the  pharynx,  both  in  respect  of  their  cause  and  manner  of 
evolution.  The  aphthous  affection  in  the  mouth,  or  in  the  throat,  is  a 
rather  deep  ulceration,  analogous  to  the  pustule  of  ecthyma  in  the  skin.  It 
occupies  an  isolated  situation,  is  exceedingly  painful,  lasts  a  long  time,  is 
easily  reproduced,  and  is  almost  always  associated  with  a  general  chronic 
state.  In  a  large  proportion  of  cases,  the  herpetic  eruption  shows  itself 
simultaneously  on  other  parts  of  the  cavity  of  the  mouth,  on  the  sides  and 
tip  of  the  tongue,  on  the  internal  surface  of  the  cheeks  and  lips,  and  on 
the  roof  of  the  palate.  There  is  no  possible  room  for  doubt  in  diagnosis, 
when,  as  is  usually  the  case,  the  herpes  is  seen  on  the  lips:  we  can  then 
verify  the  similarity  of  the  affection  seen  at  the  orifice  of  the  mouth,  by 
comparing  it  with  that  which  occupies  the  pharynx,  and  there  constitutes 
membranous  sore  throat. 

A  case  in  point  came  under  your  notice :  the  patient  was  an  unmarried 
woman,  28  years  of  age,  who  lay  in  bed  No.  4  of  our  St.  Bernard  Ward. 
She  had  been  suffering  for  a  month  from  catarrh,  when  one  morning  she 
washed  her  room  :  she  in  consequence  took  cold,  and  felt  very  much 
knocked  up.  Next  day,  however,  she  went  to  her  work,  and  continued  at 
it  during  the  whole  day,  although  she  felt  very  uncomfortable.  In  the 
evening,  she  had  rigors  and  fever.  On  the  following  day,  she  again  went 
to  the  shop  where  she  worked :  and  she  recollects  distinctly  that  she  had 
on  that  day  a  fever-spot  [bouton  de  fievre]  on  her  lip.  Ou  the  fourth  day 
from  that  on  which  she  washed  her  room,  her  general  discomfort  was  so 
great  that  she  had  to  remain  in  bed :  she  experienced  a  sensation  of  burn- 
ing pain  in  the  face.  On  the  fifth  day  she  had  violent  sore  throat,  with  a 
general  feeling  of  prostration,  lassitude,  and  pains,  loss  of  appetite,  and 
difficulty  of  breathing.  Under  these  circumstances,  she  made  application 
for  admission  to  an  hospital,  at  the  central  office  :  when  at  that  office,  she 
became  sick  and  had  copious  vomiting  of  bilious  matters. 

She  was  sent  to  our  wards  in  the  Hotel-Dieu.  We  were  particularly 
struck  with  the  anxiety  and  dyspnoea  depicted  on  her  countenance.  Her 
voice,  however,  was  quite  natural.  No  morbid  condition  of  the  respiratory 
organs  was  revealed  by  auscultation  or  percussion.  The  sore  throat  was 
severe,  deglutition  was  difficult,  and  thei*e  existed  an  incessant  fatiguing 
cough.  On  examining  the  pharynx,  we  saw  the  red  and  swollen  tonsils  : 
the  uvula  also  was  inflamed,  and  glued  as  it  were  to  the  left  pillar  of  the 
veil  of  the  palate.  The  entire  mucous  membrane  of  these  parts  was  cov- 
ered with  whitish  spots  having  the  appearance  of  false  membrane.  There 
was  high  fever  and  hot  skin:  the  pulse  was  125.  The  patient  also  had 
gastro-intestinal  symptoms,  such  as  anorexia,  ardent  thirst,  a  bitter  taste  in 
the  mouth,  and  constipation.  The  state  of  the  patient  continued  very 
similar  next  day,  but  there  was  less  dyspucea  and  fewer  membranous 
patches.  The  treatment  was  limited  to  the  use  of  mulberry  syrup  gargles, 
and  taking  barley-water.  She  was  put  on  low  diet,  and  only  got  soups. 
On  the  eighth  day  from  the  beginning  of  the  attack,  the  fever  had  subsided, 
the  respiration  was  freer,  and  the  local  affection  had  to  a  great  extent  dis- 

*  F£ron  (de  Lille)  :   De  1'Angine  Herpetique.     [These  Inaugurate.]    Paris,  1858. 


320  COMMON    MEMBRANOUS    SORE    THROAT. 

appeared.  There  were  only  some  whitish  points  on  the  right  tonsil,  the 
swelling  of  which,  as  well  as  of  the  other  parts,  was  greatly  diminished. 
Two  days  later,  the  patient  left  the  hospital,  being  quite  recovered.  The 
duration  of  her  malady  was  ten  days. 

AVe  had  a  young  man  in  our  wards,  in  whom  the  symptoms  of  the  dis- 
ease were  even  more  precisely  characterized.  In  addition  to  the  herpes  on 
the  pharynx,  there  was  a  profuse  eruption  of  herpetic  vesicles  on  the  cheek ; 
and,  making  allowance  for  the  diversity  of  aspect  imparted  by  diversity  of 
situation,  it  was  impossible  not  to  see  the  essential  identity  of  the  affection. 

Some  of  you,  I  presume,  recollect  this  young  man.  He  was  an  English 
domestic  servant,  aged  16.  He  came  into  hospital  at  the  end  of  February 
1868,  and  in  five  clays  left  quite  recovered.  His  bed  was  No.  1  of  St. 
Agues's  Ward.  He  had  just  come  from  a  long  journey,  during  which, 
having  been  exposed  to  abrupt  variations  of  temperature,  he  took  cold. 
On  reaching  Paris  on  the  19th  February,  he  only  experienced  great  fatigue, 
but  next  morning,  he  had  a  feeling  of  general  discomfort.  During  the  day 
he  had  slight  vomiting  and  rigors  :  he  complained  of  pains  in  the  head  : 
and  went  to  bed,  where  he  perspired  profusely.  On  the  21st,  all  of  these 
symptoms  had  increased  :  there  was  ardent  fever :  and  so  great  was  the 
patient's  debility  that  he  was  obliged  to  keep  his  bed.  He  had  a  great 
deal  of  headache,  and  he  began  to  feel  pain  in  the  throat.  At  the  same 
time,  there  appeared  on  the  lip  a  pimple,  which  he  called  a  bouton  defievre. 
The  sore  throat  became  rapidly  worse :  he  had  passed  a  bad  night,  and  there 
was  coryza  with  lachrymation.  By  the  23d,  the  pharyngeal  symptoms 
had  abated,  but  there  was  profuse  salivation.  A  physician,  who  was  called 
in,  sent  him  to  the  Hotel-Dieu,  after  touching  his  throat  with  a  solution, 
regarding  the  composition  of  which  the  patient  was  not  able  to  inform  us. 

On  his  admission  to  our  wards,  I  observed  on  his  face  an  eruption,  which 
had  come  out  since  the  morning.  Several  groups  of  vesicles,  mostly  of  the 
size  of  a  pin's  head,  but  some  a  little  larger,  were  to  be  seen  on  the  right 
cheek,  resting  on  a  bright  red  base,  in  a  line  between  the  temple  and  the 
mouth.  Some  of  these  vesicles,  presenting  all  the  characters  of  herpes, 
were  situated  on  the  ala  of  the  nose  and  on  the  right  labial  commissure  : 
there  were  likewise  others  on  the  left  commissure  and  on  the  chin.  The 
herpes  on  the  lips,  however,  being  more  advanced  than  that  in  other  local- 
ities, was  beginning  to  dry  up.  The  patient  complained  of  violent  pain 
and  annoying  heat  in  the  face. 

On  examining  the  cavity  of  the  mouth,  we  detected  general  redness  of 
the  mucous  membrane,  particularly  at  the  right  side,  where  herpetic  ves- 
icle- were  disseminated:  on  the  tongue,  also,  there  were  some  of  the  vehi- 
cles. Iii  do  situation  were  the  redness  and  eruption  more  decided  than 
on  the  isthmus  of  the  fauces.  The  tonsils,  red  and  swollen,  also,  the  uvula 
and  veil  of  the  palate,  likewise  vn\,  were  covered  with  vesicles,  sonic  of 
which  were  white,  semi-transparent  and  acuminated,  others  were  ulcerated, 
and  others  again  were  covered  with  a  fibrinous  exudation,  forming  a  layer 
with  jagged  vi\'j;v<  extending  beyond  the  ulcerated  surface.  Before  118, 
then,  we  had  the  herpetic  vesicle  in  its  different  phases  of  evolution.  The 
lower  part  of  the  pharynx  participated  in  the  general  redness.  Inn  exhib- 
ited none  of  the  characteristic  eruption.    The  patient  suffered  from  pain 

in  the  throat,  and  an  tineas  J  let  ling  which  excited  constant  COUgh  :  the 
cough  was  guttural  and  painful.      There  was   scarcely  any  fever,  and    next 

day,  it  had  completely  subsided.  I  prescribed  only  emollient  gargles.  *  >u 
February  28th,  the  young  man  left  the  hospital,  having  quite  recovered* 

He  bad  DO  sore  throat;  and  nothing  remained  on  the  face  to  indicate  where 

the  berpes  had  been,  except  a  few  red  mark-. 


COMMON    MEMBRANOUS    SORE    THROAT.  321 

I  must  not  omit  to  mention  some  other  forms  of  herpes  affecting  mucous 
membranes,  to  which  Bretonneau  was  iu  the  habit  of  calling  the  attention 

of  his  pupils,  ami  which  I  have  many  times  pointed  out  to  you.     I  refer  to 
herpes  of  the  conjunctiva,  and  herpes  of  the  vulva. 

It  often  happens,  that  when  the  herpes  has  the  degree  of  confluence 
which  it  had  in  the  young  Englishman  whose  case  I  have  just  related, 
there  is  a  group  of  vesicles  on  one  of  the  eyelids  :  in  such  a  case,  one  or 
two  vesicles  may  form  on  the  conjunctiva,  or  even  on  the  cornea.  When 
situated  on  the  cornea,  they  produce  an  exceedingly  painful  keratitis, 
sometimes  accompanied  by  photophobia,  but  which  yields  very  easily  to 
treatment.  This  form  of  ophthalmia  is  in  general  very  imperfectly  under- 
stood. 

Every  one  is  aware  that  herpes  of  the  prepuce  is  very  common,  and  that 
it  is  often  coincident  with  guttural  and  labial  herpes  ;  but  from  the  reluc- 
tance of  women  to  make  known  such  complaints,  it  is  a  less  familiar  fact 
that  herpes  affects  the  inner  surface  of  the  labia  majora  in  the  same  circum- 
stances, and  perhaps  as  often,  as  it  attacks  the  prepuce  in  males.  Dr.  Ber- 
nutz,  when  physician  to  the  Venereal  Hospital  for  Women,  more  than  once 
discovered  herpes  of  the  neck  of  the  uterus,  which,  like  guttural  herpes,  is 
often  associated  with  fever,  acute  pain  in  the  lower  part  of  the  abdomen, 
and  leucorrheea.  This  is  the  explanation  of  those  attacks  of  transient  me- 
tritis which  we  see  coincident  with  common  membranous  sore  throat,  and 
which  sometimes  so  greatly  alarm  women. 

I  now  return,  gentlemen,  to  the  consideration  of  the  differential  diagnosis 
of  common  membranous  sore  throat  and  diphtheria. 

There  is  no  difficulty  in  the  diagnosis,  when  the  herpetic  eruption  of  the 
pharynx  is  non-confluent;  and  the  diagnosis  is  still  more  easy,  when  the 
eruption  is  seen  on  other  parts  of  the  mucous  membrane  of  the  mouth  and 
on  the  lips,  as  it  then  presents  itself  in  its  own  unmistakable  characters. 
When  the  eruption  is  confluent,  and  when  there  is  a  pseudo-membranous 
exudation  on  the  tonsils  and  veil  of  the  palate,  the  coexistence  of  herpes  of 
the  lips  or  face  will  signally  enlighten  the  physician  as  to  the  nature  of  the 
membranous  sore  throat  he  is  called  upon  to  treat,  and  will  at  the  same 
time  enable  him  to  distinguish  it  from  diphtheria.  But  when,  as  often 
occurs  in  practice,  the  membranous  affection  of  the  throat,  under  which  the 
special  characters  of  herpes  have  disappeared,  when  this  membranous 
affection  exists  alone,  hesitation  is  allowable.  Although  the  ulcero-mem- 
branous  lesion  often  assumes  the  particular  appearance  which  I  have  just 
described,  it  is  necessary  for  diagnostic  usefulness  that  this  appearance  be 
cmite  distinctively  marked,  and  that  an  opportunity  has  been  afforded  of 
exactly  ascertaining  the  characters  of  the  affection ;  this  is  especially  diffi- 
cult in  children,  who  submit  badly  to  the  necessary  examination.  It  is 
quite  true,  that  during  the  progress  of  the  local  disease,  we  still  find,  at 
least  in  some  cases,  numerous  features  of  its  primitive  appearance ;  but 
nevertheless,  at  the  very  time  when  it  is  of  importance  to  form  an  opinion, 
error  is  often  unavoidable.  Without  being  afraid  of  too  much  insisting  on 
the  point,  I  again  repeat,  that  in  cases  in  which  you  cannot  form  a  decisive 
diagnosis  between  common  membranous  sore  throat  and  diphtheritic  sore 
throat,  you  ought  to  lose  no  time  in  adopting  active  measures,  and  proceed 
just  as  if  you  had  to  do  with  an  undoubted  case  of  malignant  sore  throat. 
Do  this  all  the  more  fearlessly  that  (as  Bretonneau  justly  remarks,)  the 
topical  applications  suited  to  stop  diphtheritic  inflammation,  so  far  from 
aggravating  the  common  membranous  sore  throat,  shortens  its  duration. 

On  the  other  hand,  gentlemen,  you  must  not  hastily  come  to  the  con- 
clusion that  you  have  a  case  of  diphtheria,  when  the  malady  may  be  the 
vol.  i. — 21 


322  COMMON    MEMBRANOUS    SORE    THROAT. 

milder  affection  :  such  a  mistake  may  afterwards  prove  unfortunate.  Grant 
that  you  have  cured  a  certain  number  of  your  supposed  cases  of  diphther- 
itic sore  throat  by  emetics,  mercurial  preparations,  or  other  remedies.  En- 
couraged by  apparent  success,  you  will  employ  the  same  treatment  when 
you  encounter  a  real  case  of  diphtheria ;  but  then,  the  remedies  which  had 
seemed  so  efficacious  will  fail,  and  be  the  cause  of  your  losing  precious 
time  which  ought  to  have  been  used  in  contending  with  a  disease  demand- 
ing prompt  and  energetic  measures. 

When,  in  the  course  of  these  clinical  lectures,  I  shall  have  to  speak  to 
you  of  thrush  [muguef],  I  will  state  the  characters  by  which  diphtheria 
and  the  common  membranous  sore  throat  can  be  distinguished  from  some 
affections  with  which  they  still  are  often  confounded. 

When  you  have  diagnosed  with  certainty  herpes  of  the  pharynx,  your 
anxiety  regarding  the  issue  of  the  case  is  at  an  end.  It  will  get  well  spon- 
taneously. The  only  treatment  required  will  consist  of  borax  or  alum 
mouth-washes,  and  astringent  gargles. 

Bear  in  mind,  however,  gentlemen,  that  I  shall  have  to  return  to  this 
point,  and  to  adduce  cases  to  show  that  a  common  membranous  may 
become  the  starting-point  of  a  malignant  sore  throat. 

Remarkable  examples  of  the  transformations  to  which  I  allude  are  given 
in  the  reports  of  epidemics  of  sore  throat  which  prevailed  in  France  during 
1858.  Permit  me,  gentlemen,  to  repeat  to  you  what  I  said  in  the  account 
which  I  was  appointed  by  the  commission  on  epidemics  to  read,  in  their 
name,  to  the  Academy  of  Medicine  at  its  sitting  on  the  22d  November, 
1859* 

The  characteristic  feature  of  the  epidemics  of  the  year  1859  was  the  con- 
comitance of  common  membranous  and  diphtheritic  sore  throats.  Previous 
to  the  appearance  of  the  diphtheritic  affection,  there  was  observed  in  many 
districts  a  marked  predisposition  to  simple  sore  throat :  the  cases  of  mild 
sore  throat,  however,  though  only  simple  herpes  of  the  pharynx,  did  not 
always  present  the  regular  symptoms  usually  met  with  in  that  affection. 
Some  cases  were  unusually  protracted  in  their  course.  In  others  the  mem- 
branous affection  degenerated  ;  and  the  physician  had  to  ask  himself  whether 
he  could  maintain  a  favorable  prognosis.  This  state  of  the  medical  consti- 
tution was  no  doubt  preparatory  to  the  advent  of  serious,  in  succession  t" 
the  simple  prevalent,  sore  throats.  Not  only  was  the  one  affection  seen  to 
succeed  the  other,  but  in  partial  epidemics,  both  pathological  forms  were 
observed  to  be  more  or  less  closely  associated. 

Cases  collected  by  eminent  physicians,  and  in  different  parts  of  the  Em- 
pire, leave  no  room  for  doubt  on  this  point.  The  similarity,  or  rather,  I 
may  say,  the  identity  of  what  was  seen  at  the  same  time  in  different  locali- 
ties was  most  remarkable:  and  the  only  difference  observed  was  that  the 
relation  between  the  benignant  and  malignant  sore  throats  varied  accord- 
ing to  the  localities. 

In  some  places,  the  benignant  form  predominated;  adults  were  attacked 
more  frequently  :  there  were  fewer  cases  which  were  nol  mild,  and  deaths 
were  exceptional  occurrences.  Such  was  the  character  of  the  epidemic  in 
some  communes  in  the  arrondissemenl  of  Hazebrouck,  and  in  the  arron- 
dissemeiu  of  Macon,  where   in    nearly    l<><>  cases,  there  were   hardly  30 

deaths;    in  the  arrondissemenl  of  Apt,  where  in  80 Cases    I  were  fatal:    and 

in  the  arrondissemenl  of  Gourdon,  where  the  mortality  was  I  in  the  loo. 

In  other  places,  (m  the  contrary,  the  occurrence  of  the  benignanl  form 
was  exceptional.      The  patients  who  recovered  rapidly  were  few  in  number, 


*  Memoires  de  l'Aciidemii;  Lmplriale  de  Bd6decine,  t    wiv,  p   31. 


GANGRENOUS    SORE    THROAT.  323 

and  were  always  adults ;  but  even  in  children,  among  whom  the  mortality 
was  great,  mortal  diphtheria  often  began  under  the  formed'  an  herpetic 
eruption.    That  happened  in  the  communes  of  Vien  and  Thiel  in  the  arron- 

dissement  of  Moulins;  also  in  the  departments  of  ( 'harente-Inferieure,  Deux- 
Sevres,  Meuse,  Nievre,  Sa6ne-et-Loire,  as  well  as  in  other  departments, 
where  Drs.  Castel,  Dusouil,  Madere,  Plissard,  and  Guillemaut  pointed  out-, 
each  in  his  own  locality,  the  occurrence  id' simple  sore  throat  in  adults,  and 
the  transformation  of  the  herpetic  eruption  into  characteristic  diphtheritic 
patches,  which  ran  their  fatal  course. 

These  are  the  circumstances,  gentlemen,  in  which  you  must  with  re- 
doubled vigilance  watch  your  patients.  These,  also,  are  the  cases  in  which 
there  is  not  only  no  harm,  but  a  great  advantage — even  when  the  herpetic 
nature  of  the  sore  throat  is  best  characterized — in  employing  the  same  topi- 
cal treatment  that  is  demanded  by  diphtheria:  it  will  not  in  any  degree 
aggravate  the  common  membranous  affection. 


LECTURE  XVIII. 

GANGRENOUS  SORE  THROAT. 

Gangrenous  Sore  Throat  from  Excess  of  Inflammation. —  Gangrenous  Sore 
Throat  Supervening  as  a  Complication  of  severe  Diseases  such  as  Dysen- 
tery, Typhoid  Fever,  &c. —  Gangrenous  Sore  Throat  as  a  Complication  of 
Scarlatinous  and  Diphtheritic  Son'e  Throat. — Primary  Gangrenous  Sore 
Throat. 

Gentlemen:  The  considerations  into  which  I  have  entered  in  relation 
to  membranous  sore  throat  are  equally  applicable  to  the  affections  regard- 
ing which  I  to-day  propose  to  address  some  words  to  you.  The  lesion,  as  I 
have  already  told  you,  is  not  a  sufficient  criterion  by  which  to  establish  the 
diagnosis,  and  I  show7ed  you  examples  of  pseudo-membrane  appearing  in 
sore  throats  essentially  different  in  their  nature.  The  same  remark  is  ap- 
plicable to  gangrene. 

Gangrene  of  the  pharynx  and  tonsils  is  indeed  sometimes,  though  very 
rarely,  a  termination  of  inflammatory  sore  throat ;  it  results  from  excess  of 
inflammatory  action.  The  gangrene  may  also  occur  as  a  complication  of 
a  sore  throat  of  specific  character ;  as,  for  example,  when  it  is  an  epiphenom- 
enon  in  scarlatina,  measles,  or  typhoid  fever,  or  when  it  supervenes  in  the 
course  of  any  other  great  epidemic  disease — in  dysentery,  for  example,  as 
seen  by  you  in  the  patient  who  lay  in  bed  No.  11  of  St.  Agnes's  Ward. 

The  patient,  as  you  will  recollect,  was  a  young  lad,  who  was  admitted,  on 
the  21st  August,  into  the  clinical  wards,  for  a  frightful  dysentery,  which  re- 
sisted every  kind  of  treatment  by  which  I  endeavored  to  subdue  it.  He 
died  on  the  19th  October.  At  the  autopsy,  we  found  extensive  ulcerations 
of  the  intestines,  the  lesions  characteristic  of  epidemic  colitis,  and  at  many 
points,  sphacelus  of  the  mucous  membrane.  In  this  case,  dysentery  lent 
some  of  its  malignity  to  the  constitution  of  the  patient,  who,  from  being  ex- 
hausted by  fatigue  and  misery,  was  in  a  condition  of  all  others  the  most 
unfavorable  for  struggling  against  so  formidable  a  disease.  It  was  during 
the  latter  days  of  the  patient's  life,  that  we  saw  the  pharyngeal  affection 


324  GANGRENOUS    SORE    THROAT. 

come  on.  He  complained  of  sore  throat,  and  difficulty  in  swallowing:  his 
voice  was  nasal.  On  examining  the  pharynx,  we  detected  a  dark  gray 
patch  on  the  right  tonsil :  the  breath  was  repulsively  fetid,  and  character- 
istic. The  slough  had  the  appearance  of  heing  surrounded  by  projecting 
irregular  edges,  and  the  neighboring  parts  were  of  a  livid  red.  Cauteriza- 
tion with  fuming  hydrochloric  acid  did  not  sensibly  modify  the  character 
of  the  gangrenous  surfaces,  which  were  excavated  by  very  deep  ulcers.  The 
sphacelus,  however,  did  not  extend  in  breadth  beyond  the  parts  primarily 
invaded.  * 

Gangrene  of  the  pharynx  is  rarely,  though  sometimes,  met  with  in  diph- 
theritic sore  throat.  When  it  occurs,  it  is  as  a  complication  of  a  pseudo- 
membranous affection,  precisely  as  it  occurs  in  scarlatino-membranous  sore 
throat,  in  cutaneous  diphtheria,  and  still  more  in  diphtheria  of  the  vulva, 
in  which  gangrene  of  the  vagina  is  more  common  than  in  other  forms  of 
diphtheria. 

Again,  gangrene  of  the  pharynx  often  supervenes  in  diphtheria  as  the 
predominant  anatomical  element  in  malignant  sore  throat.  It  is  preceded 
by  the  appearance  on  the  tonsils  of  plastic  exudations  more  or  less  thick, 
and  covering  a  greater  or  less  surface.  But  the  spots  of  exudation  which 
first  appear  remain  limited,  and  gangrene  soon  begins  :  it  is  at  first  super- 
ficial, but  afterward-,  it  invades  and  deeply  destroys  the  tissues. 

Here  is  an  example  of  this  superficial  gangrene. 

On  Mondav,  23d  April,  Dr.  Leon  Blondeau,  my  former  chef  de  clinique, 
was  called  about  midday  to  a  child  suffering  from  membranous  sore  throat. 
The  patient  was  a  boy  of  three  and  a  half  years  of  age,  of  good  constitu- 
tion, who  generally  enjoyed  excellent  health.  He  had  only  been  a  short 
time  resident  in  Paris.  For  about  fifteen  days,  he  had  seemed  out  of  health. 
He  had  an  almost  constant  little  cough :  he  was  becoming  thinner,  and  was 
losing  the  freshness  of  his  complexion.  He  had  been  under  the  treatment 
of  a  phvsician  who,  having  diagnosed  membranous  sure  throat,  vigorously 
cauterized  the  left  tonsil  with  potassa  fusa,  there  existing  in  that  situation 
a  whitish  exudation,  corresponding  with  swollen  cervical  glands.  After  the 
cauterization,  he  had  on  several  occasions  practiced  insufflation  of  alum 
into  the  throat.  On  attentively  examining  the  pharynx,  there  was  seen  <>n 
the  left — the  cauterized — tonsil,  a  grayish-white,  pultaceous-looking  de- 
posit, which  much  more  resembled  the  plastic  exudation  of  common  mem- 
branous than  of  diphtheritic  sore  throat.  On  the  right  tonsil,  there  was  a 
thin  layer  of  grayish  opaline  substance,  and  three  or  four  semi-transparent 
spots  like  the  vesicles  of  herpes.  The  swollen  tonsils  presented  a  bright 
red  appearance  around  the  places  where  the  plastic  exudation  existed:  the 
veil  of  the  palate  and  the  uvula  were  likewise  red,  but  showed  no  trace  of 
fals  •  membrane.  The  child  complained  of  pain  in  the  throat,  and  had  sonic 
difficulty  in  Bwallowing.  The  fever  was  moderate;  and  there  was  nothing 
alarming  in  the  general  condition. 

During  the  evening,  a  sort  of  thin  slough  became  detached  from  the 
cauterized  surface  of  the  left  tonsil,  and  the  right  tonsil  was  Been  to  be 
covered  with  an  exudation  similar  to  that  which  in  the  morning  had  covered 
the  other:  the  cervical  glands  on  the  right  side  were  swollen,  and  the  swell- 
ing was  greater  than  it  had  been  on  the  hi'i  side.  Both  tonsils  were  ener- 
getically cauterized  with  the  -olid  sulphate  of  copper.  There  was  nothing 
particular  to  be  seen  on  the  uvula  or  veil  of  the  palate.  The  voice  was  per- 
fectly char,  ami  quite  unaltered  in  tone.  Bwallowing  seemed  to  be  accom- 
plished with  some  difficulty,  a  symptom  which  might  arise  from  the  pain 
caused  by  the  inflammation  which  the  cauterization  had  excited,  and  which, 
probably,  was  also  the  explanation  of  the  child's  repugnance  to  food. 


GANGRENOUS    SORE    THROAT.  325 

On  the  Tuesday  morning,  there  was  found  on  the  left  tonsil  a  sort  of 
slough,  which  had  been  observed  to  be  partially  detaehed  on  the  previous 
evening;  and  on  the  right  tonsil,  there  was  a  similar  deposit,  which  also 
was  becoming  separated.  These  deposits  covered  superficial  ulcerations  of 
a  deep  red  color,  and  the  redness  extended  to  the  mucous  membrane  of  the 
veil  of  the  palate  and  uvula.  The  glandular  swelling  was  less  conspicuous 
than  on  the  previous  day.  The  general  condition  was  not  changed.  Not- 
withstanding the  difficulty  which  he  had  in  swallowing,  the  child  took  some 
broth.  Till  Wednesday  evening,  the  disease  had  made  no  progress.  A 
portion  containing  chlorate  of  potash,  which  had  been  prescribed  when  the 
symptoms  first  appeared,  was  continued:  and  the  necessity  of  nourishment 
was  insisted  on. 

On  the  Wednesday  eveniug,  the  glands  in  the  neck  were  very  painful  and 
a  good  deal  more  swollen,  particularly  on  the  right  side,  where  the  cellular 
tissue  was  involved.  The  little  patient  complained  of  pain  in  the  right  ear. 
There  was  apparently,  no  sensible  change  in  the  state  of  the  pharynx.  It 
must  be  stated,  however,  that  examination  of  the  throat  was  attended  with 
extreme  difficulty,  in  consequence  of  the  almost  insurmountable  resistance 
offered  by  the  child.  The  sudden  increase  of  the  glandular  swelling  was 
alarming.  Still,  the  prognosis  was  formed  under  reservation,  because  there 
was  no  sensible  change  in  the  general  state  of  the  patient:  he  took  food 
more  willingly  than  on  the  previous  evening,  and  sat  up  in  bed  to  play. 

He  passed  a  good  night.  Next  morning  (Thursday),  the  glandular 
swelling  was  found  to  have  disappeared  to  a  great  extent.  No  new  symp- 
tom was  observed.  By  the  evening,  the  aspect  of  affairs  had  completely 
changed.  Although  the  child  had  asked  for  food,  and  had  twice  seemed 
to  take  with  a  certain  amount  of  satisfaction  the  meat  offered  to  it  (declin- 
ing bread,  however),  there  was  a  striking  change  in  the  physiognomy.  A 
pale  hue,  a  complete  blanching,  had  taken  the  place  of  the  till  then 
natural  color  of  the  skin.  The  eyes  were  puffy  ;  and  in  the  raesian  line  of 
the  lower  lip  there  were  two  reddish-brown  spots,  caused  by  the  effusion  of 
blood  under  the  mucous  membrane.  The  glandular  swelling  in  the  cer- 
vical region,  which  was  still  greatest  on  the  right  side,  had  again  acquired 
the  enormous  proportions  of  the  previous  evening.  The  veil  of  the  palate, 
rising  up  as  high  as  the  level  of  the  tonsils,  was  greatly  swollen,  and  of  a 
livid  red  color ;  but  on  bringing  the  nose  as  near  as  possible  to  the  child's 
mouth,  it  was  impossible  to  detect  any  characteristic  odor.  As  the  child 
submitted  better  to  examination,  the  condition  of  the  diseased  parts  was 
more  easily  ascertained.  Two  dark  gray  masses  were  seen  floating  in  front 
of  the  ulcerations,  from  which  they  were  detached,  though  still  adherent  to 
the  parts  by  their  inferior  margin.  When  the  ulcerations  were  touched, 
they  yielded  a  mixture  of  blood  and  mucus,  but  at  no  point  was  there 
visible  any  trace  of  false  membrane.  The  voice  had  preserved  its  natural 
tone ;  respiration  was  free,  but  it  was  noisy,  as  in  persons  suffering  from 
inflammatory  sore  throat. 

On  the  Friday,  the  condition  of  the  child  was  desperate.  At  two  in  the 
morning,  he  had  been  seized  with  the  most  distressing  restlessness  and 
anxiety.  His  breathing  was  oppressed;  his  countenance  had  become  fright- 
fully pale  ;  and  his  skin  was  covered  with  a  cold  sweat.  Just  as  the  phy- 
sician arrived,  the  agonies  of  death  were  beginning.  The  mental  faculties, 
however,  remained  unimpaired.  Respiration  had  that  character  of  anxiety 
which  it  presents  in  malignant  diseases ;  the  inspiration  was  noisy,  as  in 
persons  affected  with  oedema  of  the  glottis.  Although  the  voice  was  en- 
feebled, it  was  not  altered  in  tone.  The  veil  of  the  palate  was  much  swollen  ; 
its  entire  surface  was  purple-red,  this  color  being  deepest  in  the  neighbor- 


326  GANGRENOUS    SORE    THROAT. 

hood  of  the  tonsils.  There  was  a  sanious  discharge  from  the  nostrils;  but 
within  them  there  was  no  appearance  of  plastic  exudation,  nor  gangrenous 
spot.  Such  a  state  of  matters  afforded  no  room  for  a  gleam  of  hope.  Still, 
a  large  cup  of  coffee  without  milk  was  ordered,  and  a  quarter  of  an  hour 
after  it  had  been  taken,  he  was  given  some  syrup  of  ether,  when  he  took 
hold  of  the  vessel  and  spoon  presented  to  him.  Speaking  very  distinctly, 
he  complained  of  pain  in  the  throat,  and  with  his  finger  pointed  out  the 
situation  of  the  swollen  glands.  Soon  after  the  arrival  of  the  physician, 
the  child  died  suddenly  in  a  faint. 

Although  it  was  impossible  to  obtain  a  necroscopic  examination,  the  de- 
tails of  the  case  are  sufficiently  complete  to  leave  very  little  room  for  doubt- 
ing that  there  was  superficial  gangrene  of  the  pharynx.  The  specially 
remarkable  circumstance  to  which  I  wish  to  call  your  attention  is,  that  the 
characteristic  deposits  of  diphtheria  occupied  a  very  small  surface,  and 
remained  confined  to  their  original  localities;  and  so,  as  I  formerly  said, 
gangrene  became  the  predominating  element  of  the  disease. 

Gentlemen,  you  will  find  recorded  in  different  publications,  and  partic- 
ularly in  the  Gazette  Medicate  de  Paris,  and  the  Bulletins  de  la  Societt  An- 
atomique,  a  good  many  cases  in  which  gangrene,  supervening  as  a  compli- 
cation of  diphtheritic  sore  throat,  had  deeply  destroyed  the  implicated 
tissues.  Allow  me  to  place  before  you  the  details  of  one  of  these  cases,  as 
given  in  a  paper  published  by  Dr.  Gubler  in  the  Archives  Generates  de 
Medeeine,  for  May,  1857.  The  case  is  one  of  malignant  membranous  and 
gangrenous  sore  throat,  complicated  with  diphtheria  of  the  nasal  fossa?. 

The  patient,  a  woman  of  twenty-four  years  of  age,  came  into  the  wards 
of  my  colleague  of  the  Beaujon  Hospital  on  the  26th  February,  1836.  She 
had  been  confined  four  months  previously  ;  and  it  would  appear  that  the 
infant  had  had  the  same  disease  as  the  mother.  The  woman  stated  that 
her  child  had  had  a  hoarse  cough,  and  had  "coughed  up  skins,"  an  im- 
portant circumstance,  as  Dr.  Gubler  justly  observes.  The  woman  had 
been  ill  for  six  days,  at  the  date  of  her  admission  to  the  hospital.  Her 
attack  had  commenced  with  severe  pain  in  the  throat,  and  great  difficulty 
in  swallowing.  The  submaxillary  glands  on  the  right  side  were  engorged 
and  painful.  The  symptoms  did  not  seem  to  have  been  ushered  in  by  a 
febrile  paroxysm. 

At  his  first  visit,  Dr.  Gubler  observed  that  the  woman  could  hardly 
speak.  Her  voice  was  snuffling,  and  articulation  was  difficult:  but  she  was 
not  without  voice,  nor  was  there  any  symptom  to  indicate,  that  the  larynx 
was  involved.  So  great  was  the  difficulty  in  deglutition,  that  the  patient 
dreaded  the  necessity  of  swallowing  as  a  punishment,  though  it  were  only 
the  swallowing  the  saliva.  Her  mouth  remained  constantly  half  open  to 
facilitate  respiration,  and  give  exit  to  the  flow  of  saliva,  and  to  the  viscid 
mucus  detached  by  the  painful  efforts  to  cough.  The  right  submaxillary 
region  was  very  swollen,  hard,  red,  and  painful.  On  examining  the  throat, 
a  large  grayish  patch  was  seen  on  the  right  Bide  of  the  isthmus  of  the  lane.-: 
t  was  easily  detached  by  the  handle  of  a  -p. inn  ;  it  seemed  to  he  a  super- 
ficial slough  of  a  portion  of  mucous  membrane,  of  which  the  dermis  had 
been  previously  infiltrated  by  plastic  products.  The  Burface  exposed  by 
the  removal  of  the  patch  was  ulcerated  and  granular:  it  hied  freely.  Both 
nasal  fossae  were  equally  involved,  as  was  apparent  from  the  snuffling  char- 
acter of  the  voice,  and  from  the  respiration  being  exclusively  performed 
through  the  mouth.  A  false  membrane,  sofl  in  consistence,  yellowish  in 
color,  and  differing  in  appearance  from  the  grayish  patch  already  men- 
tioned, \s  a-  extracted  from  each  nasal  fossa.  The  removal  of  these  false 
membranes  was  followed  by  considerable  epistaxis.     Upon  examining  the 


GANGRENOUS    SORE    THROAT.  327 

gray  patches  with  the  microscope,  Dr.  Guhler  found  that  they  were  evi- 
dently sloughs  of  mucous  membrane  infiltrated  hy  plastic  exudation,  and 
that  the  substances  removed  from  the  nasal  fossae  were  undoubtedly  pseudo- 
membranous productions. 

The  patient  was  in  great  anxiety:  she  remained  constantly  sitting  up, 
and  her  whole  energies  seemed  concentrated  in  her  attempts  to  clear  her 
mouth  from  saliva  and  viscid  mucus.  Her  hands,  which  she  always  had 
out  of  bed,  were  very  cold.  The  pulse  was  weak,  small,  and  rather  quick  : 
on  the  evening  of  the  same  day,  it  became  quicker. 

The  affected  parts  were  cauterized  with  pure  hydrochloric  acid  ;  and  the 
nasal  fossae  were  twice  injected  with  a  solution  of  nitrate  of  silver,  the 
strength  of  which  was  forty  centigrammes  (6  grains)  to  thirty  grammes  (11 
drachms)  of  water.  The  patient  was  ordered  decoction  of  cinchona,  to 
which  coffee  was  added  ;  and  there  was  also  prescribed  a  julep  containing 
two  grammes  of  extract  of  cinchona.     Some  broth  was  given  to  her. 

Next  day,  February  27th,  it  was  observed  that  the  glands  situated  below 
the  chin  were  swollen  :  the  diphtheritic  patch  (or  slough)  extended  to  the 
anterior  surface  of  the  veil  of  the  palate,  to  the  right  margin,  the  point,  and 
left  margin  of  the  uvula :  on  the  uvula,  there  remained  an  isolated  portion 
of  healthy  mucous  membrane.  The  difficulty  of  swallowing  had  now  be- 
come so  much  aggravated  as  to  amount  to  an  almost  complete  impossibility: 
the  glandular  enlargement  was  very  painful  on  pressure :  the  nasal  fossa? 
were  more  impervious  than  ever  to  air :  the  hands  were  cold,  because  they 
were  always  out  of  bed.  There  was  a  good  deal  of  fever,  and  the  pulse  was 
100.  The  use  of  the  decoction  of  cinchona  Avith  coffee  was  continued  ;  and 
there  were  also  prescribed  a  julep  containing  4  grammes  of  chlorate  of  pot- 
ash, a  mouth-wash  containing  8  grammes  of  the  same  salt,  and  an  opiated 
liniment  for  rubbing  over  the  cervical  glands. 

On  the  28th,  the  general  appearance  of  the  patient  was  improved,  and 
the  anxiety  seemed  to  be  diminished  :  the  pulse  had  fallen  to  80  or  84,  but 
it  was  small  and  sharp:  the  skin  was  cool,  but  not  cold:  the  extremities  had 
a  somewhat  violet  color :  the  glandular  swelling  was  diminished,  and  there 
was  less  redness  and  tension  of  the  skin  over  the  glands.  There  was  also 
an  amelioration  in  the  condition  of  the  throat,  and  the  isthmus  of  the  fauces 
was  less  swollen  :  on  the  right  pillar,  there  was  a  very  apparent  loss  of  sub- 
stance :  in  that  situation,  the  false  membranes  did  not  seem  to  have  increased : 
the  obstruction  of  the  nasal  fossa?  remained.  The  treatment,  as  before,  was 
continued. 

On  the  29th,  there  was  a  further  diminution  in  the  glandular  swelling. 
At  the  lower  part  of  the  throat,  sloughing  surfaces  were  visible,  and  on  the 
posterior  part  of  the  pharynx,  there  was  a  pseudo-membranous  patch. 

On  the  1st  March,  the  patient  complained  of  severe  pains  in  the  ears, 
particularly  when  she  swallowed:  she  had  mentioned  this  symptom  on  pre- 
vious days,  but  it  had  not  before  caused  her  so  much  suffering.  These 
pains  indicated  that  the  specific  inflammation  was  spreading  to  the  Eusta- 
chian tubes:  the  hearing  of  the  patient,  nevertheless,  was  good:  the  nostrils 
were  still  obstructed,  and  this  obstruction  arose  from  swelling  of  the  pituitary 
membrane  to  which  the  nitrate  of  silver  had  been  applied.  The  pharyngeal 
surface  seemed  to  be  less  coated  with  false  membrane  and  pultaceous  exu- 
dation. Between  morning  and  evening,  the  pulse  rose  from  80  to  100. 
A  gargle  of  the  decoction  of  marshmallows  and  pojipy-beads  was  substi- 
tuted for  the  chlorate  of  potash  mouth-wash. 

On  the  4th,  there  was  no  longer  any  false  membrane  to  be  seen  on  the 
pharynx  or  uvula,  but  there  was  an  uneven  layer  of  it  on  the  right  pillar 
of  the  fauces. 


328  GANGRENOUS    SORE    THROAT. 

Till  the  6th,  there  did  not  appear  to  be  any  change  in  the  general  con- 
dition of  the  patient ;  but  on  that  day,  just  as  she  was  attempting  to  rise, 
she  was  seized  with  faintness  and  a  desire  to  vomit.  It  was  then  observed, 
that  there  was  paralysis  of  the  veil  of  the  palate:  in  drinking,  the  fluids 
were  returned  by  the  nose :  the  voice  was  very  snuffling.  There  was,  how- 
ever, less  obstruction  of  the  nasal  fossa?  than  formerly,  and  she  had  some 
power  of  snuffing  up.  She  breathed  freely  through  the  right  nostril,  but 
not  so  well  through  the  left.  Consequent  upon  the  administration  of  a 
purgative  enema  on  the  previous  evening,  she  had  had  a  little  diarrhoea. 
She  had  had  in  the  evening  vomiting  and  epigastric  pains :  she  described 
the  pains  as  cramps  and  colics. 

Next  day — the  7th — her  condition  became  very  serious  :  the  face  had  a 
pinched  look  :  on  the  eyelids,  over  the  cheek-bones,  and  on  the  lips,  there 
was  a  purplish  hue :  the  skin  of  the  rest  of  the  face  was  of  a  cadaverous 
yellow :  the  hands  were  livid  :  the  tongue  was  pale  :  there  was  aphonia  : 
and  although  there  was  nothing  to  show  the  existence  of  any  pulmonary 
or  cardiac  lesion,  the  respiration  was  oppressed.  The  pulse  had  fallen 
almost  incredibly  low — to  22  beats  in  the  minute.  The  patient  was  in  a 
state  of  passive  delirium,  and  looked  as  if  in  the  algid  stage  of  cholera. 
A  cordial  potion  was  prescribed. 

On  the  8th  March,  at  the  visit,  the  depression  of  the  vital  powers  was 
as  great  as  on  the  previous  evening.  Two  days  later,  she  died  in  a  state 
of  coma. 

In  this  case,  as  in  the  previous  case,  an  autopsy  could  not  be  obtained. 
But  you  will  find  in  the  medical  periodicals,  particularly  in  the  "  Bulletins 
de  la  Societe  Anatomique,"  similar  cases  in  which  were  demonstrated  after 
death,  scalpel  in  hand,  the  formidable  symptoms  produced  by  sphacelus  of 
the  pharynx. 

You  perceive  then,  gentlemen,  that  gangrene  of  the  pharynx  may  super- 
vene as  a  complication  of  diphtheria.  I  have  never  denied  that  this  may 
take  place  ;  but  I  have  said,  and  now  repeat,  that  this  complication  is  rare. 
Moreover,  I  am  convinced  that  there  has  very  often  been  mistaken  for 
gangrene  that  which  was  only  gangrene  in  appearance.  I  need  not,  how- 
ever, at  present  insist  on  this  point,  as  I  shall  have  to  return  to  it  at  some 
length,  when  discussing  the  subject  of  diphtheria  in  future  lectures. 

But  independently  of  secondary,  there  are  different  kinds  of  primary 
gangrene.  The  rarest  of  them  all  is  gangrene  from  excess  of  inflammatory 
action.  There  is  also  a  description  of  gangrene,  which,  supervening  in  the 
course  of  certain  severe  diseases  causing  profound  prostration,  such  as 
dysentery,  typhoid  fever,  small-pox,  diphtheria,  is  a  kind  of primitive  gan- 
grenous mre  throat:  it  ought  to  be  looked  on  as  a  distinct  disease,  having 
as  its  fundamental  character  mortification  of  the  mucous  membrane  of  the 
pharynx,  which  resembles  gangrene  of  tin;  mouth,  appears  suddenly,  and 
sometimes  extends  to  the  cheeks  and  lips. 

Primitive  gangrenous  sore  throat  likewise  comes  on  independent  of  any 
antecedent  morbid  influence,  independent  of  epidemic  influences  which 
produce  malignant  diphtheritic  sore  throat:  it  sometimes  attacks  persons 
who  seem  to  be  in  the  full  vigor  of  health,  attacking  them  without  any 
appreciable  cause,  and  often  causing  death  with  a  degree  of  rapidity,  some- 
wliat  variable,  but  never  in  the  sudden  manner  in  which  it  occurs  in  malig- 
nant diphtheria,  that  frightfully  formidable  disease  of  which  1  shall  have 
to  speak  to  you.  This  affection,  however,  may  terminate  in  recovery,  a-  I 
had  an  opportunity  of  observing  in  the  case  of  a  young  man  whom  I  saw 
in  consultation  with  Dr.  E.  Vidal. 

This  kind  of  gangrene  is  characterized  by  the  presence   of  dark-gray 


GANGRENOUS    SORE    THROAT.  329 

patches  on  the  tonsils  ;  the  patches  are  sometimes  quite  black,  surrounded 
by  yellow  excavated  edges,  which  are  more  or  less  elevated,  when,  the 
affection  having  made  progress,  the  slough  has  a  tendency  to  separate  from 

the  soft  parts.  When  the  slough  has  separated,  whether  spontaneously  or 
in  consequence  of  cauterization,  a  more  or  less  deep  ulceration  is  seen  in 
its  place.  The  gangrene  may  remain  confined  to  one  point  ;  but  there  are 
other  cases  in  which  it  gradually  extends  to  the  neighboring  parts,  invad- 
ing the  veil  of  the  palate,  and  the  uvula  (which  it  may  destroy  more  or 
less  completely),  and  taking  possession  of  the  back  part  of  the  pharynx 
and  the  aryteno-epiglottidean  folds. 

The  mucous  membrane  surrounding  the  sphacelated  parts  assumes  a  livid 
red  color,  and  presents  the  characters  of  ©edematous  inflammation. 

There  is  a  characteristic  fetor  exhaled  with  the  breath  :  this  fetor,  as 
is  natural  to  suppose,  is  greater  in  proportion  to  the  extent  of  the  lesion. 
The  gangrenous  smell  has  been  sometimes  compared  to  the  odor  of  fseces. 

The  patients  complain  of  very  acute  pain  in  the  throat,  which  pain  is 
increased  during  deglutition.  When  the  affection  gains  the  veil  of  the 
palate,  and  even  when  it  remains  confined  to  the  tonsil,  speech  is  embar- 
rassed and  the  voice  is  snuffling. 

The  cervical  glands  become  implicated  ;  sometimes  the  extent  of  their 
swelling  is  as  great  as  in  malignant  diphtheritic  sore  throat :  and  at  other 
times  there  is  complete  absence  of  glandular  swelling,  a  symptom  which  is 
never  absent  in  diphtheritic  sore  throat. 

This  disease  is  also  recognized  by  the  extreme  severity  of  the  general 
symptoms,  which  testify  to  the  malignant  nature  of  their  cause,  and  to  the 
general  poisoning  of  the  system.  All  the  organic  functions  are  greatly 
depressed  ;  digestion  languishes  ;  there  is  loss  of  appetite ;  and  the  animal 
temperature  is  notably  lowered  :  the  skin  of  the  extremities  presents  that 
livid  appearance  which  characterizes  the  algid  stage  of  cholera,  and  has 
a  relation  to  the  disordered  state  of  the  hsematosis  of  the  general  circula- 
tion: but  there  is  no  fever.  Indeed,  so  far  from  there  being  any  fever,  the 
pulsations  of  the  heart  and  the  pulse  at  the  wrist  are  below  the  normal 
standard.  Death  is  the  consequence  of  depression  of  the  vital  powers  ;  and 
the  patients  either  die  in  a  state  of  syncope,  the  mind,  up  to  the  last,  being 
not  at  all  or  very  little  affected  ;  or  else  they  die  in  a  state  of  coma. 

The  case  which  I  am  now  going  to  relate,  occurred  under  my  own  obser- 
vation, and  the  report  of  it  is  drawn  up  by  Dr.  Millard.  It  will  give  you 
an  idea  of  the  symptoms  which  may  supervene  in  this  kind  of  gangrenous 
sore  throat. 

The  patient,  M.  Man  eel,  was  the  son  of  a  Parisian  physician.  He  was 
twenty-three  and  a  half  years  of  age,  a  non-resident  hospital  pupil,  tall, 
strong,  of  good  constitution,  and  of  nervous  temperament.  He  had  com- 
plained for  several  months  of  frequently  feeling  lassitude,  and  of  falling 
into  fits  of  low  spirits  without  any  cause.  After  a  slight  attack  of  stomati- 
tis, he  became  very  irritable,  and  from  time  to  time  was  tormented  with 
neuralgia.  Under  these  circumstances,  a  perceptible  change  took  place  in 
his  appearance ;  his  physiognomy  became  somewhat  altered,  and  the  ordi- 
nary paleness  of  his  complexion  was  sensibly  increased. 

On  August  8th,  1853,  he  was  seized,  without  any  apparent  cause,  with 
rigors  and  a  feeling  of  general  discomfort.  He  could  not  take  dinner,  and 
went  to  bed.  Next  day,  there  was  observed  a  seemingly  slight  inflamma- 
tion of  the  left  tonsil.  There  was  not  much  fever,  but  there  was  a  mani- 
fest prostration  of  the  wdiole  system. 

Three  or  four  days  later,  Dr.  Man  eel,  being  alarmed  at  the  state  of  his 
son,  called  in  to  consult  with  him  on  the  case,  two  hospital  physicians,  Drs. 


330  INFLAMMATORY    SORE    THROAT. 

Boucher  de  la  Ville-Jossy  and  Legroux.  These  gentlemen  could  detect 
nothing  particular  in  the  condition  of  the  throat ;  but  they  were  struck 
with  the  fetor  of  the  breath. 

On  the  16th  or  17th  of  the  month,  I  was  sent  for.  I  was  at  once  struck 
with  the  gangrenous  fetor  of  the  breath.  On  examining  the  pharynx,  I 
found  a  gangrenous  patch  on  the  left  side  of  the  anterior  pillar  of  the 
fauces  ;  and  the  gangrene  seemed  to  me  to  have  a  tendency  to  extend  to 
the  veil  of  the  palate.  I  freely  cauterized  the  parts  with  hydrochloric- 
acid. 

On  the  following  days,  I  saw  the  patient  in  consultation  with  MM. 
Andral  and  jSTelaton.  ^Ye  insisted  upon  the  necessity  of  an  essentially 
tonic  general  treatment,  embracing  good  soup,  generous  wine,  and  cinchona. 
There  was  almost  no  fever  :  the  digestive  functions  were  in  a  pretty  good 
state :  the  voice  was  snuffling,  but  it  was  a  remarkable  circumstance,  that 
there  was  but  little  difficulty  in  deglutition.  The  breath  was  very  fetid. 
There  was  no  thoracic  complication.  The  complexion  was  exceedingly 
pale.  This  poor  young  man  had,  moreover,  fallen  into  a  state  of  great 
-moral  prostration. 

Some  days  later,  a  very  serious  symptom,  double  vision,  manifested  itself. 

During  the  night  of  the  27th  and  28th  of  August,  when  his  pulse  was 
being  felt,  the  patient  for  the  first  time  complained  of  pain  in  the  right 
forearm.  Very  soon,  similar  pains,  then  considered  rheumatic,  were  felt 
in  the  other  limbs  ;  but  forty-eight  hours  aferwards,  we  discovered  that 
they  depended  on  phlebitis  of  the  superficial  veins.  The  pulse  had  now 
become  smaller  and  more  frequent.  The  gangrene  of  the  pharynx,  however, 
though  it  had  not  become  circumscribed,  had  extended  very  little.  There 
was  no  difficulty  in  swallowing.  There  was  no  enlargement  of  the  glands, 
a  circumstance  to  which  I  wish  particularly  to  call  your  attention. 

On  the  3d  or  4th  September  we  observed  that  the  left  side  of  the  upper 
lip  was  a  little  swollen,  and  we  soon  perceived  a  double  gangrenous  patch 
on  that  lip  and  the  corresponding  gum.  There  was  some  puffiness  of  the 
face,  and  considerable  alteration  of  the  features. 

On  the  7th  September  the  patient  was  seized  with  delirium,  which  ceasing 
only  at  intervals  continued  till  death,  which  occurred  during  the  night  of 
the  9th  and  10th. 


LECTURE  XIX. 

INFLAMMATORY  SORE  THROAT. 

Recovery  is  Spontaneous. — Distinct  from   Rheumatic  Sore  Throat. — Distinct 
also  front  the  Sore  Throat  caused  by  tli>'  Secretion  from  the  Tonsils. 

Gentlemen:  There  arc  some  diseases  which  are  both  the  glory  and  the 
opprobrium  of  every  kind  of  treatment :  thej  terminate  spontaneously  in 
recovery,  but  no  therapeutic  measures  can  arresl  their  course.  Inflamma- 
tory sore  throal  belongs  to  this  class  of  diseases,  and  to-day  1   propose  to 

speak  to  you  of  a  ca.-e  in  point   which  yon  have  lately  seen. 

The  patienl  was  a  woman  who  lay  iii  hed  Nd.  1  of  Si.  A.gnes's  Ward. 

Consequeni    upon    a  chill,  .-he  was   seized   with   violent    pain    in    the   throat. 

( )n  the  lirst  day  of  the  attack  she  had  no  fever,  hut  she  experienced  general 
discomfort,  and  the  lymphatic  glands  on  the  left  Bide  of  the  neck  were 


INFLAMMATORY    SORE    THROAT.  331 

slightly  swollen.  Next  day  she  was  received  into  the  Hdtel-Dieu.  Sin- 
was  then  in  a  decidedly  febrile  condition.  She  complained  of  pain  in  the 
throat,  and  on  examining  the  pharynx  I  perceived  that  it  was  of  a  bright 
red  color,  that  there  was  some  swelling  of  the  left  tonsil,  and  that  on  it 
there  was  a  whitish  patch  formed  by  a  thin  layer  of  deposit,  which,  if  it 
had  not  been  looked  at  with  some  attention,  might  have  been  taken  for 
diphtheritic  exudation.  The  pains  became  more  severe,  while,  at  the  same 
time,  the  fever  increased.  On  the  fifth  day  of  her  attack  this  woman  had 
great  difficulty  in  swallowing  fluids,  which,  by  partly  passing  into  the 
larynx,  caused  slight  paroxysms  of  cough.  These  symptoms  increased  in 
severity;  and,  on  the  sixth  day,  the  parts  implicated  were  more  swollen, 
there  was  increased  difficulty  in  deglutition,  and  an  almost  absolute  impos- 
sibility of  swallowing  liquids,  which  returned  by  the  nose.  The  voice  was 
singularly  modified  in  tone.  The  patient,  suffering  from  a  state  of  great 
anxiety,  tormented  by  want  of  sleep  and  unappeasable  thirst,  implored  me 
to  give  her  relief,  which  it  was  not  in  my  power  to  bestow :  but  I  expected 
nature,  by  her  own  unaided  powers,  to  afford  that  desired  relief.  And  so 
it  was :  for  next  day  the  great  anxiety  and  the  pain  in  the  throat  had  sub- 
sided as  if  by  enchantment.  The  cause  of  all  the  suffering  had  been  an 
abscess  situated  behind  the  veil  of  the  palate  and  in  the  left  tonsil.  Instant 
relief  had  been  afforded  by  the  spontaneous  opening  of  that  abscess ;  and 
forty-eight  hours  after  this  occurrence  the  cure  was  complete. 

The  patient  had  had  the  affection  called  tonsillitis, acute  amygdalitis, inflam- 
mation of  the  tonsil,  inflammatory  sore  throat,  or  inflammatory  cynanche,  using 
eynanche  in  the  sense  in  which  it  was  employed  by  the  old  medical  authors. 
I  prefer  the  latter  two  names,  because  they  do  not  define  the  seat  of  the 
disease,  which,  as  a  general  rule,  does  not  occupy  the  tonsil  itself,  but  the 
cellular  tissue  surrounding  it. 

Inflammatory  sore  throat  is,  I  repeat,  gentlemen,  one  of  the  diseases 
which  are  at  once  the  glory  and  the  reproach  of  all  kinds  of  medical  treat- 
ment— the  reproach,  because  medicine  never  prevails  against  them,  in  this 
sense,  at  least,  that  it  is  impotent  in  stopping  the  course  or  shortening  the 
duration  of  the  attack — and  the  glory,  because  they  terminate  in  spontane- 
ous recovery  whatever  we  do,  so  that  there  is  a  temptation  to  ascribe  to 
medicine  the  honor  of  the  natural  cure. 

You  are  too  well  acquainted  with  the  anatomical  characters  of  quinsy 
[esquinaneie~],  and  its  phenomena,  for  me  to  think  it  necessary  to  give  you 
in  this  place  a  description  which  you  will  find  in  all  your  text-books.  I 
ihall,  therefore,  restrict  myself  to  the  statement  of  some  general  facts  of 
practical  utility.  Let  me  point  out  to  you  that  the  free  surface  of  the  tonsils 
is  very  often  covered  with  a  whitish  deposit,  formed  either  by  mucus  or  by 
a  plastic  exudation  constituting  a  membranous  patch.  This  deposit  has  a 
creamy,  sometimes  yellowish,  aspect:  it  is  not  very  adherent  to  the  tonsil, 
not  thick,  and  not  consistent.  It  may  deceive  the  eyes  of  less  experienced 
observers,  and  suggest  the  idea  that  the  affection  is  diphtheritic. 

Inflammatory  sore  throat,  once  declared,  does  not  recede  any  more  than 
an  inflammation  of  the  arm.  In  the  latter  you  may  sometimes  usefully 
interpose  by  dividing  the  tissues  rendered  exceedingly  tense  by  the  inflam- 
mation, and  by  making  incisions  you  will  afford  egress  to  the  pus  which  is 
going  to  be  formed:  but  this  is  not  curing  the  inflammation,  which,  not- 
withstanding your  interference,  will  follow  not  the  less  its  natural  course. 
It  is  not  so  in  inflammatory  sore  throat.  I  know  that  it  has  been  proposed, 
and  you  have  read  the  proposal  in  the  works  which  are  in  your  hands,  to 
scarify  or  cut  the  affected  parts  with  lancet  or  bistoury :  and  it  has  been 
proposed  to  lacerate  them  in  a  more  barbarous  manner  with  Museux's  for- 


332  INFLAMMATORY    SORE    THROAT. 

ceps,  upon  the  supposition  that  the  proceeding  would  afford  relief  to  the 
patients.  These  methods  of  treatment,  gentlemen,  exceedingly  open  to 
objection  in  theory,  are  very  little  suited  for  practical  application.  I  doubt 
whether  they  have  ever  produced  the  benefits  expected  of  them  ;  and  I  have 
seen  cases  in  which  they  were  positively  injuriously  increasing,  in  place  of 
moderating,  the  violence  of  the  irritation. 

Every  kind  of  treatment  has  been  put  in  requisition  against  this  malady. 
For  a  long  time  the  antiphlogistic  method  was  extolled,  and  there  are  still 
some  who  proclaim  its  efficacy  in  inflammatory  sore  throat.  Bleedings 
from  the  arm,  bleedings  from  the  feet,  bleedings  from  the  ranine  vein ; 
bleedings  called  derivative,  accomplished  by  applying  leeches  to  the  neck, 
the  anus,  or  the  vulva ;  the  abstraction  of  blood  by  cupping  from  between 
the  shoulders  or  from  the  sides  of  the  neck,  have  been  vaunted  as  being 
very  useful.  It  has  even  been  recommended — in  the  true  spirit  of  Brous- 
sais — to  apply  leeches  to  the  interior  of  the  pharynx ;  but  this  singular 
fancy  will  not  admit  of  discussion.  Bleeding  by  phlebotomy  is  now  gener- 
ally abandoned  in  the  treatment  of  inflammatory  sore  throat,  but  it  is  other- 
wise in  respect  of  local  depletion,  for  nothing  is  more  common  than  to  apply 
leeches  externally  over  the  angles  of  the  jaw. 

The  revulsive  treatment,  a  term  applied  to  the  administration  of  emetics 
and  purgatives,  has  continued  longer  in  repute.  I  believe  that  in  some 
cases,  when  there  is  a  saburral  state  of  the  alimentary  canal,  the  employ- 
ment of  evacuants,  particularly  of  ipecacuan,  is  indicated ;  but,  except  under 
such  circumstances,  their  usefulness  is  very  doubtful. 

For  the  third  time  I  repeat  that  antiphlogistic^,  revulsives,  topical  astrin- 
gents, and  all  other  kinds  of  treatment,  are  without  power  to  impede  the 
course  of  inflammatory  sore  throat,  the  naturally  short  duration  of  which 
nothing  can  curtail,  and  the  termination  of  which  in  recovery  invariably 
occurs.  During  my  very  long  medical  life  1  have  never  known  death  to 
occur  from  this  malady.  This  fact  is  enough  to  show  you  how  far  it  is 
from  being  a  serious  disease.  At  the  same  time,  however,  while  I  announce, 
and  while  no  one  will  deny,  its  benignity,  I  admit  that  it  may  sometimes 
bring  death  in  its  train.  We  can  understand  that  death  may  result  from 
the  propagation  of  inflammation  from  the  throat  to  the  upper  part  of  the 
larynx:  that  inflammation  reaching  the  neighborhood  of  the  aryteno-epi- 
glottideau  ligaments  may  lead  to  cedematous  infiltration  of  these  membra- 
nous folds  ;  and  that  patients,  under  such  circumstances,  may  be  carried  oil' 
in  paroxysms  of  suffocation. 

In  how  many  days  does  the  malady  run  its  course?  This  important 
question  was  partly  answered  thirty  years  ago  by  my  honorable  col  league. 
Dr.  Louis.*  Of  twenty-three  patients  attacked  with  inflammatory  sore 
throat,  who  were  placed  under  observation,  thirteen  were,  and  ten  were 
not,  bled.  '  The  average  duration  of  the  disease  was  nine  days  in  those  who 
were  bled  ;   it  was  ten  days  and  a  quarter  in  those  whit  were  not  bled.      An 

energetic  treatment,  therefore,  which  appeared  to  shorten  the  duration  of 

the  malady  only  by  some   hours,  cannot  be  said    to  have  had  more  than  an 

unimportant  influence.  It  must  be  stated,  however,  that  in  some  cases,  In- 
flammatory sore  throat  runs  its  course  in  a  period  much  shorter  than  the 
average  periods  named  by  Louis;  for  the  abscess  sometimes  opens  on  the 
fourth  or  fifth  day.  Very  frequently,  also,  it  happens,  that  when  an  amount 
of  relief  is  experienced  which   Iead8  to  the  belief  that  the  cure  is  imminent. 


*  Louis:   Rechorches  eur  lee  Eft*ets  de  la  Saigneedans  quelques  Maladies  Enflam- 
matoiree,  A:'1.     Paris,  L886. 


INFLAMMATORY     SORE    THROAT.  333 

the  opposite  side  becomes  inflamed,  and  ;i  period  longer  than  in  the  first  in- 
stance elapses  before  the  pus  rinds  its  exit. 

Acquaintance  with  these  tacts  is  indispensable,  for  they  are  directly  appli- 
cable in  practice.     If  we  ignore  the  natural  progress  of  diseases,  we  are 

tempted  to  interfere,  and  to  interfere  vigorously,  in  such  a  malady  as  that 
now  under  consideration,  which  sets  in  with  a  demonstration  of  such  appar- 
ently formidable  symptoms.  In  paint  of  fact,  inflammatory  sore  throat  is 
accompanied  by  symptoms  which  regarded  only  in  their  external  aspect 
look  far  more  serious  than  those  of  diphtheritic  sore  throat.  The  latter 
makes  its  appearance  insidiously;  the  disease  silently  makes  rapid  progress; 
and  death  is  often  imminent,  when  the  symptoms  are  only  beginning  to 
alarm  the  family  of  the  patient.  The  former,  on  the  other  hand,  sets  in 
with  more  disturbance.  From  its  very  beginning  severe  symptoms  manifest 
themselves,  but  though  they  may  all  at  once  assume  a  very  alarming  aspect, 
they  never  become  desperate.  Membranous  sore  throats  of  the  most  terri- 
ble description — those  which  kill  by  general  toxaemia,  without  the  pellicular 
inflammation  having  extended  to  the  larynx — such  malignant  sore  throats, 
gentlemen,  in  general  cause  little  suffering  to  those  whom  they  carry  off: 
they  are  much  less  painful  than  inflammatory  sore  throats,  which,  though 
presenting  the  most  alarming  appearances,  are  in  reality  devoid  of  danger. 
They,  however,  though  not  dangerous,  cause  intolerable  pain,  which  is  in- 
creased by  the  movements  involved  in  deglutition,  and  is  constantly  being 
excited  by  the  desire  to  swallow  the  saliva  secreted  in  great  abundance,  or 
by  the  tickling  sensation  produced  at  the  base  of  the  tongue  by  the  uvula 
enlarged  in  consequence  of  oedematous  infiltration.  The  pain  extends  to 
the  ear,  from  the  inflammation  being  propagated  along  the  Eustachian 
tube :  it  likewise  extends  to  the  jaw-bones  and  lateral  parts  of  the  neck. 
The  unhappy  patient  swallows  with  the  greatest  difficulty,  is  unable  to  turn 
his  head,  and  frequently  can  neither  open  his  mouth  nor  move  his  tongue. 
There  is  a  change  in  the  tone  of  his  voice,  and  sometimes  he  cannot  speak: 
the  respiration  is  embarrassed  :  and  suffocation  seems  to  be  impending.  In 
addition  to  these  symptoms,  which  produce  a  very  anxious  condition  in  the 
patient,  there  is  feverish  excitement:  the  skin  is  hot,  the  pulse  is  full  and 
frequent,  the  face  is  red  and  congested.    In  some  cases,  delirium  supervenes. 

A  physician,  w7ho,  believing  that  he  had  to  do  with  a  severe  and  serious 
disease,  should  deem  it  necessary  to  adopt  more  or  less  energetic  treatment, 
would  be  confirmed  in  his  erroneous  belief:  for' he  could  not  fail  to  give  to 
his  treatment  the  honor  of  a  speedy  cure.  Let  him  not  be  in  such  haste  to 
congratulate  himself  on  his  success,  for  very  often,  in  place  of  having  done 
good,  his  treatment  has  been  mischievous. 

The  fact  is,  that  spontaneous  recovery  takes  place  within  nine  or  ten,  and 
sometimes  within  four  or  five  days.  As  soon  as  the  symptoms  of  the  sore 
throat  have  disappeared,  there  is  an  immediate  return  to  health,  and  all 
that  is  requisite,  is  to  take  precautionary  measures,  with  a  view  to  prevent  a 
relapse.  But  if  the  patient  has  been  bled  at  the  arm,  or  leeched,  particu- 
larly if  he  be  a  child  or  a  delicate  person,  some  time  must  elapse  before  he 
recovers  from  the  exhaustion  caused  by  the  loss  of  blood.  This  consecutive 
anaemia  will  be  worse  than  the  affection  which  has  been  so  uselessly  com- 
bated :  it  w7ill  induce  debility,  loss  of  appetite,  impaired  digestion,  palpita- 
tion of  the  heart,  and  other  nervous  disorders.  These  symptoms  will  continue 
for  a  month  or  more. 

I  know,  gentlemen,  how  difficult  it  sometimes  is  to  remain  passive  when 
patients  are  waiting  to  receive  relief  at  your  hands ;  and  this  difficulty  is 
all  the  greater  in  consequence  of  inflammatory  sore  throat,  one  of  the  most 
painful  of  diseases,  throwing  those  who  are  suffering  from  it  into  a  state  of 


334:  INFLAMMATORY    SORE    THROAT. 

great  anxiety  and  impatience.  Nevertheless,  practitioners  who  have  before 
passed  through  similar  trials  resign  themselves  to  do  nothing,  knowing  the 
course  which  the  malady  will  take.  A  friend  of  mine,  one  of  the  most 
honorable  physicians  of  Paris,  has  often  suffered  from  quinsies  in  the 
course  of  his  life.  After  having  treated  them  on  all  possible  plans,  he  has 
for  a  long  time  been  in  the  habit  of  doing  nothing.  Upon  one  occasion, 
when  we  were  talking  about  quinsy,  he  said  to  me  :  "  I  am  now  very 
clever  in  the  treatment  of  this  affection  :  I  give  my  patients  barley-water 
when  they  are  able  to  drink,  and  I  prescribe  foot-baths  :  to  these  measures 
I  restrict  my  treatment.  I  do  better  still  in  my  own  case — if  better  be 
possible — I  confine  myself  to  my  bedroom  and  my  bed,  and  wait  patiently ; 
my  sore  throats  get  well  quite  as  quickly  as  they  used  to  do."  One  of  my 
hospital  colleagues,  who  also,  for  the  last  ten  '  or  twelve  years,  has  been 
subject  to  attacks  of  inflammatory  sore  throat,  has  adopted  the  plan  of 
doing  no  more  than  the  physician  whose  personal  experience  I  have  just 
quoted. 

The  expectant  is  consequently  the  best  treatment  which  we  can  adopt 
in  quinsy :  but  I  admit  that  it  is  the  most  difficult  plan  to  follow  out  in 
practice,  particularly  when  the  practitioner  is  beginning  his  career,  and 
has  not  yet  gained  that  confidence  which  he  will  afterwards  acquire.  To 
satisfy  the  justifiable  impatience  of  your  clients,  prescribe  for  them  reme- 
dies which  are  not  very  active.  If  you  cannot  in  reality  cure,  you  will  at 
least  be  able  to  afford  illusion  to  the  sufferers,  and  will  avoid  disparaging 
yourself  by  an  avowal  of  therapeutic  impotence.  Order  acidulated  sooth- 
ing gargles,  and  emollient  fumigations,  though  all  the  while  you  know  per- 
fectly well  that  they  will  contribute  nothing  to  the  cure  of  a  malady  which 
will  cease  spontaneously  at  its  own  appointed  time. 

I  have  already  said  that  when  inflammatory  sore  throat  has  once  declared 
itself,  it  never  goes  back  :  you  will,  however,  hear  some  men  gravely  main- 
tain that  they  have  cut  it  short  during  the  first  three  days.  According  to 
them,  this  happy  result  is  sometimes  brought  about  by  the  use  of  leeches, 
emetics,  insufflations  of  alum,  gargles  of  chlorate  of  potash,  borax,  and 
cauterization  with  the  nitrate  of  silver.  Let  me  endeavor  to  explain  these 
facts. 

In  the  first  place,  gentlemen,  where  is  the  physician  of  skill  sufficient 
to  decide  whether  a  sore  throat  which  has  just  made  its  appearance  is  cer- 
tain to  be  a  quinsy?  For  my  own  part,  I  completely  renounce  all  claim 
to  ability  to  give  a  positive  opinion  under  such  circumstances,  and  I  doubt 
whether  others  are  more  competent. 

Besides  inflammation  of  the  pharynx,  there  is  another  kind  of  painful 
sore  throat, — the  rheumatic  *<>rc  throat. 

A  person  subject  to  rheumatic  pains,  catches  cold.  Some  hours  after- 
wards, he  feels  acute  pain  in  the  throat,  pain  of  such  a  character  as  i"  pic- 
vent  him  from  swallowing  a  drop  of  water  or  even  the  saliva — the  degluti- 
tion of  very  small  quantities  of  fluid  occasioning  much  more  suffering  than 
the  passage  of  the  alimentary  bolus.  This  is  explained  by  the  feci  that  to 
propel  very  small  quantities  of  fluid  towards  the  oesophagus,  the  contrac- 
tions of  the  pharynx  must  ho  more  energetic  than  when  it  has  to  grasp  a 
bulky  body.  Upon  examining  the  affected  parts,  we  see  that  the  interior 
of  the  pharynx,  and  the  veil  of  the  palate  are  more  or  less  red  :  the  inflamed 
uvula  is  oedematous  and  elongated.  All  the  phenomena  of  inflammation 
disappear  with  great  rapidity,  they,  like  other  affections  of  a  rheumatic 
character,  being  in  their  nature  of  short  duration.  In  fact,  on  the  next 
or  the  next  following  day  after  the  beginning  of  such  a  sore  throat,  the 

pain  will  have   disappeared    as    if  by  enchantment,  ami    at  the    same    tiim 


DIPHTHERIA.  335 

another  pain  will  have  taken  possession  of  the  neck,  producing  wry-neck  : 
then,  in  twenty-four  hours,  it  will  he  the  shoulder  which  will  be  the  scat 
of  pain.  Next  day,  the  patient  will  complain  of  lumbago.  As  for  the 
sore  throat,  its  duration  will  have  been  about  from  thirty  to  forty-eight 
hours.  If  your  diagnosis  at  the  commencement  of  the  attack  was  incipient 
inflammatory  sore  throat,  and  you  have  in  haste  used  the  therapeutic  meas- 
ures at  your  command,  you  will  have  led  yourself  to  believe  that  you  have 
cut  short  au  inflammatory  sore  throat.  The  physicians  to  whom  I  have 
just  been  alluding,  as  having  boasted  of  causing  the  abortion  of  attacks  of 
inflammatory  sore  throat,  were  misled  by  having  had  to  do  with  these 
rheumatic  sore  throats.  Patients  who  have  several  times  had  this  kind  of 
sore  throat  will  be  quite  as  able  to  distinguish  it  from  inflammatory  sore 
throat,  as  a  gouty  subject  is  to  discriminate  between  the  pain  of  gout  and 
the  pain  of  accidental  arthritis  :  but  the  physician  is,  I  repeat,  unable  at 
the  beginning  of  an  attack  to  decide  whether  a  sore  throat  is  rheumatic  or 
inflammatory. 

There  is  another  form  of  inflammatory  sore  throat,  about  which  I  see 
very  little  in  classical  works  ;  and  of  which  I  have  shown  you  some  exam- 
ples in  the  wards.  In  persons  subject  to  persistent  chronic  inflammation 
of  the  tonsils,  it  often  happens  that  the  secretions  from  the  interlobular 
clefts  become  altered  in  character  and  thickened,  so  as  to  form  small,  fetid, 
and  irregularly  shaped  cheesy  masses.  These  masses  act  as  if  they  were 
foreign  bodies,  causing  active  inflammation  and  very  acute  pain  :  they  fre- 
quently give  rise  to  the  issue  from  the  tonsils  of  the  little  pointed  concre- 
tions which  you  remember  to  have  seen.  The  exit  of  these  bodies  is  pre- 
ceded by  acute  suffering  and  superficial  ulceration ;  unless  the  physician, 
by  using  energetic  pressure,  squeeze  out  the  small  mass,  so  as  at  once  to 
terminate  a  sore  throat  which  is  exceedingly  painful,  but  far  from  being 
serious.  Excision  of  the  tonsils  ought  certainly  to  be  recommended  to 
persons  very  subject  to  this  form  of  sore  throat. 


LECTURE  XX. 

DIPHTHERIA,  OR  MAL  EGYPTIAQUE. 

Gentlemen  :  For  several  years  past,  reports  sent  to  the  Academy  of 
Medicine,  and  communications  to  the  scientific  journals,  have  been  calling 
attention  to  deadly  epidemics  of  diphtheria  in  different  parts  of  France, 
epidemics  which  have  not  spared  the  departments  of  the  south,  the  centre, 
the  north,  west,  or  east.  Similar  epidemics  have  also  been  prevalent  in 
foreign  countries — in  England  (where  for  sixty  years  diphtheria  had  almost 
been  unknown),  in  America,  Germany,  and  Spain.  This  terrible  scourge, 
diphtheria,  has  consequently  of  late  more  than  ever  awakened  the  attention 
of  the  public  and  of  the  medical  profession.  In  fine,  the  numerous  cases 
which  have  recently  occurred  in  our  clinical  wards  put  me  in  a  position  to 
lay  before  you  my  views  oti  this  important  subject  ;  and  it  is  my  duty  to 
do  so.  I  intend,  therefore,  in  consecutive  lectures,  to  speak  of  this  disease, 
which  is  one  of  the  severest  scourges  of  humanity.  I  do  not  propose  to 
treat  the  subject  in  an  exhaustive  manner  :  I  only  mean  to  discuss  the 
most  practical  points,  and  to  take  my  illustrations  from   cases  which  we 


336  DIPHTHERIA. 

have  seen  together.  Do  not  suppose,  however,  gentlemen,  that  I  am  going 
to  give  you  complete  narratives,  nor  even  abstracts  of  the  numerous  cases 
of  diphtheria  which  have  been  reported  under  your  observation  :  while  I 
shall  make  profitable  application  of  them  as  we  proceed  with  the  subject, 
while  I  shall  likewise  support  my  propositions  by  references  to  my  private 
practice,  to  the  experience  of  my  colleagues,  and  to  that  of  different  authors 
who  have  written  on  the  disease,  I  shall  avoid  giving  long  histories,  and 
quote  no  more  details  of  cases  than  are  necessary  to  enable  you  to  under- 
stand my  argument.  I  shall  also  insist,  gentlemen,  upon  the  necessity  of 
adopting  a  mode  of  treatment,  of  which  the  utility  even  is  at  present  dis- 
puted :  I  shall  oppose  this  deplorable  tendency  to  stray  from  that  right 
path  which  has  hitherto  been  followed  by  the  best  observers. 

Diphtheria  is  pre-eminently  a  specific  disease.  It  is  contagious.  Its 
manifestations  appear  on  the  mucous  membranes  and  skin ;  on  both,  it 
presents  similar  characters.  I  say  that  it  declares  itself  on  the  mucous 
membranes  and  skin,  because  diphtheria  really  has  that  character  in  com- 
mon with  specific  and  contagious  diseases,  such  as  the  eruptive  fevers  and 
syphilis ;  but  with  this  difference,  however,  that  it  does  not  attack  the  ex- 
ternal integument,  except  when  denuded  of  epidermis.  Diphtheria  shows 
a  marked  preference  for  the  pharynx,  for  the  air-passages  and  particularly 
the  larynx,  constituting  the  affections  commonly  known  as  membranous 
sore  throat  [angine  couenneuse],  or  malignant  sore  throat  [angine  maligne], 
formerly  designated  gangrenous  sore  throat  [mal  de  gorge  gangreneux]  :  aud 
suffocative  sore  throat  [angine  suffocante],  now  more  particularly  called 
croup  [croup],  in  which  the  larynx  is  the  chief  seat  of  the  disease.  Diph- 
theria, also,  often  invades  the  mucous  membrane  of  the  nose,  mouth,  vagina, 
prepuce,  and  glans  penis.  Of  all  its  forms,  pharyngeal,  laryngeal,  buccal, 
nasal,  vaginal,  anal,  or  cutaneous,  the  pharyngeal  is  by  far  the  most  com- 
mon. In  some  epidemics,  it  almost  exclusively  assumes  the  pharyngeal 
form,  carrying  off  its  victims  by  croup,  the  disease  extending  to  the  larynx 
and  trachea.  This  is  a  form  of  diphtheria  very  different  from  that  which 
kills  by  a  sort  of  general  poisoning,  like  septic  and  pestilential  diseases. 
The  attention  of  observers  has  always  been  more  particularly  directed  to 
the  pharyngeal  form,  because  it  is  the  most  common :  it  is  the  form  de- 
scribed by  writers  of  bygone  centuries — it  is  the  typical  form  of  Breton- 
neau's  treatise  on  diphtheria,* — and  it  is  with  the  consideration  of  this 
form  that  we  shall  commence  the  study  on  which  we  are  now  going  to  enter. 


Diphtheritic  Sore  Throat  and  Croup.  [Pharyngeal  and  Laryn- 
geal Diphtheria.] 

Occurs  in  all  Climates  and  all  Season*. —  Chiefly  attack*  Children. —  Manner 
in  which  it  is  Propagated. —  Glandular  Swellings. —  The  Color  of  the 
False  Membranes:  their  Smell  simulating  that  of  Gangrene.— lis  propa- 
gdUonto  the  Larynx. —  Croup. —  Tntermittence  of  Symptom*. —  Generally 

proves  Fatal  irhen  it*  Progress  is  not  Stopped. 

A  boy  four  years  of  age,  when  in  perfect  health,  was  Beized  with  Bore 
throat,  which  al  firsl  was  of  so  slighl  a  character  as  nol  to  alarm  his  family. 
After  one  or  two  days,  it  was  observed  that  tne  boy  was  losing  his  color, 


*  Brktonnkm  :  EtechercheB  but  ['Inflammation  Speciale  du  Tiesu  Muqueux  el 
on  particulier  sur  hi  Diphth6rite.     Paris.  L826. 


DIPHTHERITIC    SORE    THROAT    AND    CROUP.  337 

that  he  was  duller  than  usual,  and  indifferent  to  his  ordinary  games.  He 
had  some  cough,  but  no  fever,  and  although  he  ate  with  diminished  appetite, 
lie  kept  up  all  day.  It  was  by  the  merest  chance  thai  the  nature  of  his 
malady  was  discovered.  The  family  physician  having  been  called  in  to  an- 
other child,  who  was  suffering  from  epileptic  vertigo,  was  accidentally  con- 
sulted. He  was  struck  with  the  pale  skin  ;  and  he  observed  slight  swelling 
in  the  submaxillary  region  :  forthwith  perceiving  swollen  glands,  he  ex- 
amined the  throat,  and  found  that  the  pharynx  and  tonsils  were  bright  red, 
that  the  tonsils  were  enlarged,  and  that  on  the  right  one,  there  was  a  gray- 
ish, rather  thick  false  membrane.  He  came  to  the  conclusion,  that  the 
case  was  one  of  diphtheritic  sore  throat;  and  at  once  vigorously  cauterized 
the  affected  parts  with  solid  nitrate  of  silver,  and  detached  the  false  mem- 
brane by  means  of  the  caustic.  During  the  same  evening,  and  on  the  morn- 
ing and  evening  of  the  following  day,  the  cauterization  was  repeated.  In 
the  intervals  between  the  applications  of  the  nitrate  of  silver,  insufflations 
with  powdered  alum  were  employed.  In  accordance  with  the  express 
orders  of  the  physician,  the  little  patient  got  nutritious  diet,  and  a  tonic 
mixture  the  chief  ingredient  of  which  was  wine  of  cinchona.  The  malady 
was  stopped  from  going  further :  the  general  paleness,  however,  continued 
for  some  time  longer,  and  ere  long  paralysis  of  the  veil  of  the  palate  su- 
pervened. The  child  was  sent  to  the  country,  whence  he  returned  in  six 
weeks,  in  perfect  health. 

The  case  I  have  now  described  is  one  of  pharyngeal  diphtheritic  sore 
throat — ordinary  pharyngeal  diphtheria.  The  insidious  onset  of  the 
disease,  the  mildness  of  the  general  symptoms,  the  absence  of  fever  at  the 
time  when  the  physician  discovered  the  symptoms,  the  low  spirits  of  the 
child,  the  paleness  of  the  skin,  the  swelling  of  the  submaxillary  glands, 
and  the  presence  on  the  right  tonsil  of  the  characteristic  pseudo-membran- 
ous exudation  superabundantly  justified  the  prompt  diagnosis.  The  pa- 
ralysis of  the  veil  of  the  palate  which  supervened  some  days  later,  still 
further  confirmed  it ;  and  I  have  no  doubt  that  the  energetic  treatment 
•  which  was  employed  from  the  very  first,  cut  short  the  disease,  which  might 
under  other  circumstances  have  gradually  extended,  got  possession  of  the 
larynx,  and  produced  croup. 

This  pharyngeal  diphtheritic  sore  throat  is  met  with  in  all  seasons  and 
in  all  climates.  Not  without  a  certain  degree  of  surprise,  I  have  some- 
where read  that  this  disease  is  chiefly  observed  in  northern  countries  and  in 
cold  moist  climates,  while  it  is  almost  unknown  in  the  south  of  France  and 
in  Italy.  The  person  who  put  forth  this  singular  opinion*  must  have  had 
a  very  imperfect  acquaintance  with  the  history  of  medicine,  not  to  know 
that  the  disease  was  described  by  Aretreus  ;  that  it  is  just  membranous  sore 
throat;  that  it  was  endemic  in  Egypt  and  Syria,  having  from  that  circum- 
stance received  its  names  of  Egyptian  and  Syrian  nicer,  names  which,  as  is 
stated  by  Bretonneau,  were  given  to  it  in  the  epoch  of  Homer  rather  than  , 
of  Hippocrates.  He  must,  I  would  farther  remark,  have  been  imperfectly 
acquainted  with  the  history  of  medicine,  not  to  have  known  that  Carnevale, 
Nola,  and  Sgambati  have  left  us  accounts  of  epidemics  of  morbus  strangu- 
latorius  which  prevailed  in  Italy  at  the  beginning  of  the  seventeenth  cen- 
tury, when  similar  epidemics  were  observed  in  Spain  by  Villareal,  Fontecha, 
Nunez,  Herrea,  De  Heredia,  Mercatus,  and  Tamajo.     At  the  present  day, 

*  An  exactly  opposite  statement  was  made  by  "Wedel,  an  author  of  the  last  cen- 
tury, who  stated  that  diphtheritic  sore  throat,  which  he  called  angina  infantilis  con- 
tagiosa, was  more  frequent  in  Italy  than  in  the  north  of  Europe:  "  in  Italia  frequentior 
quam  apud  Boreales  Europazas.'"     [De  morb.  infant.,  cap.  xx,  p.  77.] 

vol.  I.— 22 


338  DIPHTHERIA. 

throughout  all  France,  as  I  have  said,  we  still  meet  with  similar  desolating 
epidemics  of  this  kind  of  sore  throat. 

Diphtheria  spares  no  particular  age  :  it  chiefly,  however,  attacks  young 
subjects,  and  generally  those  who  are  between  three  and  six  years  old. 

It  begins  with  a  more  or  less  decided  redness  of  the  pharynx,  with  swell- 
ing generally  of  one,  but  sometimes  of  both  tousils.  Soou  afterwards,  there 
is  seen  on  the  affected  part  a  sharply  defined  whitish  patch,  at  first  formed 
by  a  layer  of  what  looks  like  coagulated  mucus ;  it  is  semi-transparent, 
grows  concrete  and  thick,  and  very  soon  assumes  a  membranous  consistence. 
This  exudation,  immediately  after  its  formation,  is  easily  detached,  as  it 
only  adheres  to  the  surface  on  which  it  rests  by  very  slender  filaments  ex- 
tending into  the  muciparous  follicles. 

The  mucous  membrane  under  the  patch  is  perfectly  healthy,  even  close 
to  where  the  epithelium  is  destroyed  :  if  it  sometimes  has  an  appearance  of 
being  hollowed  out,  this  arises  from  its  being  swollen  around  the  exudation, 
so  as  to  form  a  sort  of  cushion  with  a  hole  in  the  middle.  The  occurrence 
of  ulceration  is  exceptional.  Generally,  I  repeat,  the  mucous  membrane  is 
healthy,  or  it  presents  no  other  change  than  an  increased  vascularity.  On 
cautiously  detaching  the  false  membrane,  there  is  not  the  slightest  oozing 
of  blood:  it  can,  moreover,  be  often  shown,  with  the  aid  of  the  microscope, 
that,  on  its  surface  which  adhered  to  the  mucous  membrane,  the  epithelium 
remains  with  its  vibratory  cilia  intact. 

Some  hours  later,  the  pseudo-membrane,  more  prominent,  convex  towards 
its  centre,  and  thin  at  its  edges,  has  increased  in  size,  and  covers  more  of 
the  tonsil:  it  has  now  assumed  a  yellowish-white  color,  and  is  becoming 
more  and  more  adherent  to  the  parts  first  affected.  The  color  may  vary 
from  yellowish-white  to  deep  yellow,  or  even  to  gray  or  black.  Generally, 
when  the  veil  of  the  palate  begins  to  be  inflamed,  the  uvula  becomes  swollen  : 
after  some  hours  or  a  day,  the  side  of  the  uvula  next  the  tonsil  which  is 
covered  with  false  membrane,  becomes  covered  with  a  similarly  colored 
exudation.  Often,  within  twenty-four  or  thirty-six  hours,  the  entire  uvula  is 
enveloped  like  a  gloved  finger.  At  the  same  time,  upon  the  other  tonsil,  a 
similar  patch  has  appeared,  and  will  soon  cover  it.  The  back  part  of  the 
pharynx,  thus  commencing  to  be  as  it  were  carpeted  on  both  sides,  by  and 
by  exhibits  long,  narrow,  longitudinal  strise  of  a  deep  red  color,  amid  which 
forms  a  little  band  of  concrete  matter;  and  then  patches  of  false  membrane 
appear,  which  finally  unite  with  one  another.  From  this  time,  if  the  child 
be  docile,  submitting  easily  to  the  examination  required,  and  allowing  the 
tongue  to  be  quite  depressed,  a  view  is  obtained  of  the  uvula,  both  pillars 
of  the  veil  of  the  palate,  both  tonsils,  and  the  back  of  the  pharynx  com- 
pletely covered  with  the  coating  which  I  have  described.  When  an  attempl 
is  made  to  detach  these  false  membranes  with  forceps,  they  can  be  torn  off 
in  strips:  in  this  way  I  have  removed  from  the  uvula  a  pseudo-membranous 
w  envelope  shaped  like  a  thimble. 

( renerally,  from  the  very  beginning  of  the  attack,  the  lymphatic  glands 
at  the  angle  of  the  jaw,  those,  therefore,  which  correspond  with  the  first 
affected  tonsil,  arc;  turgid.  This,  gentlemen,  is  an  almosl  invariable  phe- 
nomenon, or  at  least,  it  is  not  wanting  once  in  ten  times.  Its  importance, 
therefore,  is  great,  and  all  the  greater,  that  in  common  membranous  sore 
throat,  a  malady  generally  mild,  but  liable  to  he  mistaken  for  that  DOW 
under  consideration,  this  glandular  engorgement  is  entirely  absent,  or,  if  it 

exist  at  all,  is  present  in  a  much  less  degree  than  in  pharyngeal  diphtheria. 

At  the  invasion  of  the  disease  the  fever  is  pretty  high,  hut  after  the 

second   day  it    begins  to  subside,  and    by  the  third  or  fourth  day  has  quite 

disappeared;  the  patient  then  only  experiences  in  a  slight  degree  feelings 


DIPHTHERITIC    SORE    THROAT    AND    CROUP.  339 

of  general  discomfort,  as  indicated  by  prostration,  low  spirits,  and  a  certain 
amount  of  weakness.  Sometimes,  the  only  thing  of  which  he  complains  is 
a  difficulty,  often  very  slight,  in  swallowing;  so  that,  in  general,  at  the 
beginning  of  the  attack,  there  is  nothing  to  occasion  much  alarm. 

When  left  to  itself,  the  affection  generally  remains  from  three  to  six  days 
confined  to  the  pharynx.  The  older  the  subject,  the  longer  is  the  disease 
in  becoming  developed  by  progressively  invading  the  parts  accessible  to 
sight.  False  membranes  form  more  rapidly  in  children  than  in  adults, 
from  the  greater  plasticity  of  the  blood  in  the  former.  In  children  be- 
tween three  and  six  years  of  age,  both  tonsils  and  the  posterior  part  of  the 
pharynx  may  be  coated  with  diphtheritic  exudation  in  about  thirty-six  or 
forty-eight  hours,  whereas  in  adults,  and  still  more  in  old  people,  from  five 
to  eight  days  may  elapse  before  all  the  parts  are  invaded. 

In  patients  who  allow  a  thorough  examination  of  the  pharynx  to  be 
made,  the  false  membranes  can  from  day  to  day  be  seen  to  grow  thicker  by 
the  addition  of  the  new  layers  which  form  below  those  first  formed :  these 
different  deposits  assume  a  stratified  arrangement.  The  pseudo-membran- 
ous layers  which  are  most  superficial  become  soft,  and  are  easily  torn. 
The  membranous  patches,  altered  in  color  by  the  alimentary  substances, 
drinks,  and  medicines  taken  by  the  patient,  by  matters  vomited,  or  by 
blood  from  the  pharynx  and  posterior  nares,  become  grayish  or  blackish, 
so  as  to  resemble  a  gangrenous  slough.  Under  these  circumstances,  the 
false  membranes  are  the  more  liable  to  be  mistaken  for  gangrenous  sloughs, 
that  they  become  putrid,  and  exhale  a  disgustingly  fetid  odor.  This, 
gentlemen,  as  you. will  recollect,  is  what  took  place  in  a  girl  twelve  years 
of  age,  who  was  lately  under  our  observation  in  St.  Bernard's  Ward.  Her 
breath  had  an  intolerably  gangrenous  smell,  and  when  with  the  assistance 
of  a  dossil  of  lint,  I  removed  the  detritus  covering  the  tonsils  and  veil  of 
the  palate,  I  found  that  it  consisted  of  a  grayish  matter  which  exactly 
simulated  gangrenous  detritus ;  but  so  far  from  being  gangrenous  detritus, 
when  the  mucous  membrane  of  the  affected  parts  were  wiped,  that  is  to  say, 
the  mucous  surface  which  had  been  covered  with  this  detritus,  it  appeared 
red,  hardly  excoriated,  and  certainly  presenting  no  trace  whatever  of  gan- 
grene. 

The  resemblance  to  gangrene  which  invests  the  diphtheritic  product  is  a 
point  of  sufficient  importance  in  relation  to  the  question  before  us  to  justify 
me  in  pausing  for  a  few  minutes  to  consider  it.  It  explains  to  us  why  diph- 
theritic was  for  so  long  confounded  with  gangrenous  sore  throat,  and  wThy 
it  got  the  names  of  "angine"  and  "  mal  de  gorge  gangreneux,"  still  applied 
to  it  by  many  physicians. 

In  studying  diphtheritic  sore  throat  in  the  child,  and  comparing  it  with 
the  disease  as  seen  in  the  adult,  it  is  found  that  in  the  former  it  has  very 
seldom,  and  in  the  latter  very  commonly,  a  gangrenous  aspect.  Are  we  to 
conclude  from  this  fact  that  gangrene  really  exists  in  the  diphtheria  of 
adults?  No:  its  existence  is  only  apparent ;  true  gangrene,  except  in  ex- 
tremely rare  cases,  is  not  met  with  in  the  diphtheria  of  adults  more  than  in 
the  diphtheria  of  children :  in  my  whole  medical  career,  I  have  only  met 
with  three  such  cases.  I  readily  grant,  however,  that  such  statements  do 
not  easily  obtain  credence.  Even  now,  although  I  have  ascertained  that 
gangrene  is  an  exceedingly  rare  occurrence  in  diphtheria,  although  I  know 
perfectly  well  that  at  the  termination  of  the  case,  whether  the  Issue  be  re- 
covery or  death,  I  shall  be  able  to  demonstrate,  either  on  the  living  subject 
or  on  the  dead  body,  as  the  case  may  be,  that  the  mucous  membrane  is 
devoid  of  even  the  slightest  trace  of  sphacelus ;  although  I  know  that  I 
shall  find  only  in  some  cases  a  few  small  excoriations,  I  am  still,  at  the  first 


340  DIPHTHERIA. 

glance,  unable  to  shut  out  completely  the  idea  of  gangrene.  In  the  young 
girl,  our  patient  in  St.  Bernard's  Ward,  I  was  perfectly  certain  that  this 
gangrene  did  not  exist,  and  you,  too,  held  with  confidence  the  same  opinion  ; 
nevertheless,  struck  with  the  horrible  fetor  of  the  breath,  and  seeing  the 
grayish  flesh-like  pulp  which  covered  both  tonsils,  we  could  not  prevent 
ourselves  from  thinking  of  mortification  of  the  mucous  membrane,  sphacelus 
of  the  subjacent  cellular  tissue,  and  a  still  deeper  destruction  of  parts. 
Thus,  gentlemen,  you  can  understand  how  diphtheritic  has  been  confounded 
with  gangrenous  sore  throat:  thus,  also,  you  can  understand  how  some 
physicians  still  confound  the  two  diseases,  and  why,  in  the  accounts  of 
epidemics  of  croup,  there  is  such  frequent  mention  of  gangrenous  sore  throat, 
when  in  reality  the  affection  is  pellicular  or  pseudo-membranous. 

Let  me  add  a  few  words  on  the  manner  in  which  the  membranous  exu- 
dations are  circumscribed  in  the  situations  in  which  they  are  formed. 
Sometimes,  they  are  surrounded  by  a  bright  red  border :  at  other  times, 
they  seem  not  to  be  encircled,  and  thus,  as  I  told  you,  at  the  commence- 
ment of  the  lecture,  the  pseudo-membranous  deposit  becoming  thinner  at 
the  edges,  shows  itself  on  the  neighboring  parts.  In  the  latter  case,  we 
have  more  cause  to  dread  the  disease  spreading  than  in  the  former. 

It  is  true  that  pharyngeal  diphtheria  if  left  to  itself  may  remain  confined 
to  the  pharynx,  and  Bretonneau  himself  has  cited  examples  of  this,  which 
indeed  is  not  uncommon  in  some  epidemics  ;  but  generally,  it  extends, 
when  preventive  measures  are  not  employed.  In  some  cases,  it  reaches  the 
oesophagus,  and  even  proceeds  to  the  cardiac  orifice  of  the  stomach.  The 
illustrious  physician  of  Tours  has  recorded  two  examples  of  this,  and  simi- 
lar cases  have  also  been  mentioned  by  Borsieri :  almost  invariably,  how- 
ever, it  invades  the  larynx  and  trachea,  constituting  what  is  called  croup. 
Such  is  the  usual  course,  and  most  common  termination  of  diphtheria.  In 
point  of  fact,  we  see  many  more  of  those  who  are  attacked  by  this  disease 
die  from  croup  than  from  malignant  sore  throat,  of  which  I  shall  afterwards 
have  to  speak,  which  proves  fatal  after  the  manner  of  septic  diseases. 

The  propagation  of  the  diphtheritic  affection  to  the  larynx  was  Ion-:  ago 
fully  recognized.  Aretseus  has  described  it  in  his  chapter  "DeTonsil- 
larum  Ulceribus,"  where  you  will  find  the  earliest  notice  of  membranous 
sore  throat:  he  speaks  of  it  under  the  designation  of  ulcera  pesbift  ra,  arid 
refers  to  the  names  "Egyptian"  and  "Syrian  Ulcer,"  by  which  it  was  then 
designated.  Read  in  the  annals  of  medicine  the  histories  of  epidemics 
which  are  therein  recorded,  and  you  will  see  that  not  only  was  the  exten- 
sion of  the  disease  to  the  larynx  perfectly  well  known,  but  was  a  subject 
which  specially  engaged  the  attention  of  physicians.  By  whatever  name 
the  laryngotracheal  affection  is  called,  it  is  almost  universally  recognized 
as  the  cause  of  death.  It  is  then,  I  repeat,  by  croup  that  the  victims  of 
laryngeal  diphtheria  are  killed.  I  am  not  at  present  speaking  only  of 
sporadic,  but  also  of  epidemic  diphtheria. 

Such  are  the  symptoms  of  the  affection  which,  iu  the  seventeenth  ecu 
tury,  was  called  (/>irri>ii//i>  by  the  Spaniards,  and  male  in  ccmna  by  the 
Italians.  The  name  given  to  it  by  (he  Spanish  and  Italian  physician.-  was 
morbus  8trangulatorius :  the  Americans  called  ii  suffocative  sore  throat  al  the 
close  of  last  century,  and  it  is  at  present  known  to  us  by  the  Scottish  name, 
croup. 

You  bave  had,  gentlemen,  only  too  many  opportunities  of  seeing  the 
laryngeal  symptoms  in  patients  broughl  into  the  hospital  at  different  stages 
of  the  disease.  You  had  once  an  opportunity  of  observing  their  commence- 
ment. 

The  subject  of  the   case  to  which  I  refer  was  8  hoy  of  eighteen   month.-. 


DIPHTHERITIC    SORE    THROAT    AND    CROUP.  341 

He  came  into  the  Hotel-Dieu  along  with  his  mother.  Both  were  affected 
with  very  confluent  sudoral  eruptions,  but  were  not  otherwise  out  of  health. 
Six  days,  however,  after  their  arrival  in  our  wards  (where  there  was  a 
child  With  croup  and  a  woman  with  pseudo-membranous  sore  throat),  the 
mother  complained  of  sore  throat.  On  examination,  wre  found  the  right 
tonsil  and  the  uvula  coated  with  false  membrane,  and  the  cervical  glands 
enlarged.  I  immediately  cauterized  the  affected  parts  with  hydrochloric 
acid :  next  day,  the  membranous  deposit  had  almost  disappeared,  but  in 
twenty-four  hours  it  was  reproduced  in  greater  abundance,  and  in  a  thicker 
layer  than  at  first,  upon  the  uvula  as  well  as  upon  both  tonsils.  The  cau- 
terization was  repeated,  and  it  was  practiced  again  on  the  following  day, 
although  an  appreciable  amelioration  was  noted,  and  which  did  not  turn 
out  deceptive.     This  patient  recovered. 

Her  child,  however,  was  attacked  three  days  after  her  own  seizure.  In 
the  child  we  observed  a  thick,  whitish  concretion  upon  the  right  commis- 
sure of  the  lips,  which  was  slightly  excoriated.  I  cauterized  the  part :  and, 
taking  into  account  the  age  of  the  subject,  I  told  you  that  danger  was  im- 
pending. 

On  the  second  day,  the  diphtheria  had  taken  possession  of  both  commis- 
sures :  but  the  tonsils  as  well  as  pillars  and  veil  of  the  palate  presented 
nothing  abnormal,  not  even  redness.  On  the  following  day,  there  was  a 
diminution  in  the  thickness  of  the  false  membranes  on  the  lips;  but  it 
appeared  to  me  that  the  child's  voice  was  becoming  hoarse.  When  my 
chef  cle  clinique,  Dr.  Moynier,  made  his  evening  visit,  he  observed  hoarse- 
ness and  a  cough  which  had  a  hissing  character  :  the  voice  was  muffled. 
The  patient  had  had  fits  of  suffocation  during  the  clay.  The  disease  had 
in  no  degree  extended  to  the  tonsils  or  palate.  An  emetic  was  prescribed. 
When  I  saw  the  patient  fourteen  or  fifteen  hours  later,  I  learned  that  the 
suffocative  attacks  had  become  so  violent  and  so  frequent  that  tracheotomy 
had  been  deemed  necessary.  The  operation  was  performed  by  the  interne 
on  duty.  At  the  moment  of  opening  the  trachea,  a  false  membrane  was 
expelled.  I  found  the  child  free  from  fever,  and  the  neck  much  swollen  : 
it  died  during  the  day.  On  the  morning  of  the  day  on  which  it  died,  I 
detected  the  presence  of  pneumonia  of  the  right  lung,  characterized  by  a 
blowing  sound,  dulness  on  percussion,  and  oppressed  breathing. 

At  the  autopsy,  we  did  not  find  any  deposit  on  the  tonsils  or  veil  of  the 
palate,  but  the  larynx  and  trachea  were  invaded  by  false  membrane,  which 
extended  even  to  the  most  distant  bronchial  ramifications.  The  character- 
istic lesions  of  pneumonia  were  found  throughout  the  whole  of  the  lower 
lobe  of  the  right  lung,  as  well  as  disseminated  in  several  parts  of  both 
lungs. 

The  presence  of  croup  is  first  announced  by  a  small  dry  cough,  which 
comes  in  quickly  succeeding  fits  of  short  duration.  The  voice,  up  to  this 
time  unaffected,  now  becomes  a  little  changed,  and,  like  the  cough,  has  a 
special  character,  with  which  it  is  important  to  be  acquainted  :  it  does  not 
admit  of  description,  but  can  never  be  forgotten  once  it  has  been  observed. 

The  cough  is  not  sonorous  and  loud,  but  on  the  contrary  is  hoarse,  muf- 
fled, and  has  a  sound  which  may  be  compared  to  the  distant  barking  of  a 
puppy.  The  term  croupy  [croupale]  conveys  a  false  impression,  and  is  much 
more  applicable  to  the  cough  of  laryngismus  stridulus  or  false  croup.  The 
cough  is  at  first  very  frequent,  but  it  generally  loses  that  characteristic  as 
the  disease  advances. 

After  a  short  time,  the  breathing  is  affected.  The  difficulty  of  breathing 
occurs  at  an  earlier  pei-iod  in  childreu  than  in  adults.  It  usually  begins 
during  the  night;  and  there  is  produced  at  the  same  time  a  laryngotracheal 


342  DIPHTHERIA. 

whistling  sound  at  each  inspiration,  which  is  also,  but  less  audibly,  heard 
during  expiration.  This  whistling  sound  is  best  marked  after  each  fit  of 
coughing:  it  is  caused  by  an  inspiration,  short,  dry,  and  metallic-sounding, 
which  can  be  quite  well  heard  at  some  distance.  On  auscultating  the 
trachea  and  posterior  part  of  the  chest,  this  sound  strikes  so  strongly  on  the 
ear  as  to  mask  the  murmur  of  the  vesicular  expansion.  The  causation  of 
this  laryngotracheal  whistling  is  explained  by  the  mechanism  of  the  vocal 
apparatus.  The  sound  is  louder  during  inspiration,  because  the  lips  of  the 
glottis  have  then  a  tendency  to  approach  each  other,  thus  increasing  the 
difficulty  of  the  entrance  of  the  air,  whilst,  on  the  contrary,  during  expira- 
tion, the  lips  tend  to  separate.  Generally,  the  pain  felt  in  the  larynx  is 
not  severe,  but  it  is  excited  by  the  fits  of  coughing:  it  is  not  confined  to  the 
larynx,  but  extends  to  the  trachea  and  anterior  part  of  the  sternum. 

The  disease  goes  on  increasing  in  severity,  the  false  membranes  extend- 
ing and  thickening:  the  cough,  however,  goes  on  diminishing  in  frequency, 
the  fits  occurring  only  at  intervals  of  a  quarter  of  an  hour,  half  an  hour, 
or  even  longer:  it  also  loses  some  or  all  of  its  hoarseness.  The  voice  itself, 
which  had  a  hoarse  and  somewhat  metallic  sound,  in  its  turn  fails,  and  the 
patient  often  becomes  voiceless.  Aretseus  said  :  vox  nihil  significat.  The 
symptoms  which  generally  accompany  difficulty  of  breathing  in  pseudo- 
membranous laryngitis  are  evidence  of  the  presence  of  diphtheritic  deposit 
on  the  lips  of  the  glottis.  You  can  see  at  once  why  this  should  be  so.  You 
are  aware  that  a  little  mucus  adherent  to  the  vocal  cords  is  sufficient  to 
change  the  tone  of  the  voice,  to  make  it  hoarse,  and  sometimes  even  to 
occasion  aphonia.  It  is  not  surprising,  then,  that  the  formation  of  false 
membrane  on  the  lips  of  the  glottis  should  be  a  still  more  decided  cause  of 
loss  of  voice.  What  occurs  is  exactly  what  takes  place  when  you  place  a 
piece  of  wet  parchment  between  the  reeds  of  a  clarinet  or  bassoon :  the  cor- 
rectness of  this  comparison  is  enhanced  by  the  great  similarity  which  false 
membrane  bears  to  parchment  swollen  from  being  wet.  The  reeded  instru- 
ment constituted  by  the  larynx  is  in  this  way  made  unfit  to  perform  its 
part :  the  voice  and  the  cough  become  more  and  more  changed  as  the  de- 
posit increases  on  the  vocal  cords,  and  at  last  they  both  cease.  This  is  a 
physical  phenomenon  which  is  perfectly  explained  by  the  arrangement  of 
the  parts  concerned.  On  some  rare  occasions  it  happens  that  the  hoarse 
cough  returns,  and  that  the  metallic  voice  is  again  heard  in  consequence  of 
violent  expiratory  efforts  having  occasioned  the  detachment  and  expectora- 
tion of  the  false  membrane;  or,  it  may  be  that  the  false  membrane  which 
coats  the  glottis  is  so  thin  as  not  to  prevent  the  air  from  vibrating  as  it 
traverses  the  larynx.  Speaking  generally,  it  may  be  said  that  the  cough, 
at  first  croupy,  becomes  less  and  less  sonorous. 

I  have  said  that  difficulty  of  respiration  supervenes  in  the  infant  after 
the  lapse  of  a  very  short  time,  and  that  it  likewise  occurs  in  the  adult,  hut 
not  at  so  early  a  stage;  this  symptom  rapidly  increases  in  severity.  There 
then  sometimes  occurs  a  phenomenon  to  which  I  must  call  your  attention, 
because;  it  may  mislead  you  as  to  the  nature  of  the  disease,  or  at  hast  in- 
duce you  to  put  faith  in  the  efficacy  of  the  treatment  which  you  have  em- 
ployed. Although  the  laryngeal  lesion  continues,  although  there  is  a  per- 
manent mechanical  obstacle  to  the  passage  of  air,  although  the  false  mem- 
brane  which   occasions   this   obstacle   remains  adherent  to   the   vocal  cords, 

tie-  difficulty  of  breathing  ia  intermittent.     A  child  or  an  adult  may  have 
during  the  day  several  his  of  dyspnoea,  proceeding  even   to  suffocation. 

During   the  intervals  helween    the  fits,  if  the  patient   is  not  agitated  by  the 
presence  of  the  physician  or  any  other  cause,  if  nothing   occurs  to  quicken 

respiration,  it  is  nearly  as  regular  as  in  a  person  in  health,  ami  no  laryngeal 


DIPHTHERITIC    SORE    THROAT    AND    CROUP.  343 

whistling  is  audible.  But  from  time  to  time,  at  first,  every  hour  or  every 
two  or  three  hours,  and  then  at  shorter  and  shortening  intervals,  a  suffoca- 
tive fit  comes  on  without  any  immediately  exciting  cause.  The  patient  sits 
up,  and  sometimes  gets  up  abruptly,  to  search,  out  of  bed,  for  that  air  in 
which  he  stands  in  need.  He  makes  immense  efforts  to  breathe,  throwing 
back  the  head,  opening  wide  the  mouth,  and  convulsively  contracting  all 
the  muscles  which  co-operate  in  respiration.  The  suffocative  fit,  which  lasts 
from  four  to  six  minutes,  is  succeeded  by  a  calm  which  lasts  for  a  certain 
time. 

These  facts,  pointed  out  by  Royer-Collard,*  and  Bretonneau,f  did  not 
escape  the  observation  of  our  predecessors.  I  cannot  resist  quoting  to  you 
the  words  of  Borsieri,  who  had  specially  devoted  to  this  subject  a  paragraph 
of  his  chapter  on  croup.  It  is  entitled  "  Fallax  morbi  mitigatio;"  and  is  to 
the  following  effect:  "  Animadvertendum  quoque  est  non  raro  et  subito 
pneter  rationem,  et  sine  ulla  materice  obstruentis  excretione  omnia  sic  in  melius 
verti,  ut  liberior,  imo  naturalis  omnino  respiratio  reddatur,  ut  infantes 
puerive  e  lecto  surgere  et  obambulare  possint:  paulo  post  vero  fallaci  hinc 
symptomatum  quieti  novum  repente  succedere  insultum,  ssepe  numero 
gravem." 

This  intermittence  in  the  suffocative  symptoms  has  been  justly  attributed 
to  a  spasmodic  stricture  of  the  glottis,  caused  by  the  inflammation  of  the 
mucous  membrane  of  the  air-passage,  or  by  the  presence  of  the  plastic 
lymph  poured  out  into  its  cavity :  it  may  also  depend  upon  a  combination 
of  both  these  causes.  This  is  the  opinion  of  Nieusseux,  of  Albers  of  Bre- 
men, of  Jurine,  and  of  the  members  of  the  Academy  commissioned  to  report 
on  the  papers  submitted  in  the  competitive  examination  of  1812.  Farther, 
the  commission,  adopting  the  views  of  Albers  of  Bremen,  said  that  the 
pseudo-membranous  deposit  sometimes  formed  a  purely  mechanical  obstacle 
to  the  entrance  of  air  into  the  bronchial  tubes ;  that  most  commonly  it  was 
spasm  alone  which,  by  nai-rowing  the  air-passage,  stopped  and  impeded 
respiration.  Bretonneau  disputes  the  accuracy  of  this  explanation :  accord- 
ing to  him,  the  mechanical  obstacle  occasioned  by  the  formation  of  false 
membrane  explains  everything.  "  As  to  the  intermissions,"  he  says,  "  they 
belong  to  a  numerous  class  of  pathological  phenomena.  Where  is  the  prac- 
titioner who  has  not  observed  them?  Is  not  the  pain  of  cancer,  stone,  and 
other  diseases  intermittent,  though  its  cause  is  permanent?"  Though  the 
element  spasm  does  not  in  my  opinion  hold  the  important  place  assigned  to 
it  by  some  in  croup,  it  yet,  I  think,  plays  a  very  important  part  in  this 
affection,  as  well  as  in  the  chronic  diseases  which  my  illustrious  master  uses 
as  illustrative  examples  in  his  sentences  just  quoted.  From  the  importance 
of  this  subject,  I  shall  afterwards  return  to  it:  and  I  shall  specially  have 
occasion  to  revert  to  it,  when  I  speak  of  symptomatic  affections  of  the  ner- 
vous system,  particularly  of  angina  pectoris  and  asthma. 

To  continue  the  description  :  The  suffocative  attacks  follow  one  another 
more  rapidly,  and  at  the  same  time  become  more  and  more  violent :  very 
soon  there  is  no  interval  at  all,  the  suffocative  struggle  being  continuous  up 
to  the  agony  of  death :  the  laryngeal  sound  also  becomes  permanent.  From 
time  to  time,  the  poor  children,  in  a  state  of  excitement  which  it  is  impossi- 
ble to  describe,  suddenly  sit  up,  seize  their  bed  curtains  and  tear  them  with 
convulsive  frenzy:  they  sometimes  strip  off  the  paper  from  the  wall  with 
their  nails  :  they  throw  themselves  on  the  necks  of  their  mothers  or  of  those 
about  them,  embracing  them  and  trying  to  clutch  whatever  they  can  as  a 

*  Boyer-Collard  :  Dictionnaire  des  Sciences  Medicales. 
j  Bretonneau  :  Traite  de  la  Diphtherite. 


34:4  DIPHTHERIA. 

something  to  hold  by.  At  other  times,  it  is  against  themselves  that  they 
direct  their  impotent  efforts,  grasping  violently  the  front  of  the  neck,  as  if 
to  tear  out  from  it  something  which  was  suffocating  them.  The  puffy,  pur- 
ple face,  and  the  haggard  sparkling  eyes  express  the  most  painful  anxiety 
and  the  most  profound  terror :  the  exhausted  infant  then  falls  into  a  sort  of 
stupor,  during  which  respiration  is  difficult  and  hissing.  The  face  and  lips 
are  pale,  and  the  eyes  sunken.  At  last,  after  a  supreme  effort  to  breathe, 
the  agonies  of  death  begin,  and  the  struggle  ends  without  there  having  been 
any  severe  suffocative  symptoms  such  as  might  have  been  looked  for  from 
the  previous  attacks. 

In  adults,  the  picture  is  still  more  frightful.  The  violence  of  the  suffo- 
cative attacks,  the  sort  of  frenzy  which  takes  possession  of  the  dying  sub- 
ject, vainly  struggling  to  get  rid  of  the  obstacle  to  respiration,  it  is  impos- 
sible to  depict.  At  last,  when  the  lips  have  become  livid  and  the  face 
turgid,  when  asphyxia  has  reached  its  last  stage,  the  adult,  like  the  child, 
falls  into  a  state  of  stupor,  and  dies  generally  in  a  state  of  prostration.  To  ' 
use  Borsieri's  words:  "Sic  irrequieti  assidue  jactantur,  donee  penitus  pros- 
trati  jaceant  et  strangulati  pereant."  I  say  generally,  because  in  some  ex- 
ceptional cases  the  patient  is  carried  off  by  a  fit  of  suffocation. 

As  I  have  already  remarked,  the  intermittence  of  the  suffocative  fits  is  a 
fact  very  important  to  be  acquainted  with,  inasmuch  as  ignorance  of  it 
might  lead  you  into  error.  Suppose,  for  example,  that  having  been  called 
in  to  a  case  of  croup,  you  resorted  to  some  particular  treatment,  that  you 
applied  leeches,  abstracted  blood  from  the  arm  or  foot,  gave  an  emetic,  or 
applied  a  blister  to  the  front  of  the  neck  or  to  the  chest ;  and  suppose  further, 
that  immediately  after  you  had  done  one  or  more  of  these  things,  there  oc- 
curred one  of  those  intervals  of  calm  of  which  I  have  spoken,  you  might 
ascribe  this  to  the  efficiency  of  your  treatment,  while,  nevertheless,  the  dis- 
ease had  only  followed  its  natural  course.  It  is  important,  therefore,  to  be 
aware  of  the  fact,  that,  independent  of  treatment,  the  suffocative  fits  are  in- 
termittent. Besides  intermittence  depending  upon  the  element  of  spasm 
entering  into  the  case,  there  is  also  intermittence  arising  from  expulsion  of 
the  false  membrane  which  causes  the  suffocative  attacks. 

It  happens  sometimes — once,  perhaps,  in  six  or  eight  times — that  in  a 
paroxysm  of  vomiting  or  cough,  the  larynx  is  all  at  once  cleaned,  the  child 
or  adult  discharging  strips  of  false  membrane  or  membranous  tubes,  which 
come  from  the  glottis  and  windpipe.  When  this  occurs,  there  is  all  at  once 
as  complete  quietude  as  if  tracheotomy  hud  been  performed.  The  patient 
falls  into  a  tranquil  sleep,  and  may  remain  quiet  for  six,  eight,  ten,  fifteen, 
or  twenty-four  hours.  The  relations  then  entertain  hopes  of  recovery,  in 
which  the  physician  even  is  tempted  to  participate.  He,  however,  cannot 
lose  sight  of  the  fact  that  diphtheria  is  a  disease,  which,  though  it  occasion- 
ally grants  a  respite,  docs  not  as  readily  bestow  a  pardon,  lie  cannoi  for- 
get that  when  a  false  membrane  is  detached  from  the  larynx  or  trachea, 
another  begins  to  form  in  its  place:  that  the  exudation,  passing  anew- 
through  its  Stages,  again  Covers  the  parts  with   a   layer  which    at    6rsl  thin, 

gradually  becomes  thick,  ami  so  at  hist  re-establishes  the  obstacle  which 
formerly  existed. 
Suffocative  attacks,  similar  to  those  which  formerly  occurred,  will   take 

place,  and  if,  as  before,  the  new  diphtheritic  deposit  should  be  expelled, 
there  will  ahvavs  lie  a  fear  of  its  again  forming.  I  have  seen  children  ex- 
pel three  or  four  successive  pseudo-membranOUS  formations,  and  sink  at 
[asl   from    the   disease.      However,  I    must    also  add,  that    I    have  seen    in   a 

few  rare  cases,  ultimate  recovery  after  the  spontaneous  expulsion  of  false 
jnembranes.     Bui  so  exceptional  and  rare  are  such  cases,  that  during  the 


DIPHTHERITIC    SORE    THROAT    AND    CROUP.  345 

whole  of  my  long  professional  career,  I  have  only  met  with  six,  though  the 
□umber  of  cases  of  croup,  both  in  adults  and  children,  which  I  have  seen, 
is  great. 

It  is  a  remarkable  fact,  that  although  the  expulsion  of  the  false  mem- 
branes undoubtedly  offers  favorable  chances  of  recovery  to  the  patient,  they 
are  less  favorable  when,  recovery  not  having  taken  place  spontaneously,  one 
is  forced  at  a  later  stage  to  resort  to  tracheotomy.  In  other  words,  the 
operation  will  be  less  likely  to  succeed  in  a  child  who  has  discharged  false 
membranes,  than  in  one  who  has  not :  you  will  at  once  perceive  the  reason 
of  this. 

The  presence  of  pseudo-membranous  products  in  the  larynx  and  trachea 
show,  that  the  diphtheritic  inflammation  has  reached  them.  After  tracheot- 
omy, the  extension  of  the  inflammation  seems  to  cease.  The  expulsion  of 
diphtheritic  products,  by  retarding  the  crisis  at  which  operative  interference 
becomes  imperative,  allows  the  inflammation  to  extend  in  such  a  way,  that 
in  a  child  who  has  got  rid  of  pseudo-membrauous  tubes,  whether  by  the 
efforts  of  coughing  or  vomiting,  and  who  has  in  consequence  experienced 
temporary  amendment  and  in  whom  the  necessity  for  operating  has  been 
thereby  postponed  for  forty-eight  hours,  you  run  the  risk  of  having  the 
bronchial  tubes  invaded  with  false  membranes,  even  to  their  remote  rami- 
fications ;  whereas,  in  another  who  has  had  at  the  beginning  tracheotomy 
performed,  followed  by  expulsion  of  false  membranes,  this  state  of  matters 
will  be  rarely  found. 

I  have  already  said  that  in  rare  cases — cases,  however,  which  are  not  so 
rare  as  is  commonly  believed — the  disease  in  place  of  pursuing  its  usual 
progress  from  the  pharynx  to  the  larynx  and  trachea,  follows  the  opposite 
course,  and  attacking  in  the  first  instance  the  trachea,  or  beginning  even  in 
the  bronchial  tubes,  ascends  to  the  larynx.  Finally,  diphtheria,  declaring 
itself  simultaneously  in  different  situations,  may  at  the  first  onset  of  the 
disease  exist  in  the  interior  of  the  larynx,  trachea,  and  bronchial  tubes, 
while  it  is  also  manifested  in  parts  accessible  to  sight. 

This  is  what  took  place  in  the  little  boy  of  St.  Bernard's  Ward,  of  whose 
case  I  have  just  been  speaking.  I  will  now  relate  another  similar  case 
which  occurred  in  the  Children's  Hospital,  and  was  reported  by  Dr.  Leon 
Blondeau  during  his  internat  there  under  Dr.  M.  P.  Guersant. 

A  little  boy  of  three  and  a  half  was  admitted  on  the  9th  of  November, 
1847,  to  the  Hospital  in  the  Rue  de  Sevres,  presenting  all  the  characteristic 
symptoms  of  croup.  On  Saturday,  30th  of  October,  he  had  been  seized 
with  fever  :  on  the  Tuesday  following,  the  eruption  of  measles  was  observed : 
it  was  of  moderate  intensity,  but  the  morbillous  catarrh  was  very  severe. 
On  the  Saturday,  and  still  more  on  the  Sunday,  attention  was  drawn  to  a 
decided  embarrassment  in  the  breathing,  and  a  hoarseness  in  the  voice,  both 
of  which  progressively  increased. 

When  the  child  was  brought  to  the  hospital,  the  following  symptoms  were 
observed.  The  face  was  pale,  and  of  a  livid  tint.  There  was  considerable 
dyspnoea.  The  nasal  fossa?  were  obstructed  by  a  thick  grayish  mucus;  but 
on  carefully  examining  the  throat,  no  appearance  of  false  membrane  could 
be  detected.  The  patient  was  made  to  vomit,  but  not  even  temporary 
amendment  resulted  from  this  proceeding.  The  excitement  and  oppression 
were  extreme.  The  pulse  was  120  in  the  minute.  On  auscultating  the 
chest,  sonorous  rhonchi  were  heard. 

The  presence  of  exudations,  evidently  diphtheritic,  in  the  nasal  fossae, 
having  led  to  the  idea  that  possibly  there  were  false  membranes  behind  the 
veil  of  the  palate,  an  attempt  was  made  to  introduce  into  that  situation  a 
hair  pencil  charged  with  a  strong  solution  of  nitrate  of  silver.     This  pro- 


346  DIPHTHERIA. 

ceeding  greatly  increased  the  excitement.  It  is  worthy  of  notice  that  in 
this  case,  there  was  never  any  enlargement  of  the  submaxillary  glands,  a 
fact  explained  by  the  absence  of  pharyngeal  lesion.  Another  emetic  was 
prescribed — five  centigrammes  (between  four  and  five-sevenths  of  a  grain) 
of  tartar  emetic. 

On  the  19th  of  November,  the  child  was  more  tranquil,  and  the  dyspnoea 
was  slight;  but  the  cough  was  hoarse,  the  voice  gone,  the  countenance  livid, 
and  the  deposit  in  the  nasal  fossae  persistent.  The  pulse  was  128,  small,  and 
thready.  By  the  evening,  there  had  been  no  vomiting ;  but  the  child  had 
had  ten  green  stools.  The  breathing  had  again  become  very  oppressed,  and 
the  respirations  were  46  in  the  minute.  The  child  was  in  a  state  of  orthop- 
noea.  The  voice  was  entirely  gone :  expiration  was  not,  but  inspiration 
was,  noisy,  and  sounded  as  if  something  were  impeding  it :  the  cough  was 
very  hoarse.  The  nose  and  ears  were  cold  :  the  livid  hue  of  the  counte- 
nance was  increasing,  and  the  eyes  (generally  closed)  had  a  very  languid 
expression.  The  poor  child  was  constantly  moving  its  head  from  side  to 
side,  as  if  in  search  of  a  position.  But  it  soon  fell  into  a  state  of  collapse 
arising  from  asphyxia,  and  increased  by  the  debility  occasioned  by  the 
numerous  alvine  evacuations  which  had  taken  place  during  the  day.  Con- 
sciousness was  unimpaired. 

During  the  night,  two  violent  suffocative  fits  occurred :  next  day,  the 
asphyxia  was  greater  than  it  had  been  in  the  evening.  The  face  wTas  pale 
and  puffy  :  the  lips  were  cold  and  colorless.  The  mind,  however,  seemed 
quite  clear,  the  child  expressing  by  signs  that  he  wished  to  drink.  He 
swallowed  easily.  Death  occurred  during  the  day,  without  any  attempt 
having  been  made  to  perform  tracheotomy,  which  from  the  course  taken  by 
the  disease  would  have  been  useless. 

At  the  autopsy,  the  respiratory  passages  of  both  lungs  were  found  lined 
with  false  membrane  from  the  larynx  to  the  first  ramifications  of  the  bron- 
chial tubes  ;  and  below  that,  the  tubes  were  filled  with  thick  mucus.  In  the 
nasal  fossa?,  were  found  the  exudative  products  which  had  been  seen  during 
life  :  but  neither  in  the  pharynx  nor  mouth  was  there  anything  which  could 
correctly  be  called  false  membrane. 

In  conclusion,  to  repeat  what  I  have  just  been  saying — and  the  point  is 
of  sufficient  importance  to  justify  my  recurring  to  it — although  the  expul- 
sion of  the  false  membranes  may  in  a  few  cases  lead  to  the  spontaneous  cure 
of  croup,  it  is  certain  that  when  the  disease  has  followed  its  usual  down- 
ward course,  the  chances  of  a  successful  result  from  tracheotomy  is  much 
less  when  membranous  tubes  have  been  expelled,  inasmuch  as  that  is  evi- 
dence of  the  disease  having  extended  to  the  ramifications  of  the  bronchial 
tubes.  This  extension  of  the  disease  sometimes  proceeds  very  far,  and  I 
have  seen  cases  in  which  children  have,  after  tracheotomy,  brought  up  false 
membrane  moulded  in  the  very  minute  bronchial  ramifications.  I  still  have 
in  my  museum  one  of  these  arborizations  of  false  membranes,  which  I  have 
shown  you,  and  which  was  obtained  under  your  own  observation  at  the 
autopsy  of  a  little  girl  who  died  in  our  St.  Bernard's  Ward.  This  diph- 
theritic arborization,  comprising  the  trachea  ami  the  large  tubes,  extended 
to  the  fourth  ramifications.  1  met  with  a  similar  ease,  in  a  child  of  five 
years  of  age,  who  was  cured  by  tracheotomy.  The  false  membrane  VM 
expelled  at  the  time  of  the  operation. 

ft  must  be  stated  that  generally,  in  two-thirds  of  the  cases  according  to 
the  statistics   collected    by    Uretoiiiiean,   as   well    as   according  to   those    of 

Dr.  Hussenot,*  the  false  membranes  do  not   extend  below  the  trachea. 


snr:  Th.'-.-i-  Inaugurate,  Boutenueen  1880. 


DIPHTHERITIC    SORE    THROAT    AND    CROUP.  347 

This  is  a  remarkable  fact,  and,  as  I  shall  afterwards  have  to  remind  you, 
has  a  bearing  favorable  to  resorting  to  tracheotomy  in  this  disease.  It 
appears,  however,  that  in  some  epidemics,  the  extension  of  the  membran- 
ous formations  to  the  bronchial  tubes  is  more  usual  and  more  rapid  than 
in  the  epidemics  which  have  come  under  my  observation. 

Dr.  Peter,  who  had  an  opportunity  of  studying  a  severe  epidemic  of 
diphtheria  at  the  Children's  Hospital,  in  discussing  my  opinions  on  this 
subject,  thus  expresses  himself: 

"  Dr.  Trousseau  describes  with  care  the  different  localizations  of  diph- 
theria :  nevertheless,  my  own  observations  justify  me  in  believing  that 
bronchial  diphtheria  is  more  frequent  than  the  clinical  professor  supposes, 
for  I  have  noted  it  as  occurring  in  nearly  half  the  cases — 54  times  in  121 
cases.  I  can  also  affirm  that  diphtheria  extends  with  incredible  rapidity 
to  the  bronchial  tubes,  a  fact,  till  now,  far  from  being  known.  In  four 
days,  a  considerable  surface  of  the  bronchial  mucous  membrane  may  be 
coated  with  false  membrane  ;  and  it  is  generally  between  the  second  and 
fourth  days  inclusive,  that  the  bronchial  tubes  are  invaded,  if  they  are  to 
be  invaded  at  all.  We  must  not,  however,  attach  undue  importance  to  the 
gravity  of  this  prognostic,  nor  regard  bronchitic  diphtheria  as  an  absolute 
contraindication  to  tracheotomy:  indeed,  on  the  one  hand,  it  is  impossible 
— from  the  frequency  and  rapid  development  of  bronchitic  diphtheria — to 
be  certain  that  an  asphyxiated  croup  patient  does  not  present  that  compli- 
cation ;  and  on  the  other  hand,  we  know  of  more  than  one  case  of  recovery 
in  which  false  membranes,  manifestly  moulded  in  the  bronchial  tubes,  were 
ejected  through  the  canula."* 

Let  me  now,  gentlemen,  say  a  word  on  the  general  symptoms  and  com- 
plications of  the  disease.  At  first,  as  I  have  already  said,  there  is  febrile 
excitement.  There  is  also  engorgement  of  the  glands,  more  considerable  than 
in  some  other  kinds  of  sore  throat,  but  less  than  in  the  sore  throat  of  scar- 
latina, or  in  malignant  diphtheritic  sore  throat.  The  fever  continues  for 
one  or  two  days,  and  then  ceases,  whilst  the  malady  progresses.  The  pain 
in  the  throat  is  so  insignificant  that  children  of  four  or  five  years  of  age  who 
are  able  to  express  what  they  feel,  make  no  complaint  of  it.  This  almost 
complete  absence  of  constitutional  symptoms  and  pain  in  the  throat  allows 
the  malady  so  insidiously  to  make  way,  that  the  physician  is  not  called  in 
till  it  has  reached  the  larynx,  that  is  to  say,  not  till  croup  has  declared 
itself.  By  this  time,  the  pseudo-membranous  formations  which  at  first 
occupied  the  pharynx  have  had  time  to  become  detached,  and  there  may 
then  be  hardly  any,  or  not  even  a  shred  of  them  remaining  on  the  tonsils, 
or  on  any  part  of  the  mucous  membrane  of  the  palate.  This  fact  is  im- 
portant :  it  quite  explains  the  cases  in  which  pseudo-membranous  laryn- 
gitis was  supposed  to  have  been  developed  all  at  once,  and  not  to  have  been 
propagated  downwards  from  the  pharynx. 

We  have  now,  gentlemen,  come  to  the  point  at  which  it  is  necessary  to 
speak  of  sudden  croup :  the  subject  is  one  which  has  a  good  claim  on  us  to 
stop  to  consider  it.  You  will  hear  it  said  by  men,  recognized  as  possessing 
experience,  that  they  have  often  seen  death  from  croup  in  children  in  whom 
the  pharynx  had  not  been  implicated.  Prior  to  Bretonneau  reading  his 
first  work  on  diphtheria  to  the  Academy  in  1818,  before  the  publication  of 
his  treatise  in  1826,  the  occurrence  of  sudden  croup  was  generally  believed  : 
the  belief  was  that  membranous  croup  begun  in  the  larynx.     Bretonneau, 

*  Peter  (Michel):  Des  Lesions  Bronehiques  et  Pulmonaires  ;  et  particuliere- 
ment  de  la  Bronchite  Pseudo-membraneuse  dans  le  Croup.  [Gazette  Hebdomadal  re, 
1863.] 


348  DIPHTHERIA. 

however,  maintained  and  demonstrated  that  almost  always — at  least  19  times 
in  20 — the  pharynx  is  the  starting-point  of  the  malady.  His  friend  Guer- 
sant,  for  many  years  physician  to  the  Children's  Hospital,  after  having 
maintained  the  first  opinion,  took  the  same  ^iew  of  the  matter  as  Breton- 
neau  as  soon  as  his  attention  was  awakened  to  the  question.  Since  that 
time,  every  one,  at  Paris  or  elsewhere,  who  has  taken  the  trouble  to  examine 
the  subject  has  come  to  the  same  conclusion.  I  have  seen  perhaps  more  of 
croup  than  the  busiest  physicians  of  the  capital,  from  the  circumstance  of 
my  having  been  for  eighteen  years  intrusted  with  the  department  for  sick 
children  in  the  hospitals,  also  because,  from  my  having  introduced  trache- 
otomy into  the  treatment  of  laryngeal  diphtheria,  I  have  frequently  had 
the  honor  of  being  consulted  as  to  the  advisability  of  that  operation ;  and  I 
declare  to  you  that  the  proposition  of  my  venerated  master  is  the  truth, 
that  in  most  cases  croup  begins  in  the  pharynx. 

But  I  do  not  deny  that  there  is  such  a  thing  as  a  sudden  attack  of  croup 
\le  croup  d'emblee].  Not  only  do  I  believe  that  the  pellicular  disease  may 
strike  its  first  blow  at  the  larynx,  but  I  even  admit  that  it  may  make  its 
first  attack  upon  the  bronchial  tubes.  Examples  of  this  have  been  men- 
tioned by  Guersant  and  many  others.  Dr.  Yvaren,  in  his  report  on  the 
epidemic  of  diphtheria  which  prevailed  at  Avignon  in  1858,  states  that  its 
special  character  was  the  sudden  manner  in  which  the  larynx  and  bronchial 
tubes  were  attacked.  I  have  already  mentioned  two  cases  to  you  in  which 
the  disease  appeared  simultaneously  in  the  bronchial  tubes  and  trachea,  as 
well  as  in  parts  accessible  to  sight.  Why  should  it  be  looked  on  as  sur- 
prising that  diphtheria  should  all  at  once  localize  itself  in  the  mucous  mem- 
brane of  the  laiynx,  in  the  same  way  that  it  localizes  itself  in  the  mucous 
membrane  of  the  nose,  mouth,  or  vagina?  I  do  not  deny,  then,  that  croup 
may  begin  in  the  larynx,  but  I  maintain  that  its  doing  so  is  a  rare  and 
exceptional  occurrence. 

The  former  belief  in  the  greater  prevalence  of  this  occurrence  arose  from 
the  insufficient  manner  in  which  patients  were  examined.  The  throat  was 
not  explored  with  necessary  care ;  and,  again,  as  the  medical  man  was 
called  in  late,  there  had  been  time  for  the  pharyngeal  false  membranes  to 
disappear:  the  late  arrival  of  the  physician  arising,  as  I  have  already  -aid. 
from  the  mildness  of  the  general  and  local  precursory  symptoms.  When 
you  are  sent  for  to  a  child  who  you  arc  told  has  been  ill  from  croup  for 
only  two  days,  get  the  relations  to  recall  the  preceding  circumstances,  and 
you  will  learn  that  the  child  had  been  suffering  for  a  longer  period  :  you 
will  learn  that  for  five  or  six  days  he  had  been  eating  less,  had  been  com- 
plaining of  a  little  difficulty  in  swallowing,  and  had  been  refusing  to  take 
any  kind  of  food  which  was  at  all  hard,  such  as  the  crust  of  bread,  and  you 
will  learn  also  that  there  had  been  observed  a  little  swelling  of  the  neck  : 
these  are  symptoms  of  sore  throat,  and  of  the  prior  existence  of  false  mem- 
branes which  you  have  come  too  late  to  see. 

To  return  to  the  general  symptoms:  In  practice,  when  you  have  to  do 
with  the  diseases  of  childhood,  let  me  counsel  you  to  he  on  your  guard  if 
there  are  symptoms  present  which,  though  Blight  in  appearance,  may  in 
reality  be  the  commencement  of  a  terrible  malady.  When  yon  see  a  child 
which  has  been  Buffering  tor  some  days  from  feelings  of  genera]  discomfort, 

and   an  insignificant  amount  of  lever,  but    is  unable  to  tell   you  whence   its 

sufferings  proceed,  at  once  examine  the  slate  of  the  throat,  depress  the 
tongue  iii  such  a  way  as  to  enable  you  to  see  to  the  bottom  of  the  pharynx, 
and  in  many  cases  you  will  find  that  the  discomfort  has  been  the  announce- 
ment of  diphtheria,  and    thai    there  is  a  deposit  of  false   membrane  on    the 

tonsils  and  veil  of  the  palate. 


DIPHTHERITIC    SORE    THROAT    AND    CROUP.  349 

Iti  tlir  adult  mutters  pursue  a  similar  course.  The  general  discomfort 
and  the  febrile  excitement  are  so  slight  as  to  he  hardly  recognizable,  and 
there  is  almost  an  absence  of  sore  throat:  you  will  sometimes  meet  with 
patients  having  the  pharynx  coated  with  false  membrane,  and  who  never- 
theless make  but  very  slight  complaint  of  difficulty  of  swallowing.  Here, 
however,  the  danger  is  greater  than  in  the  child.  As  the  adult  has  the 
laryngeal  orifice  proportionally  larger  than  the  child,  and  the  calibre  of 
the  trachea  also  proportionally  greater,  the  air  finds  sufficient  passage  even 
when  the.  walls  of  these  conduits  begin  to  be  covered  with  false  membrane  ; 
and  by  the  time  that  the  symptoms  of  croup  declare  themselves,  the  diph- 
theria has  had  time  seriously  to  compromise  the  ramifications  of  the  bron- 
chial tubes. 

It  is  long  since  these  phenomena  made  an  impression  on  my  mind,  for  I 
had  a  good  opportunity  of  examining  them  in  the  epidemic  of  Cologne, 
which,  in  1828,  I  was  sent  to  study  with  Dr.  Ramon.  Allow  me  to  bring 
under  your  notice  some  of  the  cases  which  then  came  under  my  personal 
observation. 

Upon  a  certain  day — a  day  too  memorable  for  me  ever  to  forget — I  was 
dining  with  M.  de  Bethune,  whose  castle  is  situated  a  short  distance  from 
Selles,  in  the  department  of  Cher,  when  a  peasant  came  for  me  in  urgent 
haste,  declaring  that  his  wife  was  in  a  state  of  suffocation.  I  immediately 
went  to  the  patient.  I  found  a  woman  of  28  years  of  age  dressed  in  holi- 
day attire  :  it  was  Whit-Sunday.  She  had  attended  mass  in  the  morning 
at  a  distance  of  a  quarter  of  a  league  from  her  home  where  she  then  was  : 
she  walked  home,  dined  as  usual,  and  was  preparing  to  go  to  vespers,  when 
she  was  suddenly  seized  with  a  fit  of  suffocation,  so  violent,  that  her  hus- 
band was  afraid  that  before  I  arrived  she  would  be  dead.  When  I  saw 
her,  the  unfortunate  woman  was  in  reality  dying.  Upon  at  once  examin- 
ing the  throat,  I  discovered  that  the  pharynx  was  covered  with  thick  false 
membrane.  The  nature  of  the  disease  was  thus  demonstrated  ;  and  as  the 
poor  woman  was  in  the  last  extremity,  nothing  but  tracheotomy  could  pre- 
vent immediate  death.  Without  any  delay,  I  proceeded  to  perform  the 
operation  :  1  was  alone,  with  the  patient's  husband  as  my  only  assistant ; 
and  a  convex-bladed  penknife,  which  I  fortunately  had  in  my  pocket,  was 
my  only  instrument :  having  no  tracheal  canula,  I  was  obliged  to  hammer 
a  rough  sort  of  one  out  of  a  ball  of  lead.  Unhappily  the  false  membrane 
had  penetrated  to  the  minute  bronchial  ramifications.  Next  day  the  pa- 
tient died. 

The  suddenness  of  the  disaster  Avhich  occurred  in  this  case  gives  you  an 
idea  of  the  slightness  of  the  constitutional  symptoms  by  which  it  had  been 
preceded.  The  case  corroborates  my  remark  to  the  effect,  that  in  pharyn- 
geal diphtheria — a  disease  which  when  it  remains  confined  to  the  pharynx 
is  a  not  very  serious  local  disease — there  is  generally  very  little  constitu- 
tional disturbance  during  the  first  days  of  the  malady. 

In  a  village  in  the  department  of  the  Indre,  where  the  disease  was  epi- 
demic, the  rural  watchman,  a  man  aged  71,  was  still  going  about  his  ordi- 
nary occupations  when  I  saw  him  under  an  attack  of  membranous  sore 
throat  which  carried  him  off  next  day  after  frightful  suffocative  fits. 

In  the  same  commune,  there  was  pointed  out  to  me  a  family,  several  of 
the  members  of  which  had  sunk  under  the  disease.  I  was  called  to  a  little 
girl  who  was  attacked  by  it.  When  I  arrived  at  her  residence  she  was 
absent,  and  had  to  be  sought  for  in  the  fields,  where  she  was  taking  charge 
of  the  turkeys.  I  waited  an  hour  for  her  :  when  she  came  in,  she  was  pant- 
ing and  could  hardly  breathe.  In  the  evening  she  died  of  croup.  Although 
this  poor  child  had  made  no  change  in  her  usual  mode  of  life,  she  had 


350  DIPHTHERIA. 

nevertheless  been  ill  for  eight  days,  though  certainly  without  any  marked 
general  symptoms  of  illness.  Like  the  woman  who  died  in  her  holiday 
attire,  and  the  rural  watchman  who  was  going  about  his  usual  occupa- 
tions till  the  day  before  his  death,  she  had  continued  to  eat,  drink,  and  go 
out  as  usual. 

Do  not  forget  these  cases,  gentlemen :  do  not  forget  that  diphtheria  very 
often  sets  in  mildly.  If  there  be  any  fever  during  the  first  twenty-four 
hours  or  first  two  days,  it  soon  ceases,  or  becomes  insignificant.  The  exist- 
ence of  the  malady  is  hardly  announced  by  a  slight  difficulty  in  swallow- 
ing. The  difficulty  of  breathing  comes  later  :  but  by  the  time  it  has  come, 
the  disease  has  reached  the  larynx,  and  will  ere  long,  a  little  sooner  or  a 
little  later,  suffocate  the  patient. 

In  so  terrible  a  disease,  the  prognosis  is  necessarily  unfavorable  in  the 
last  degree.  Left  to  itself,  it  is  almost  inevitably  fatal.  Here  are  two 
examples  of  recovery  ! 

During  the  same  Cologne  epidemic  of  which  I  have  been  speaking,  the 
prefect  of  the  department  of  Loir-et-Cher  informed  me  that  a  malignant 
sore  throat  was  desolating  the  neighboring  communes  of  Ferte-Beauharnais. 
I  proceeded  thither,  and  at  two  farms  in  the  commune  of  Tremblevif  (the 
farms  of  Roi  David  and  Grand-Pied-Blainj,  I  saw  a  spectacle  as  heart- 
rending as  it  is  possible  to  witness.  At  the  one  farm  I  only  found  remain- 
ing the  head  of  a  family  and  a  servant-girl  of  sixteen  years  of  age.  The 
man  was  sitting  in  the  chimney-corner,  and  did  not  rise  even  to  receive 
me.  His  age  was  27.  He  informed  me  that  he  and  the  maid-servant  were 
the  sole  survivors  of  eighteen  residents  in  his  house  and  on  his  farm.  The 
maid  also  had  been  ill  :  but  had  been  cured  by  the  priest  of  Tremblevif, 
who  had  eight  or  ten  times  touched  her  throat  with  the  spirit  of  salt  (hy- 
drochloric acid).  As  for  himself,  he  knew,  he  said,  the  fate  in  store  for 
him.  "  To-morrow,  or  next  day,"  said  he,  "  I  shall  die  as  my  children,  my 
wife,  my  father,  and  my  mother  have  died."  Firmly  convinced  that  such  was 
to  be  his  fate,  he  would  take  no  measures  to  avert  it.  I,  however,  examined 
his  throat :  the  tonsils  were  completely  covered  with  pseudo-membranous 
exudation  :  the  state  of  the  respiration  and  voice  showed  me  that  the 
larynx  was  not  yet  invaded.  I  endeavored  to  inspire  him  with  hope,  and 
appealing  to  the  recovery  of  his  servant,  I  said  that  all  was  not  lost,  and 
that  if  he  consented  to  be  treated  in  the  same  manner  that  she  had  been 
treated,  he  too  might  be  cured.  He  yielded  to  my  persuasion  :  and — God 
helping — my  treatment  had  the  hoped-for  result.     This  man  was  saved. 

Such,  gentlemen,  is  the  appalling  mortality  which  diphtheria  brings  in 
its  train.  Of  eighteen  individuals,  two  only  escaped  death,  and  these  two 
owed  their  preservation  to  energetic  treatment. 

Three  years  previously,  in  another  department,  epidemic  diphtheria  made 
such  ravages*  in  one. of  the  villages  in  the  environs  of  Chapelle-Veronge, 
near  Fert6-Gaucher,  that  of  sixty  children,  nearly  all  males,  Bixty  died  I 
This  fact  is  stated  by  Dr.  Ferrand.* 

When  1  arrived  in  Sologne,  1  found  the  medical  men  discouraged  to  such 
a  degree  thai  some  of  them  were  unwilling  to  visit  any  more  patients  Buffer- 
ing from  malignant  sore  throat  :  ami  the'  clergy  assured  me  that  all  who 
took  tie-  disease  inevitably  died  of  it.  At  Man-illy,  in  Villette,  of  650  in- 
habitants, 66  persons — more  than  a  tenth  of  the  entire  population — died  oj 
white  sore  throat,  as  the  parish  priest  had  designated  the  disease.  At  a  later 
period,  it  is  true,  some  recoveries  took  place,  alter  the  adoption  of  an  em- 
pirical treatment  recommended  by  a  woman  of  the  place,     li  consisted  in 

*  Ferrand:  Thfese  Inaugurate  eur  l'Angine  Blembraneuse.    r«rist  l- 


DIPHTHERITIC    SORE    THROAT    AND    CROUP.  351 

the  employment  of  a  mixture  of  vinegar  and  alum,  such  as  is  used  in  the 
country  in  the  treatment  of  the  chancrous  mouth  and  throat  of  sheep  and 
pigs. 

Pharyngeal  diphtheria,  then,  is  almost  always  mortal,  when  its  progress 
is  not  arrested  in  time  by  treatment.  There  are  forms  of  the  malady  which 
nearly  always  prove  fatal  whatever  treatment  is  adopted;  but  the  form  now 
under  consideration  is  for  the  most  part  curable,  when  recourse  is  had  to 
the  therapeutic  means  of  which  I  am  going  to  speak. 

Apart  from  paralytic  affections,  consecutive  complications  of  diphtheria, 
to  which  I  propose  specially  to  devote  a  lecture,  there  are  other  complica- 
tions which  increase  the  danger  of  the  case,  and  blast  the  hopes  of  the  phy- 
sician, at  the  very  moment  of  his  counting  on  a  cure  from  his  having 
succeeded  in  arresting  the  progress  of  the  disease  by  energetic  treatment. 
I  refer  to  enteritis  which  is  common  in  children  ;  to  pneumonia,  to  which 
Grhisi  has  called  attention  ;  and  to  interlobular  emphysema  of  the  lungs  pro- 
duced by  the  rupture  of  vesicles  in  coughing. 

The  child  to  whom  I  have  already  several  times  referred,  gave  us  an 
example  of  the  peripneumonic  complication,  which  we  have  often  met  with 
in  other  circumstances.  Latterly,  at  the  autopsy  of  another  child,  we  found 
pulmonary  emphysema. 

The  little  patient  was  admitted  to  the  hospital  when  in  the  last  stage  of 
croup.  He  seemed  dying  when  the  interne  on  duty  performed  tracheotomy. 
At  the  visit  next  morning,  fifteen  hours  after  the  operation,  the  child  had 
still  considerable  oppression.  We  hastened  to  clear  out  the  internal  canula 
which  had  become  stopped  up.  The  dyspnoea,  however,  still  continued  ; 
and  we  heard  during  expiration  a  peculiar  sound  caused  by  the  passage  of 
air  through  the  instrument,  a  sound  which  I  have  called  serratic — stridor 
serraticus — from  the  resemblance  it  bears  to  the  noise  caused  by  a  saw — 
serra — cutting  stone.  This  sound  is  a  very  valuable  sign  in  forming  a 
prognosis :  when  I  hear  it  in  children  in  whom  tracheotomy  has  been  per- 
formed, I  consider  death  as  inevitable.  And  so  it  was  in  the  case  of  our 
little  patient :  he  died  during  the  day. 

On  examining  the  body  after  death,  we  saw  the  larynx  and  trachea 
coated  with  false  membrane,  which  also  extended  into  the  bronchi  and 
their  very  remote  ramifications :  several  lobules  of  lung  were  separated  by 
large  bulla?  of  cellular  tissue  distended  with  air,  which  having  broken  up 
the  vesicles  had  thus  caused  interlobular  emphysema. 

Bretonneau  observed  this  lesion  in  two  cases  which  are  reported  in  his 
treatise  on  diphtheria  :  one  of  the  subjects  was  a  soldier  of  the  legion  of  La 
Vendee,  and  the  other  a  young  child.  The  case  of  the  latter  occurred 
during  an  epidemic  in  La  Ferriere :  the  emphysema  was  the  result  of  the 
violence  of  the  inspiratory  efforts,  just  as  in  hooping-cough,  it  is  the  result 
of  the  violence  and  frequency  of  the  paroxysms.  In  children  upon  whom 
the  operation  of  tracheotomy  has  been  performed,  you  will  sometimes  see 
this  emphysema  in  so  formidable  a  degree  as  to  have  reached  the  cellular 
tissue  of  the  neck,  shoulders,  and  chest :  but  it  is  not  the  consequence  of 
the  operation,  as  some  might  imagine,  for  it  existed  prior  to  the  operation. 

Dr.  Peter  has  always  met  with  pulmonary  emphysema  in  the  autopsies 
which  he  has  made  of  patients  who  have  died  of  croup.  In  the  majority  of 
his  cases,  the  emphysema  was  not  vesicular:  in  the  cases  in  which  the  suffo- 
cative attacks  had  been  very  violent,  interlobular  emphysema  was  found. 
Finally,  Drs.  Barthez  and  Rilliet,  and  also  Dr.  Henri  Roger,  have  described 
the  occurrence  of  general  emphysema  proceeding  from  the  successive  inva- 
sion of  the  mediastinal  and  subcutaneous  cellular  tissue.  In  a  large  majority 
of  cases,  the  emphysema  occupies  the  upper  third  and  edges  of  both  lungs ; 


352  MALIGNANT    DIPHTHERIA. 

and  Dr.  Peter  says  that  some  observers  have  failed  to  see  the  emphvsema, 
because  in  place  of  there  being  an  ansemic  and  pale  condition  of  the  tissue, 
as  is  usual  in  this  lesion,  there  is  sometimes  congestion  and  redness  of  the 
emphysematous  parenchyma.* 

Malignant  Diphtheria. 

A  much  more  Terrible  Form  of  the  Disease. — The  Local  Affection  is  as  Noth- 
ing compared  to  the  Constitutional  Symptoms. — It  Kilh,  not  like  Group 
by  Asphyxiating  the  Patients  by  Suffocative  Paroxysms,  but  it  Kills  by 
General  Poisoning  after  the  manner  of  Septic  Diseases. —  Glandular  En- 
go  rgement  considerable. — Erysipelatous  Redn ess. — Mem b ra n o w  Coryza 
and  Nasal  Diphtheria. — Diphtheritic  Ophthalmia. — Epistaxis. — Hemor- 
rhages of  every  kind. — Anaemia. 

Gentlemen  :  In  my  last  lecture  I  spoke  of  that  form  of  diphtheria  which 
may  be  called  norma],  of  that  form  of  disease  which,  beginning  in  the 
pharynx,  extends  to  the  larynx,  trachea,  and  bronchial  tubes,  so  constitut- 
ing croup,  which  proves  fatal  by  causing  asphyxia.  That  I  told  you  is  the 
most  common  form :  it  is  the  form  which  it  takes  when  sporadic,  and  also 
that  which  it  exclusively  assumes  in  some  epidemics:  it  is  even  the  most 
common  form  when  malignant  diphtheria,  of  which  I  am  now  going  to 
speak,  prevails.  For  instance,  in  a  family  in  which  four,  five,  or  six  indi- 
viduals arc  attacked,  croup  will  be  the  general  rule,  and  the  malignant 
form,  which  carries  off  persons  by  general  poisoning,  will  be  the  exception. 

Duriug  recent  years  we  have  had  several  cases  of  the  malignant  form, 
and  among  others  that  of  a  little  girl,  in  whom  you  have  had  an  opportu- 
nity of  following  the  progress  of  the  malady  step  by  step  to  its  fatal  issue. 

The  patient  was  a  girl,  aged  12,  who  had  on  the  evening  of  the  preceding 
day  been  admitted  into  the  Hotel-Dieu,  under  the  care  of  my  colleague  Dr. 
Jobert  (of  Lamballe),  who  sent  her  to  me.  Only  three  or  four  days  had 
elapsed  since  she  had  been  seized  with  sore  throat  of  so  slight  a  character, 
and  accompanied  by  so  little  fever,  that  neither  did  she  make  any  complaint 
on  the  subject,  nor  were  her  relations  in  any  anxiety  about  her  state.  The 
malady,  however,  having  increased  in  severity,  and  the  glands  of  the  neck 
having  become  obviously  swollen,  she  was  taken  to  the  hospital, and  placed, 
in  the  first  instance,  in  the  surgical  department;  but,  when  the  nature  of 
the  disease  was  perceived,  she  was  transferred  to  our  St.  Bernard's  Ward. 

\Vhen  examining  the  mouth,  at  my  first  visit,  I  was  struck  with  the  hor- 
ribly gangrenous  fetor  of  the  breath.  The  veil  of  the  palate  was  thrust 
very  niiH-h  forward  and  to  the  right,  exactly  as  in  inflammatory  sore  throat 
when  only  one  side  is  affected  ;  but  I  saw  on  the  veil  of  the  palate  a  whitish 
membranou>  exudation,  the  extent  of  which  was  sharply  defined,  and  which 
was  attached  at  its  upper  part  in  festoon  form,  near  the  palatine  arch.  This 
diphtheritic  membrane, which  reached  to  the  pillar  of  the  veil  of  the  palate. 
became  merged  in  a  sorl  of  grayish  putrilaginous  magma  occupying  the 
throat,  exuding  a  grayish  -anions  fluid  of  the  mosl  disgusting  odor.  I  pon 
the  uvula,  pushed  completely  to  the  left  by  swelling  of  the  affected  part-. 

I  saw  on  the  right  a  covering  of  whitish  deposit,  while  the  left  ride,  as  well 

as  the  corresponding  tonsil,  were  free  :  on  the  posterior  part  of  the  pharynx 
we  perceived  one  or  two  .-pot-  of  a  yellowish-white  color.     The  nostrils  were 

*  Pkikk  (Michel):  Dea  Le>i"M-  Bronchiques  el  Pulmonaires  dans  !<■  Group. 
Paris,  1868. 


MALIGNANT    DIPHTHERIA.  353 

in  a  perfectly  healthy  state.     The  swelling  of  the  lymphatic  glands  at  the 
angle  of  the  jaw,  and  of  the  submaxillary  glands,  was  considerable  on  the 

right  side,  and  there  was  a  ureal  deal  of  pain  in  the  swollen  parts:  on  the 
left  side  nothing  noteworthy  was  observed. 

I  at  once  came  to  the  conclusion  that  I  had  to  do  with  a  case  of  malig- 
nant pharyngeal  diphtheria,  one  of  the  most  terrible  of  diseases,  a  disease 
which  never  spares  when  the  physician  has  failed  to  employ  energetic  treat- 
ment, and  is  even  then  implacable  in  a  very  great  number  of  cases.  My 
prognosis,  therefore,  was  unfavorable.  Although  the  nose  was  not  yet  impli- 
cated— in  which  case  I  should  have  looked  on  a  fatal  issue  as  inevitable — the 
great  engorgement  of  the  cervical  and  submaxillary  glands  seemed  of  very 
evil  augury. 

I  immediately  instituted  the  only  treatment  which  could  afford  a  chance 
of  success.  I  vigorously  cauterized  the  affected  parts  with  a  solution  of 
nitrate  of  silver,  composed  of  one  part  of  the  nitrate  to  five  times  its  weight 
of  water,  and  then  insufflated  powdered  alum  by  means  of  a  tube.  That 
evening  and  next  morning  the  cauterizations  were  repeated,  a  saturated 
solution  of  sulphate  of  copper  being  used  in  place  of  the  nitrate  of  silver. 
Six  or  eight  times  during  the  day,  in  the  interval  between  the  cauterizations, 
powdered  alum  and  tannin  were  alternately  insufflated.  I  also  used  all 
possible  means  for  securing  the  regular  administration  of  nutriment  to  the 
child,  so  as  to  make  her  take,  wdllingly  or  by  force,  soup  and  chocolate,  as 
well  as  small  cups  of  coffee,  as  a  stimulant  and  tonic.  I  at  the  same  time 
prescribed  cinchona  in  different  forms.  AVhen  I  return  to  the  subject  of 
treatment  I  shall  tell  you  how  much  importance  I  attach  to  the  regular 
administration  of  nourishment,  and  why  I  do  so. 

When  the  patient  had  been  four  days  in  our  wards,  her  situation  was  far 
from  ameliorated.  The  glandular  engorgement  which  had  caused  me  from 
the  first  to  form  an  unfavorable  prognosis  had  increased,  and  involved  the 
cellular  tissue  of  the  cervical  and  submaxillary  regions.  Moreover,  a  symp- 
tom still  more  alarming  had  supervened — an  erysipelatous  redness  of  the 
skin,  as  if  there  was  a  deepseated  abscess.  This  erysipelatous  redness,  a 
phenomenon  to  which  Borsieri  called  attention,  is  met  with,  as  a  general 
rule,  only  in  the  very  worst  form  of  diphtheria.  I  shall  have  to  revert  to 
this  subject. 

From  the  third  day  we  observed  that  the  nostrils  were  involved.  We 
had  noticed,  on  the  evening  of  the  second  day,  that  their  lower  parts  were 
red  :  this  redness  increased,  and  next  morning  there  was  a  profuse  discharge 
from  the  surface  of  the  pituitary  membrane,  a  pseudo-membranous  secretion 
with  which  a  little  blood  wras  mingled.  The  malady  had  extended  to  the 
nasal  fossre.  This  is  a  most  unpropitious  occurrence,  as  I  shall  have  to  tell 
you  when  I  come  to  speak  of  the  course  and  prognosis  of  this  form  of 
diphtheria  ;  the  cases  in  which  it  happens  almost  invariably  prove  fatal,  if 
not  in  the  acute,  in  a  later  stage  of  the  disease. 

Nevertheless,  in  the  case  now  before  us,  the  cauterizations  were  performed 
night  and  morning  with  rigorous  exactitude :  also,  several  times  in  the 
twenty-four  hours,  the  insufflations  with  alum  and  tannin  were  repeated. 
The  child  was  fed  in  accordance  with  my  prescription. 

About  the  fourth  day,  that  is,  about  the  seventh  day  of  the  malady,  the 
appearance  of  the  throat  was  satisfactory.  The  mucous  membrane  had 
become  almost  quite  free  from  the  exudation  with  which  it  had  been  covered : 
the  uvula,  too,  wTas  quite  free  :  and  so  likewise,  very  nearly,  were  the  tonsils 
and  lower  part  of  the  pharynx.  But  during  the  daytime  of  the  third  day 
there  were  very  profuse  attacks  of  epistaxis,  which  increased  the  already 
formed  unfavorable  prognosis,  founded  on  the  glandular  engorgement  and 
vol.  i. — 23 


354  MALIGNANT    DIPHTHERIA. 

nasal  diphtheria.  The  child  was  very  pale,  and  in  an  exceedingly  prostrate 
state.  The  first  bleeding  at  the  nose  occurred  immediately  after  the  use  of 
an  injection  of  sulphate  of  copper,  but  the  injections  were  nevertheless  con- 
tinued. After  each  injection  there  was  a  considerable  mucous  discharge 
from  the  nostrils ;  and,  on  two  such  occasions,  unquestionable  pseudo-mem- 
branous deposit  was  thrown  off,  and  this  in  one  instance  retained  the  shape 
of  the  turbinated  bone  on  which  it  had  been  moulded. 

The  formidable  symptoms,  although  the  pharyngeal  affection  was  cured, 
and  although  I  had  no  reason  to  dread  an  extension  of  the  disease  to  the 
larynx  (respiration  being  quite  normal),  led  me  to  foresee  a  fatal  termina- 
tion:  I  stated  to  you  that  the  child  would  by  degrees  fall  into  a  state  of 
prostration  from  which  nothing  could  restore  her,  that  very  soon  we  should 
see  her  refuse  every  kind  of  food  and  drink,  and  that  at  last  she  would  fall 
into  a  condition  of  syncope  and  expire. 

The  event  only  too  completely  justified  my  prediction.  The  little  patient 
grew  cold,  like  a  cholera  patient :  she  had  a  tendency  to  lipothymia :  her 
pulse  was  exceedingly  weak  and  slow,  but  her  breathing  was  free :  we  tried 
in  vain  to  get  her  to  swallow  something,  and  to  overcome  her  utter  loathing 
of  food.  Although  there  was  perceptible  diminution  of  the  glandular  en- 
largement ;  although  the  state  of  the  nose  was  better,  inasmuch  as  there 
was  no  longer  any  secretion  of  the  fetid  ichorous  discharge ;  although  the 
erysipelatous  redness  had  disappeared  ;  although,  looking  only  to  the  local 
manifestations,  amendment  had  taken  place,  that  amendment  was  deceitful, 
and  the  child  died,  poisoned  by  the  diphtheritic  poison.  In  the  act  of  re- 
fusing to  drink,  and  in  turning  away  from  the  nursing  sister,  she  fainted, 
and  died  without  coming  out  of  the  faint.  This  manner  of  dying  is  frequent 
in  malignant  diphtheria. 

At  the  autopsy,  we  found  no  trace  of  pseudo-membranous  deposit  on  the 
mucous  membrane  of  the  pharynx.  Under  the  influence  of  the  topical 
treatment,  complete  detersion  had  taken  place,  the  pillars  of  the  veil  of  the 
palate,  which  had  been  covered  with  a  putrilaginous  detritus  resembling 
gangrene,  being  perfectly  free  from  morbid  matter:  the  tonsil  was  again 
occupying  its  usual  place,  and  presented  neither  gangrenous  nor  other 
lesion.  This  case  corroborates  a  statement  I  made  in  my  last  lecture,  to 
the  effect  that  diphtheria  frequently  simulates  gangrene. 

The  case  which  I  have  now  related  is  a  case  of  slow  malignant  diph- 
theria:  you  have  seen  the  swift  form  in  another  child,  which  died  about 
three  weeks  ago,  in  the  same  ward.  I  shall  lay  before  you  accounts  of 
other  similar  cases. 

One  of  my  much-lamented  hospital  colleagues,  whose  name  is  known  t«> 
all  of  you,  and  whose  works  many  of  you  possess,  Valleix,  was  in  attendance 
upon  a  little  girl  suffering  from  membranous  sore  throat.  She  recovered 
from  this  affection,  which  was  not  of  a  severe  character,  under  energetic 
treatment  adopted  by  my  unfortunate  colleague.  One  day,  when  examin- 
ing the  throat,  he  received  into  his  mouth  a  small  quantity  of  saliva  spurted 
out,  in  coughing,  by  the  patient:  he  got  the  disease.  Next  day,  on  one  of 
his  tonsils,  there  was  a  -mall  pellicular  deposit :  he  hail  slight  fever;  and 
some  hours  later,  both  tonsils  and  the  uvula  were  covered  with  false  mem- 
brane. Soon  afterwards,  there  was  a  profuse  discharge  of  serous  secretion 
from  the  nose:  the  cervical  glands  and  cellular  tissue  of  the  neck  and 
infraraaxillary  region  were  a  good  deal  swollen:  delirium  supervened, 
and  in  forty-eighl  hours  Valleix  died,  without  having  had  any  laryngeal 
symptoms. 

Very  recently,  one  of  my  provincial  colleagues  had  a  case  of  diphtheria 
and  croup,  in  which  he  was  obliged  to  resort  to  tracheotomy.     During  the 


MALIGNANT    DIPHTHERIA.  355 

operation,  a  fear  of  suffocation  arose  from  blood  getting  into  the  trachea, 
whereupon,  in  dismay,  my  imprudent  colleague  applied  his  mouth  to  the 
wound  in  the  neck,  to  suck  out  the  blood  from  the  air-passage:  he  inocu- 
lated himself  with  the  disease.  Like  Valleix,  he  died  in  forty-eight  hours 
of  malignant  sore  throat,  the  symptoms,  including  the  delirium,  having 
been  similar. 

To  these  lamentable  histories,  I  have  yet  to  add  others  equally  sad. 
Under  very  similar  circumstances,  my  friend  and  colleague,  Dr.  Blaehe, 
had  the  sorrow  to  lose  his  son,  one  of  the  most  distinguished  of  our  hospital 
internes,  a  youth  of  great  promise,  in  whom  the  charms  of  intellect  were 
united  with  the  most  solid  information.  Henri  Blaehe  was  put,  by  his 
uncle,  Dr.  Paul  Guersant,  in  charge  of  a  child  suffering  from  croup,  on 
whom  tracheotomy  had  been  performed.  He  passed  three  nights  with  the 
child.  At  the  end  of  the  third  night,  he  felt  slight  pain  in  the  neck,  and 
went  home  to  mention  it  to  his  father.  Dr.  Henri  Roger,  Dr.  Legroux, 
and  I  were  immediately  sent  for:  we  found  the  unfortunate  young  man  in 
a  very  feverish  state,  and  his  tonsils  covered  with  false  membrane.  Within 
a  few  hours,  the  swelling  in  the  neck  became  enormous,  an  incessant  dis- 
charge from  the  nose  was  established  :  delirium  set  in  at  the  end  of  the  first 
day  :  and  after  an  illness  of  seventy  hours,  our  patient  died  without  having 
had  the  slightest  affection  of  the  larynx. 

Thus,  gentlemen,  you  see  that  a  special  form  of  diphtheria  may  be  con- 
tracted by  contact  with  an  individual  suffering  from  the  ordinary  form  of 
diphtheria,  just  as  confluent  small-pox  may  be  taken  by  contact  with  one 
who  has  the  distinct  form  of  the  disease.  In  the  rapidly  fatal  malignant 
form,  there  seems  to  be  a  simultaneous  poisoning  of  the  whole  system  : 
when  the  characteristic  pellicle  begins  to  appear  on  the  tonsils  and  in  the 
nasal  fossse,  the  whole  economy  is  already  profoundly  altered.  Fortu- 
nately, the  rapidly  fatal  is  the  most  unusual  form  of  the  disease,  though  in 
some  epidemics  it  is  too  common.  From  1822  to  1844,  I  had  not  a  single 
case  of  it,  Avhereas,  wdthin  the  last  few  years,  I  have  met  with  more  than 
twenty  examples  in  Paris.  In  two  families,  to  which  I  was  called  to  cases 
of  ordinary  diphtheritic  sore  throat,  I  saw  several  patients  carried  off  by 
the  malignant,  implacable  form  of  the  malady. 

Four  years  ago,  in  one  of  the  most  illustrious  houses  of  France,  five  per- 
sons were  attacked  by  diphtheria :  two  of  the  five  had  the  disease  in  its 
ordinary  form,  while  the  other  three — a  mother  and  her  two  children — 
were  carried  off  by  the  malignant,  and  rapidly  fatal  form.  You  will  find 
histories  of  a  considerable  number  of  cases  of  this  description  in  the  reports 
of  the  epidemics  of  malignant  sore  throat  which  have  scourged  France  in 
recent  years  ;  and  particularly  in  Dr.  Perrochaud's  account  of  the  epidemic 
which  ravaged  Boulogne-sur-mer  from  January,  1855,  to  March,  1857.* 

Diphtheria,  like  other  epidemic  diseases,  has  at  one  period  a  particular 
prevailing  mood,  and  at  another  period  is  in  a  quite  different  humor:  also, 
after  having  ceased  to  exhibit  certain  characters,  it  again  assumes  them, 
and  thus  undergoes  diverse  transformations  and  reproductions  of  type. 

I  ought  to  remark,  gentlemen,  that  for  some  years  past,  we  have  been 
traversing  an  epidemic  period  in  which  malignant  diphtheria  has  been 
much  more  frequent  than  it  had  been  previously.  In  point  of  fact,  the  dis- 
ease which  we  have  to  deal  with  at  present  is  unquestionably  very  different 
from  that  of  which  Bretonneau  has  given  us  the  graphic  picture,  and  recalls 
to  our  minds  the  descriptions  of  the  malady  left  to  us  by  the  physicians  of 
the  seventeenth  century. 

*  Perrochaud  :  Mernoires  del'Aeademie  de  Medecine,  t.  xxii,  p.  91. 


356  MALIGNANT    DIPHTHERIA. 

Let  us  now  study  the  slow  form  of  malignant  diphtheria,  which  you  will 
have  to  treat  more  frequently  than  the  swiftly  fatal  form.  Tin. ugh  it  is 
frightfully  serious — more  serious  than  typhus,  cholera,  or  yellow  fever — you 
may  hope  to  save  some  patients  from  its  grasp ;  but  as  for  the  form  of  the 
disease  which  snatched  from  us  Valleix  and  Henri  Blache,  it  pitilessly  kills. 
An  example  of  the  slow  form  of  diphtheria  is  afforded  by  the  case  of  the 
young  girl  whose  history  I  have  recapitulated  to  you. 

Pellicular  deposits  appear  on  one  of  the  tonsils:  their  appearance  is  of'teu 
in  no  respect  different  from  that  presented  by  the  false  membrane  in  ordi- 
nary diphtheritic  pharyngeal  sore  throat,  but  they  sometimes  have  a  special 
aspect,  being  of  a  tawny  yellow  color,  resting  on  livid  tissues,  which  are 
frequently  cedematous.  The  patients  complain  of  pain  and  dryness  of  the 
throat,  and  difficulty  of  .-wallowing:  the  latter  symptom  is  sometimes  com- 
plained oflong  before  there  is  any  plastic  exudation,  redness,  or  other  visible 
change  in  any  part  of  the  pharynx. 

There  is  a  good  deal  of  fever:  though  there  is  not  always  more  fever  than 
in  the  simple  form  of  the  disease.  But  in  the  malignant  form,  there  is  one 
symptom  which  is  never  absent — a  symptom  redolent  of  malignity,  to  adopt 
the  expression  of  Mercatus — pestiferi  morbi  naturam  redolens: — that  symp- 
tom is  glandular  engorgement.  The  engorgement  is  considerable,  and  ex- 
tends to  the  cellular  tissue  surrounding  the  lymphatic  glands.  This  sign, 
from  the  first  of  frightfully  important  prognostic  value,  leads  one  to  fear  that 
the  case  is  of  the  malignant  form,  and  will  resist  all  treatment. 

The  skin  covering  the  swollen  parts  frequently  assumes  an  erysipelatou- 
redness,  such  as  was  observed  in  our  little  patient;  this  also  is  a  symptom 
which  unfavorably  influences  the  prognosis.  This  redness  suggests  the  idea 
of  deepseated  inflammation.  It  is  a  symptom  which  did  not  escape  the 
notice  of  the  physicians  of  past  times.  To  substantiate  this  statement,  let 
me  quote  a  sentence  from  Borsieri's  chapter  on  gangrenous  malignant  sore 
throat:  "  Nee  rarum  est  in  hujus  modi  morbo,  prozsertim  cum  epidemia  dif- 
funditur  circa  collum,  pectus  et  brachia  erumpere  ruborem  quandam  erysipela- 
todem,  scepe  cum  papulis  morbillosis  conjunetum  out  exanthemata  miliaria, 
papulasve  rubras  in  summam  eutem  alicubi  prodiri,  quin  imo  parotides  ipsas 
glandalasvt  maxillares  jugidaresve  tumefierl  ac  dolere."  You  observe  that  in 
this  passage,  in  addition  to  the  glandular  swelling  and  erysipelatous  red- 
ness which  I  spoke  of,  mention  is  made  of  miliary  and  rubeolous  eruptions, 
which  perhaps  bear  some  analogy  to  the  scarlatiniform,  erythematous,  net- 
tley,  and  pemphigoid  eruptions,  to  which  attention  has  been  railed  by  my 
colleague,  Dr.  Germain  See,  and  regarding  which  there  was  a  discussion  in 
the  Hospital  Medical  Society. 

I  now  return  to  the  subject  of  glandular  engorgement.  It  Bhows  it-elf 
particularly  at  the  angle  of,  and  below,  the  maxilla,  attacking  first  the  side 
corresponding  to  thai  of  tin-  pharynx  first  affected,  then  attacking  the  other 
3ide,  when  the  other  side  of  the  pharynx  has  become  implicated.  The  diph- 
theritic exudation  manifests  itself  more  rapidly  than  in  the  common  form 
of  pseudo-membranous  -ore  throat:  it  generally  cover-  a  part  of  the  veil  of 
the  palate.  Vou  can  recall,  as  it  is  of  very  recent  occurrence,  the  case  of 
the  little  girl  who  died  of  malignant  diphtheria,  and  whose  autopsy  we 
made.  She  specially  complained  of  great  pain  in  the  ear.  particularly  when 
she  coughed.  Pharyngeal  diphtheria  very  often  extends,  by  the  Eustachian 
tube,  into  the  auditors  passage,  and  likewise  at  the  same  time,  to  the  uose. 
After  twenty-four,  thirty-six,  or  forty-eighl  hours,  the  oasal  fossae  are  in- 
vaded. The  existence  of  membranous  deposit  is  a  fact  of  momentous  im- 
portance, and  one  to  which  I  called  your  attention  in  the  case  of  our  little 
patient  of  St.  Bernard's  Ward.    Bear  in  mind  the  circumstances :  for  when 


MALIGNANT    DIPHTHERIA.  357 

this  deposit  makes  its  appearance,  even  in  that  form  of  the  disease  which 
sets  in  mildly,  you  will  rarely  see  the  patients  recover,  whether  they  lie 
adults  or  children.  There  is,  I  repeat,  no  occurrence  so  alarming  as  an 
extension  of  the  disease  to  the  olfactory  mucous  membrane.  Of  twenty 
persons  attacked  with  nasal  diphtheria,  nineteen  die:  whereas,  in  twenty 
attacked  with  croup,  some  may  be  saved  by  tracheotomy,  as  I  hope  after- 
wards to  show  you. 

You  have  still,  I  doubt  not,  in  your  mind's  eye,  the  autopsy  of  a  child 
who  was  in  our  wards  for  four  or  five  days.  lie  took  diphtheria  when  in 
another  hospital.  When  I  saw  him,  lie  was  breathing  noisily,  and  with 
difficulty :  a  thin  serosity,  devoid  of  fetid  odor,  was  running  incessantly 
from  his  nostrils.  There  was  high  fever.  My  first  general  glance  at  this 
patient  was  enough  to  inform  me  of  the  serious  character  of  the  case,  and 
to  cause  me  to  tell  you  that  it  was  diphtheria  which  would  terminate  in 
death.  The  child,  however,  had  still  a  fresh  and  vigorous  appearance:  but 
I  saw  the  nasal  diphtheria,  and  my  experience  had  taught  me  its  alarming 
import.  On  proceeding  to  examine  the  throat,  I  detected  pellicular  de- 
posit on  the  uvula  and  both  tonsils.  A  concentrated  solution  of  sulphate 
of  copper  was  applied  to  the  mucous  membrane  of  the  throat  aud  no^e,  and 
insufflations  with  tannin  and  alum  were  employed  ;  notwithstanding  this 
treatment,  the  child  died.  In  this  case,  there  was  not  the  slightest  implica- 
tion of  the  larynx.  On  examining  the  body  after  death,  we  found  a  thick 
pseudo-membranous  coating  on  the  tonsils:  the  aryteno-epiglottidean  liga- 
ments presented  traces  of  inflammation  and  recent  plastic  exudation,  but  no 
false  membrane.  jSTo  morbid  change  was  observed  in  the  larynx  and 
trachea. 

The  child,  then,  did  not  die  of  croup,  but  of  malignant  diphtheria ;  it 
was,  moreover,  the  presence  of  the  characteristic  exudations  in  the  nasal 
fossse  which  caused  me  to  form  the  unfavorable  prognosis  so  speedily  realized 
by  the  fatal  termination  of  the  case. 

In  what  way  does  nasal  diphtheria  declare  itself?  You  have  seen  its 
mode  of  beginning  in  the  little  girl  whose  case  has  been  the  subject  of  this 
lecture.  First  of  all  a  redness  appears  at  the  orifice  of  the  nostrils,  analo- 
gous to  the  redness  seen  in  persons  suffering  from  coryza  ;  there  is  an  in- 
crease in  the  secretion  from  the  pituitary  mucous  membrane,  the  patient 
blow;s  his  nose  a  little  more  frequently  than  usual,  the  mucus  secreted  is 
mixed  with  a  minute  quantity  of  blood,  and  there  are  generally  at  the  same 
time  attacks  of  epistaxis.  Coryza,  even  slight  coryza,  supervening  in  diph- 
theria, is  a  serious  occurrence,  for  it  shows  that  the  specific  inflammation 
has  reached  the  nasal  fossa?.  Within  a  space  of  from  twenty-four  to  forty- 
eight  hours,  no  room  for  doubt  will  remain  :  there  will  then  be  a  profuse 
flow  of  a  sanious  ichor  from  the  nostrils  and  into  the  back  part  of  the  throat. 
On  examining  the  nose,  by  opening  the  nostrils  with  the  fingers  or  by  means 
of  a  speculum  auris,  the  mucous  membrane  is  seen  to  be  coated  with  false 
membrane  which  can  be  traced  even  over  the  turbinated  bones.  Our  little 
patient,  you  will  remember,  ejected  false  membrane  retaining  the  form 
moulded  on  one  of  these  bones. 

There  is  also  observable  at  the  same  time  lachrymation,  an  almost  never- 
failing  symptom,  lachrymation  resembling  that  of  persons  suffering  from 
lachrymal  tumors  or  obliteration  of  the  nasal  duct ;  it  proceeds  from  a  sim- 
ilar cause,  for  the  nasal  duct  and  lachrymal  passages  are  obstructed  by 
tumefaction  of  their  internal  mucous  lining.  In  some  cases,  the  diphtheritic 
inflammation,  and  even  the  false  membranes,  extend  from  the  nose  to  the 
eyes.  Indeed,  on  turning  over  the  eyelids,  it  is  not  unusual  to  find,  par- 
ticularly on  the  lower  eyelid,  the  conjunctiva  inflamed  and  covered  with 


358  MALIGNANT    DIPHTHERIA. 

pseudo-membranous  secretion,  the  specific  inflammation  having  been  propa- 
gated to  it,  through  the  nasal  passages,  in  succession  from  the  pharynx  and 
nasal  fossa?.  This  lesion  of  the  palpebral  conjunctiva  is  so  common  that 
we  every  year  meet  with  examples  at  the  Children's  Hospital,  particularly 
in  the  malignant  form  of  the  disease  now  under  consideration. 

The  symptoms  of  nasal  diphtheria  and  of  ophthalmic  diphtheria  are  appar- 
ently so  much  less  alarming  than  those  of  croup,  that  unless  the  physician 
has.  had  sad  experience  of  their  ominous  character,  he  will  not  despair  of 
recovery  when  he  sees  them.  If  he  looks  only  to  general  symptoms,  to  the 
moderate  character  of  the  fever,  and  the  absence  of  delirium,  he  will  not 
consider  the  debility  and  glandular  engorgement  as  indicative  of  much 
danger :  he  will  fancy  that  when  once  the  nasal  and  pharyngeal  membra- 
nous exudations  have  disappeared,  there  will  remain  nothing  to  fear.  It 
must  be  admitted,  however,  that  notwithstanding  their  essentially  dangerous 
and  almost  always  fatal  character,  recoveries  do  sometimes  occur  in  cases  in 
which  nasal  pharyngeal  false  membranes  have  been  present.  From  among 
the  rare  cases  of  this  kind  which  I  have  met,  I  will  now  recapitulate  the 
particulars  of  a  case  which  came  under  your  own  observation. 

The  patient  was  a  boy  aged  ten  and  a  half,  with  an  intelligent  counte- 
nance, light  hair,  and  lymphatic  temperament.  When  brought  to  me  by 
his  mother,  on  1st  September,  1855,  I  at  once  detected  paralysis  of  the  veil 
of  the  palate.  I  was  told  that  it  had  existed  for  three  weeks,  and  was  con- 
secutive to  an  affection,  which  from  the  description  given,  had  evidently 
been  buccal  and  nasal  diphtheria. 

From  the  beginning  of  the  attack,  the  child  had  complained  of  pain  in 
the  throat,  accompanied  by  a  swelling  of  the  glands  of  the  neck,  which 
had  not  escaped  the  observation  of  the  family.  The  onset  of  the  disease 
was  abrupt,  or  at  least  the  first  complaint  of  the  child  was  made  one  day 
on  his  coming  home  from  school.  He  then  had  high  fever.  The  symp- 
toms continued  for  forty-eight  hours.  During  that  period  he  ejected  by 
the  mouth  and  nose  white  skins  [peav.v  blanches],  which  his  mother  com- 
pared to  pieces  of  flesh.  The  symptoms  now  described  ceased  sponta- 
neously, no  treatment  of  any  kind  having  been  employed.  But  they  re- 
turned after  two  days,  and  presented  similar  characteristics.  Again  the 
child  got  rid  of  white  skins  by  expectoration,  and  on  blowing  the  nose. 
With  good  cause  the  family  took  alarm,  dreading  croup,  although  it  was 
not  known  that  there  were  any  cases  of  croup  in  the  neighborhood.  The 
patient  did  not  cough,  and  his  only  complaint  was  of  considerable  pain  in 
deglutition. 

The  malady  continued  for  six  days;  there  was  then  a  rapid  convalescence, 
and  a  return  to  former  ways.  But  still  the  child  had  symptoms  which 
alarmed  the  mother,  and  induced  her  to  come  to  seek  advice  from  me. 
The  voice  was  snivelling,  and  there  was  an  impediment  to  deglutition,  fluids 
as  soon  as  taken  returning  by  the  nose.  I  had,  therefore,  to  deal  with 
paralysis  of  the  veil  of  the  palate.  On  examining  the  throat,  I  ascertained 
that  this  pendulous  membrane  did  not  move  in  the  Bmallesl  degree  during 
'ration,  and  did  ool  contract  when  I  tried  to  excite  it  to  action  by 
touching  it  with  the  tip  of  a  feather.  The  little  patient,  moreover,  com- 
plained of  impaired  vbion,  stating  that  he  had,  as  it  were,  a  mist  before 
his  eyes.  The  pupils  were  completely  dilated,  and  did  not  contract  when 
subjected  to  strong  light  after  darkness.  Finally,  it  appeared  to  me  that 
the  gait  was  a  little  tottering;  but  this  Bymptom  had  no  great  significance, 

ise  it  was  alleged  that  from  the  time  he  was  a  year  old   feebleness  had 

perceived    in    tic    lower    limbs.      The   circumstance  which    had    most 

strii'k   the   family  was  a   change    in    the   character  of  the  child.     Till   his 


MALIGNANT    DIPHTHERIA.  359 

illness,  tractable  and  quiet,  he  had,  after  it,  become  impatient  and  difficult 
to  manage.    In  other  respects,  the  general  state  of  health  was  satisfactory. 

The  urine  was  pale,  and  became  slightly  turbid  when  treated  by  heat  and 
nitric  acid.  I  prescribed  a  tonic  and  substantial  regimen.  Unfortunately, 
I  lost  sight  of  this  case.  Here  then  is  an  example  of  recovery,  without  the 
intervention  of  art,  from  nasal  diphtheria. 

Such  eases,  however,  I  repeat  for  the  third  time,  are  rare,  exceedingly 
rare  ;  they  do  not  invalidate  the  general  rule  which  I  have  laid  down. 
Notwithstanding  the  mildness  of  the  general  symptoms,  life  is  in  serious 
jeopardy  in  persons  attacked  with  malignant  diphtheria,  when  there  is  so 
much  glandular  engorgement,  and  when  the  nasal  fossae  and  palpebral  con- 
junctiva; present  pseudo-membranous  exudations. 

Attacks  of  epistaxis,  as  I  have  already  remarked,  often  precede  the 
formation  of  false  membrane  upon  the  pituitary  mucous  membrane :  the 
bleedings  at  the  nose  constitute  the  most  important  notice  of  the  coming 
plastic  exudation,  and  they  continue  to  occur  till  it  has  almost  quite  covered 
the  inner  surface  of  the  nostrils. 

Our  little  patient  lost  nearly  100  grammes  [about  3^  fl.  ounces  Brit. 
apoth.  meas.]  of  blood  by  epistaxis — a  small  quantity  certainly,  but  never- 
theless, as  you  remarked,  some  hours  after  this  hemorrhage,  her  face  was 
exceedingly  pale,  and  her  skin  generally  had  become  very  blanched. 
Epistaxis  has,  from  the  earliest  times,  been  always  regarded  as  one  of  the 
most  serious  symptoms  in  diphtheria.  "MaMgnam  significationem  prtebet 
sanguis  stillans  e  naribus,"  said  De  Heredia,  one  of  the  authors  who  de- 
scribed the  epidemics  of  malignant  sore  throat  which  committed  ravages  in 
Spain  at  the  beginning  of  the  seventeenth  century.  A  little  further  on 
he  adds:  " Periculosissimus  censetur  sanguinis  fluxus  ex  naribus  aut  ore.'1 
Malouin,  a  French  physician,  who  wrote  upon  the  gangrenous  sore  throats 
which  he  observed  in  Paris  in  1746,  also  recognized  epistaxis  as  a  sign  of 
great  danger ;  he  states  that  several  children  in  Picardy,  who  had  this 
symptom,  died  within  nine  days  from  its  occurrence. 

But,  gentlemen,  epistaxis  is  not  the  only  form  of  hemorrhage  wdiich  we 
meet  with  ;  we  meet  with  subcutaneous  ecchymosis,  bleedings  from  the 
lungs,  alimentary  canal,  and  bladder,  in  fact  every  kind  of  hemorrhage, 
such  as  we  encounter  in  hemorrhagic  small-pox,  of  which  I  have  already 
spoken  to  you.  Let  me  quote  a  remarkable  example  from  Dr.  Peter's  work 
on  diphtheria. 

"  On  August  1st,  1858,"  says  my  colleague,  "I  was  called  from  the  Chil- 
dren's Hospital  to  visit  Marie  P — ,  a  child,  at  No.  29  Rue  de  Sevres.  For 
twenty-four  hours  she  had  been  in  high  fever,  and  for  twelve  hours  had 
suffered  from  severe  sore  throat.  When  I  saw  the  patient,  I  found  tonsilar 
sore  throat,  and  an  incipient  scarlatinous  eruption  on  the  skin.  On  the 
fourth  day  of  the  malady  the  fever  was  increased  twofold,  the  patient  was 
coughing,  and  I  detected  pneumonia  of  the  right  lung,  an  unusual  compli- 
cation of  scarlatina.  I  prescribed  some  sulphuret  of  antimony,  and  ordered 
a  blister  to  be  applied  to  the  chest. 

"  Next  day,  August  5th,  there  was  a  slight  patch  of  false  membrane  on 
each  tonsil :  the  fever  was  intense :  the  scarlatinous  eruption  was  of  a 
violet  color :  the  general  condition  of  the  patient  presented  all  the  charac- 
ters of  adynamia.  I  prescribed  a  potion  containing  quinine,  and  lemonade 
as  a  tisane.     I  ordered  that  she  should  have  some  meat  broth. 

"On  the  7th,  the  blister  was  ulcerated,  and  covered  with  a  pseudo-mem- 
branous exudation.  The  false  membranes  on  the  tonsils  had  increased  in 
extent  and  thickness,  and  had  reached  the  veil  of  the  palate :  they  were  of 
a  grayish  color  and  exhaled  a  fetid  odor.     I  caused  the  blistered  surface 


360  MALIGNANT    DIPHTHERIA. 

to  be  powdered  with  a  mixture  of  quinine  and  camphor,  and  caut?riz2d 
the  back  part  of  the  throat  with  nitrate  of  silver.  As  an  ordinary  drink, 
I  prescribed  lemonade. 

"  On  the  8th,  running  from  the  nose  had  begun  :  and  I  perceived  a  rudi- 
mentary false  membrane  at  the  orifice  of  the  left  nostril.  The  scarlatinous 
eruption  was  a  little  less  violet,  but  there  was  a  burning  fever.  The  ulcer- 
ation of  the  edges  of  the  blistered  surface  was  extending,  and  the  false 
membrane  which  covered  it  was  thicker.  So  far  from  there  being  any 
resolution  of  the  pneumonia,  there  was  an  increase ;  in  the  lower  half  of 
the  right  lung  were  heard  a  blowing  sound  and  bronchophony. 

"  On  the  9th,  10th,  and  11th,  there  was  a  general  increase  in  the  severity 
of  the  symptoms.  From  the  arms  and  thighs,  a  very  few  shreds  of  epidermis 
peeled  off,  and  the  eruption  was  slightly  paler:  but  the  burning  fever  con- 
tinued, and  a  fetid  odor  was  exhaled  from  nose  and  mouth.  Around  the 
nostrils,  there  were  excoriations.  There  was  an  acrid  discharge  from  the 
nostrils,  which  produced  excoriation  of  the  upper  lip ;  and  one  could  see 
that  the  interior  of  the  nasal  fossae  was  coated  with  false  membrane.  The 
whole  of  the  back  part  of  the  throat  was  invaded  by  the  pseudo-mem- 
branous product :  deglutition  was  very  difficult.  The  nose  and  throat  con- 
tinued in  a  fetid  state,  notwithstanding  the  frequent  use  of  injections. 

"On  the  12th,  I  found  symptoms  of  incipient  pneumonia  on  the  left  side: 
while  on  the  right,  I  heard  rales  which  almost  amounted  to  gurgling:  there 
was  profuse  expectoration  of  fetid  purulent  matter.  A  scarlatiniform 
eruption  had  reappeared.  The  excoriations  on  the  upper  lip  were  covered 
with  diphtheritic  exudation.     On  the  neck,  I  saw  two  bulla?  of  pemphigus. 

"By  the  13th,  the  bulla?  had  become  excoriated,  and  were  covered  with 
plastic  exudation.  There  were  numerous  petechia?  and  scorbutic  ecchy- 
moses  on  the  parts  which  had  been  subjected  to  pressure :  there  occurred 
attacks  of  bleeding  from  the  nose,  and  hemorrhage  from  the  vesicated 
surface.  The  false  membrane  at  the  back  part  of  the  throat  was  infiltrated 
with  blood. 

"On  the  14th,  some  bloody  sputa  informed  me  that  there  was  pulmonary 
hemorrhage.  There  were  also  hematuria  and  hemorrhage  from  the  bowels, 
symptoms  which  I  had  foreseen,  and  which,  from  the  previous  evening,  I 
had  led  the  family  to  expect.  During  the  day,  also  in  accordance  with  my 
anticipations,  the  voice  became  hoarse  from  the  invasion  of  the  larynx 
with  false  membrane.  In  the  evening,  the  voice  was  broken,  and  still  more 
decidedly  croupy. 

"On  the  morning  of  the  loth  August — the  loth  day  (if  the  disease — the 
patient  died,  after  having  passed  a  night  of  great  suffering."* 

I  could  not,  gentlemen,  place  before  you  a  more  complete  or  a  more 
sadly  interesting  case  than  that  which  I  nave  now  detailed.  Grantingthat 
scarlatina  played  its  part,  the  child  died  from  a  frightfully  malignant  diph- 
theria. Scarlatinous  sore  throat  was  the  starting-point  of  the  diphtheritic 
inflammation,  whence  originated  the  pellicular  affection  to  which  death 
was  due.  Whether  it  was  from  the  special  character  of  the  diphtheritic 
disease,  or  from  tie-  individual  attacked  being  already  under  the  dominion 
of  a  formidable  and  septic  malady — in  a  word,  in    a    condition   suitable   to 

the  engendering  of  malignity — the  diphtheria  assumed  its  terrible  form. 

The  great  blanehing  qfthe  skin,  the  amende  appearance  to  which  1  directed 
your  attention,  could  not  he  exclusively  attributed  to  the  loss  of  flood  sus- 
tained by  the  patient ;  for  though  such  losses  maybe  relatively  insignifi- 


*  Peter  (Michel) :  *)u'l<|in>-  Recherches  eur  la  Diphtheric:  m6moire  couronne* 

par  In  F:t<u  1 1 .'■  de  M6decine,  1869. 


DIVERSITY    OF    LOCALIZATION    IN    DIPHTHERIA.  361 

cant,  or  absolutely  wanting,  there  will  yet  occur  decoloration  of  the  skin; 
In  point  of  fact,  decoloration  is  a  constant  and  invariable  phenomenon  in 
the  malignant  form  of  diphtheria :  it  is  a  sign  of  the  cachectic  state  into 
which  the  individual  lias  fallen.  Out.  of  that  condition  arise  a  series  of 
symptoms  against  which  we  are  quite  unable  to  contend.  There  is  a  dislike 
to  food,  which  is  quite  invincible,  both  in  adults  and  in  children.  I  have 
often  tried  to  struggle  against  it:  many  times,  with  children,  have  I  em- 
ployed every  sort  of  device,  threats,  and  even  force,  to  compel  them  to  take 
nourishment,  hut  all  to  no  purpose;  they  resisted  every  means  used,  would 
take  neither  food  nor  drink,  and  at  last  died  from  abstinence. 

The  surface  becomes  cold.  There  then  supervene  extreme  restlessness, 
and  an  anxiety  of  countenance  painful  to  witness,  resembling  that  which 
is  seen  in  choleraic  patients  ;  or,  there  is  sometimes  a  kind  of  stillness 
which  is  even  more  alarming  than  the  restlessness.  At  last,  unexpectedly, 
the  patient  getting  up  abruptly  to  satisfy  a  call  of  nature  or  change  his 
position,  dies  suddenly  iu  a  faint.  This  happened  in  the  case  of  our  little 
patient. 

That  poor  little  girl,  gentlemen,  has  afforded  you  a  typical  example  of 
the  frightful  disease,  a  picture  of  the  leading  features  of  which  I  have  now- 
attempted  to  sketch.  Preserve  this  typical  case  in  your  memory  ;  for, 
unfortunately,  you  will  too  often  meet  with  others  like  it  in  the  course  of 
your  practice. 

Diversity  of  Localization  in  Diphtheria. 

Palpebral  Diphtheria. —  Cutaneous,  Vulvar,  Vaginal,  Anal,  and  Preputial 

Diphtheria. 

Gentlemen:  I  have  stated  to  you  that  diphtheria  manifests  itself  on  the 
mucous  membranes,  and  also  ou  the  skin  when  denuded  of  its  epidermis. 
I  said  that  the  pharynx  was  its  favorite  seat,  and  that  thence  it  extended 
to  the  larynx  and  trachea.  I  described  to  you  pseudo-membranous  sore 
throat,  that  form  of  the  disease  which  is  most  common,  which  produces 
croup,  and  thus  may  come  to  a  fatal  termination  by  inducing  asphyxia. 
I  also  pointed  out  that  the  pellicular  affection  sometimes  all  at  once  takes 
possession  of  the  larynx,  trachea,  and  bronchial  tubes,  but  that  croup 
occurring  in  this  sudden  manner  is  much  more  uncommon  than  was  at  one 
time  supposed.  I  called  your  attention  to  nasal  diphtheria,  and  to  diph- 
theria of  the  .Eustachian  tube.  I  now  propose  to  make  a  review  of  the  dif- 
ferent situations  in  which  we  find  the  manifestations  of  diphtheria. 

I  have  shown  you,  gentlemen,  how  the  pellicular  affection  advances  from 
the  nasal  fossae  to  the  eyelids.  I  must  iu  a  special  manner  return  to  this 
point,  that  I  may  read  to  you  a  description  given  by  Dr.  M.  Peter  in  his 
remarkable  work  from  which  I  have  already  quoted  : 

"At  its  first  appearance,"  says  this  young  physician,  "diphtheria  of  the 
conjunctiva,  in  the  three  cases  which  came  under  my  notice,  resembled 
simple  catarrhal  inflammation  of  the  mucous  membrane,  there  being  an 
injected  and  dry  condition  in  the  beginning,  and  then  lachrymation  ;  but 
after  a  few  hours,  as  the  case  progressed,  it  became  more  like  purulent  oph- 
thalmia.,  The  eyelids  became  swollen,  so  as  to  cover  up  the  globe  of  the 
eye  :  the  skin  was  shining,  and  stretched  over  the  cellular  tissue,  which 
was  infiltrated  with  lactescent  serosity  :  a  sero-mucous  stillicidium  was  soon 
replaced  by  a  profuse  running,  which  from  its  acrid  property  traced  a  red- 
dish painful  ridge  down  from  the  angle  of  the  nose. 

"The  eyelids  were  very  sensitive  to  the   touch,  and  on  proceeding  to 


362  DIVERSITY    OF    LOCALIZATION    IN    DIPHTHERIA. 

make  an  examination,  violent  cries  and  energetic  resistance  were  excited. 
Their  cedematous  tension  and  spasm  placed  obstacles  in  the  way  of  explora- 
tion, which  it  required  the  greatest  possible  efforts  to  overcome.  If  one 
succeeded  in  raising  the  eyelid,  the  conjunctiva  is  seen  to  be  lined  with  a 
layer  of  plastic  exudation  between  one  and  two  millimetres  in  thickness  : 
beneath  the  mucous  membrane,  there  was  sometimes  seen  a  bright,  bloody- 
looking  redness :  the  globes  of  the  eyes  were  bathed  in  a  sero-purulent 
mucous  secretion. 

"In  two  of  the  three  cases,  I  have  seen  this  secretion,  the  acridity  of 
which  was  so  great  that  it  destroyed  the  epidermis  and  excoriated  the  skin, 
invade  the  cornea,  infiltrating  itself  between  its  laminae,  depriving  it  of 
transparence,  and  causing  perforation.  This,  to  a  certain  extent,  physical 
consequence  of  palpebral  diphtheria,  caused  the  resemblance  to  purulent 
ophthalmia. 

"Again,  in  two  of  the  three  cases,  along  with  the  affection  of  the  eyelids, 
there  was  a  pseudo-membranous  coryza :  the  eyelids  and  the  lower  half  of 
the  nose,  from  their  red  and  swollen  condition,  contrasted  strongly  with  the 
rest  of  the  face,  which  was  of  livid  paleness,  and  sometimes  had  a  skeleton- 
like thinness.  In  these  two  cases,  there  was  seen  at  each  side  of  the  mesian 
line,  on  the  upper  lip,  and  at  the  angle  of  the  nose,  the  same  inflamed  ridge, 
produced  by  the  same  acrid  running. 

"  In  two  of  the  three  cases,  there  was  pseudo-membranous  sore  throat.  In 
all  the  three  cases,  the  general  symptoms  were  exceedingly  severe.  In  two 
cases,  there  was  loss  of  vision  from  the  implication  of  the  cornea.  In  two 
cases,  death  was  the  result  of  the  general  effect  of  the  disease  on  the  econ- 
omy. In  two  cases,  the  progress  of  the  disease  was  very  rapid,  being  four 
days  in  the  one  and  twelve  days  in  the  other  :  in  the  latter  case,  recovery 
took  place.  The  third  case,  speaking  relatively,  was  chronic :  in  it,  after 
twelve  days,  both  cornea?  were  quite  destroyed.  In  none  of  the  cases  was 
there  any  affection  of  the  air-passages."* 

Dr.  Peter  remarks  that  one  might  in  such  cases  at  first  suppose  that  the 
disease  was  purulent  ophthalmia,  were  not  the  diagnosis  elucidated  by  the 
concomitance  of  plastic  coryza  or  pseudo-membranous  sore  throat :  but  a 
careful  examination  of  the  eyelids  will  never  leave  any  doubt  as  to  the  real 
nature  of  the  local  affection. 

The  prognosis  is  unfavorable  :  it  is  unfavorable  on  account  of  the  lesion 
itself,  which  may  lead  to  the  loss  of  the  eyes:  it  is  unfavorable  in  respect 
of  the  general  disease,  for  in  Dr.  Peter's  three  cases,  the  plastic  ophthalmia 
was  the  manifestation  of  a  malignant  diphtheria. 

The  treatment  adopted  was  cauterization  with  the  nitrate  of  silver,  which 
was  applied  to  the  affected  surfaces,  after  they  had  been  cleared  as  much 
as  possible  from  the  plastic  exudation  :  the  affected  parts  were  likewise 
well  washed  with  water  every  hour. 

Let  me  quote  another  case,  in  which  there  was  a  different  localization  of 
i  he  diphtheria — a  case  of  vaginal  diphtheria. 

A  woman,  aged  21,  at  the  full  term  of  her  first  pregnancy,  during  which 
her  health  f{id  been  excellent,  was  seized  with    labor   pains  on  the  night  of 

Friday,  18th',  and  Saturday,  19th  November,  1859.     Thefirsl  stage  of  labor 

was  slow,  the  uterine  contractions   not   being  strong ;   and    the  second  Stage 

was  still  slower:  from  three  to  seven  o'clock  in  the  evening  of  Saturday, 
not   the   least    progress  was  made.      I  )r.  ( 'ampbell,  who  was   in   attendance 

upon  the  patient,  then  resolved  to  deliver  by  the  forceps.  The  operation, 
performed  while  the  patient  was  in  a  state  of  complete  anaesthesia  from 


:   Petbb  i  M  ichel  I  :  nwl<|u<'>  Recberchee  but  La  Diphth6rie,  185'J. 


DIVERSITY    OF    LOCALIZATION    IN    DIPHTHERIA.  363 

chloroform,  was  long  and  difficult.  After  twenty  minutes  of  arduous  ma- 
noeuvring, a  large  and  well-formed  male  infant  was  extracted.  1 1  had  slight 
excoriations  on  the  face  and  head,  the  result  of  bruising  with  the  blades  of 
the  forceps.  One  of  the  contusions  implicated  one  of  the  seventh  pair  of 
nerves,  as  was  indicated  by  paralysis  of  the  left  side  of  the  lace  prevent- 
ing the  infant  from  taking  the  breast. 

The  mother,  however,  seemed  to  rally  from  the  fatigues  of  labor,  and 
the  next  day  felt  herself  to  be  going  on  well.  On  the  morning  of  Monday, 
she  was  seized  with  pains  in  the  left  groin,  shooting  into  the  lumbar  region 
and  down  the  thigh.  Drs.  Campbell  and  Blondeau,  who  saw  the  patient 
some  hours  afterwards,  detected  incipient  peritonitis,  characterized  by  pain, 
increased  by  pressure,  in  the  left  iliac  fossa.  There  was  no  swelling  of  the 
genital  parts.  In  the  evening,  the  pain  was  more  acute,  there  was  a  good 
deal  of  fever,  heat  of  skin,  and  the  pulse  was  above  100.  The  mind  was 
not  affected.  There  had  been  neither  vomiting  nor  nausea.  The  abdomen 
was  smeared  with  a  combination  of  the  extract  of  belladonna  and  opium, 
in  the  proportion  of  three  of  the  former  to  one  of  the  latter ;  and  it  was 
also  covered  with  large  poultices  of  lintseed  meal.  On  the  Tuesday,  the 
condition  of  the  patient  seemed  to  be  worse :  the  pain  in  the  left  iliac  fossa 
continued,  and  in  the  right,  there  was  also  pain,  though  in  a  less  degree. 
There  was  a  good  deal  of  fever.  Ten  leeches  were  applied  over  the  iliac 
fossa.     In  the  evening,  the  pain  had  extended  to  the  whole  abdomen. 

Next  day,  I  was  summoned  in  consultation.  When  I  arrived,  at  half- 
past  nine  "in  the  morning,  the  peritonitis,  which  was  then  general,  had 
reached  the  peritoneal  covering  of  the  diaphragm,  as  was  indicated  by  the 
difficulty  and  pain  which  accompanied  inspiration.  The  patient  was 
affected  with  the  peritoneal  form  of  puerperal  fever,  of  which  there  were  at 
that  time  numerous  cases  in  the  wards  of  the  Hotel-Dieu  and  Hospice  de 
la  Maternite.  The  fever  was  high:  the  skin  was  hot  and  parched:  the 
pulse  was  120.  The  patient  had  her  mental  faculties  entire,  and  retained 
her  cheerfulness.  To  the  inexperienced  eye,  there  was  nothing  in  her 
situation  to  cause  alarm :  we,  however,  were  in  very  great  dismay,  because 
we  remembered  having  seen  cases  of  puerperal  women  dying  of  peritonitis, 
in  whom,  at  the  beginning  of  the  attack,  no  symptoms  of  any  gravity  had 
shown  themselves. 

We  prescribed  the  internal  use  of  the  essential  oil  of  turpentine,  from 
which  in  similar  cases  we  had  obtained  real  service :  the  external  use  of 
the  belladonna  and  opium  was  continued.  Every  hour  she  got  some  of 
the  essence,  care  being  taken  to  secure  tolerance  of  the  drug  by  giving 
along  with  each  dose  a  drop  of  laudanum,  as  soon  as  diarrhoea  supervened. 

On  the  evening  of  Friday — the  fifth  day  of  the  disease — we  perceived  a 
decided  amelioration.  The  abdomen  was  supple  :  there  was  no  longer  any 
abdominal  pain,  and  palpation  even  did  not  excite  it.  The  uterus  was 
naturally  contracted,  and  there  only  remained  a  little  pain  over  the  broad 
ligament  on  each  side,  in  which  situation  we  discovered  considerable  swell- 
ing. The  pulse  had  fallen  to  108  from  120,  and  even  from  130,  to  which 
it  had  risen  on  the  previous  day.  The  temperature  of  the  skin  was  good. 
We  were  hoping  that  we  had  attained  the  beginning  of  convalescence, 
when  other  symptoms  supervened,  which  carried  off  this  poor  woman  in 
thirty-six  hours. 

I  have  said  that  in  the  first  days  of  the  attack,  there  was  no  swelling  of 
the  external  genital  organs.  On  the  Wednesday  morning,  however,  this 
swelling  was  manifest :  the  swollen  parts  were  painful,  but  the  pain  was 
calmed  by  the  application  of  poultices  of  lintseed  meal.  This  affection, 
sufficiently  accounted  for  by  the  bruising  in  the  obstetrical  manipulations, 


364.  DIVERSITY    OF    LOCALIZATION    IN    DIPHTHERIA. 

presented  nothing  visible  which  was  worthy  of  notice,  excepting  a  slight 
excoriation  of  the  labia,  where  a  tear  had  been  made  by  the  forceps  :  this 
tear  was  about  half  a  centimetre  in  length.  On  the  Thursday,  however, 
the  sixth  day  after  delivery,  on  examining  the  parts,  and  on  using  the 
catheter,  it  was  found  that  there  was  a  large  blackish-gray  patch  on  the 
left  side  of  the  vagina:  around  this  patch,  the  mucous  membrane  was  of  a 
dull  red  color,  and  presented  plastic  exudation,  which  I  detached  with  the 
handle  of  a  spoon.  Vaginal  diphtheria  was  thus  only  too  evidently  char- 
acterized. The  part  was  at  once  energetically  cauterized  with  a  saturated 
solution  of  sulphate  of  copper;  and  an  ointment  strongly  charged  with 
tannin  was  then  applied  to  the  affected  parts.  Under  the  use  of  these 
means,  which  were  repeated  several  times  in  the  twenty-four  hours,  the 
progress  of  the  malady  seemed  to  be  arrested  :  at  all  events,  on  the  Friday 
evening,  when  I  examined  the  parts,  and  detached  the  sloughs  which  I  had 
produced,  I  perceived  that  the  subjacent  mucous  membrane  was  of  a  beau- 
tiful bright  red  color,  and  that  no  more  diphtheritic  patches  were  visible. 

The  peritonitis  was  proceeding  in  a  fair  way  to  resolution  :  we  believed 
ourselves  to  be  masters  of  the  diphtheritic  affection,  the  terrible  complica- 
tion which  had  but  a  short  time  before  deprived  us  of  every  ray  of  hope: 
we  were  in  fact  thoroughly  pleased  with  the  aspect  of  the  case,  when 
(about  three  hours  after  my  visit)  the  condition  of  the  patient  became  very 
much  disturbed.  Her  pupils  were  dilated  :  she  complained  of  pain  in  the 
throat,  and  difficulty  in  deglutition.  As  there  was  no  fever,  and  as  on 
attentively  examining  the  pharynx,  neither  redness  nor  trace  of  plastic 
exudation  could  be  discovered,  Dr.  Blondeau  attributed  the  symptoms  to 
the  action  of  the  belladonna,  of  which  there  was  still  a  thick  coat  on  the 
surface  of  the  abdomen.  He  carefully  washed  the  skin  of  the  abdomen  ; 
and  for  some  hours  afterwards  the  young  woman's  state  seemed  more  favor- 
able. But  during  the  night — about  three  in  the  morning — more  formida- 
ble symptoms  appeared.  The  patient  awoke  from  a  slumber  in  a  very 
agitated  state,  and  tormented  by  disagreeable  visions.  Her  haggard  coun- 
tenance expressed  the  most  intense  anxiety;  her  pupils  were  very  much 
dilated  :  there  was  considerable  dryness  and  pain  of  throat :  tin-  pulse  was 
140.  Upon  again  carefully  examining  the  pharynx,  there  was  absolutely 
nothing  noteworthy  to  be  seen.  All  the  symptoms  were  put  down  to  the 
account  of  the  belladonna;  and  to  subdue  them,  strong  coffee  was  pre- 
scribed. 

Next  morning,  there  was  anxiety,  febrile  excitement,  a  pulse  of  130,  and 
only  a  slight  increase  in  the  temperature  of  the  skin.  She  had  passed  a 
sleepless  night ;  but  from  the  beginning  of  her  attack,  she  had  suffered  from 
insomnia.  The  peculiar  expression  of  the  countenance,  and  the  drawn 
features,  proclaimed  a  great  change:  the  pupils  were  dilated,  and  the 
breathing  was  labored;  everything  indicated  excessive  disturbance  of  the 
system.  In  the  evening,  the  symptoms  of  malignity  were  still  more 
decided.  Next  morning,  we  came  to  the  conclusion  thai  this  unfortunate 
young  woman  was  under  the  influence  of  malignant  diphtheria,  and  that 
the  uterus  was  the   centre  of  the   mischief.      In   about   six   hours,  our  worst 

fears,  at  least  a-  to  the  nature  of  the  disease,  were  only  too  well  confirm*  d, 

for  at  midday,  we  saw,  behind  the  right  pillar  of  the  veil  of  the  palate,  a 
characteristic  exudation  of  a  tawny  yellow  color  of  the  >\/r  of  the  nail  of 
the  little  finger.  No  time  was  lost  in  vigorously  cauterizing  the  affected 
spot,  and  stripping  of}'  its  covering  of  false  membrane.  Unfortunately,  it 
was  trouble  lost,  as  we  found  ourselves  confronted  by  that  malignant  form 
of  diphtheria  regarding  which  I  am  now  lecturing — that  form  of  diphtheria 
in  which  local  manifestations  go  for  little  as  compared  to  the  general  -ymp- 


DIVERSITY    OF    LOCALIZATION    IN    DIPHTHERIA.  365 

toms,  and  in  which  topical  treatment  is  of  exceedingly  little  use.  At  six 
o'clock,  three  hours  after  the  appearance  of  the  pharyngeal  false  mem- 
brane, the  corresponding  side  of  the  uvula  was  implicated  :  some  hours 
later,  the  entire  veil  of  the  palate  was  involved,  and  covered  with  a  livid 
yellow  exudation  lying  on  the  mucous  membrane,  which  was  cedematous 
and  of  a  dull  red  color.  The  urine  was  found  to  contain  a  considerable 
quantity  of  albumen.  About  two  o'clock  in  the  morning,  the  patient  felt 
that  her  end  was  approaching.  She  spoke  to  her  family  with  great  com- 
posure, and  died  quietly,  almost  without  a  struggle,  at  a  quarter  past 
eight. 

Ou  the  same  day,  her  infant  died  of  diphtheria.  On  the  Thursday,  we 
had  observed  in  the  infant  a  plastic  exudation  on  the  alveolar  margin  of 
the  upper  maxilla.  Cauterization  with  solid  sulphate  of  copper  completely 
modified  the  affected  surface,  and  no  more  exudation  appeared  on  it.  But 
behind  the  left  ear,  on  the  excoriated  skin,  there  was  plastic  exudation  : 
this  surface  was  cauterized,  and  it  cicatrized  rapidly.  The  excoriations 
produced  by  the  forceps  ou  the  hairy  scalp  became  in  their  turn  affected: 
one  of  them,  now  a  sore  deep  and  penetrating  to  the  right  parietal  bone, 
had  a  grayish  coating,  with  edges  of  erysipelatous  redness.  The  facial 
paralysis  prevented  the  infant  from  sucking,  but  it  took  milk  from  a  glass. 
It  was  attacked  with  vomiting  and  diarrhoea  :  the  face  became  pinched, 
and  the  body  wasted  rapidly.  On  the  Sunday  morning,  convulsions  siq^er- 
vened,  and  recurred  incessantly  till  death  took  place  at  six  o'clock  in  the 
evening,  being  ten  hours  after  the  mother's  decease. 

These  two  cases  are  of  such  importance  as  to  be  laid  before  you  in  detail. 
Possibly,  while  the  diphtheritic  poisoning  may  have  imparted  to  the  puer- 
peral state,  both  in  mother  and  child,  its  appalling  malignity,  it  may  also, 
through  its  terrible  influence  on  the  economy,  have  arrested  the  peritonitis, 
Which  ceased  with  unlooked  for  promptitude.  It  is  not  an  unusual  occur- 
rence for  a  lying-in  woman  to  be  attacked  wdth  diphtheria.  Sometimes, 
and  possibly  it  was  so  in  the  case  of  our  young  woman,  the  pellicular  affec- 
tion invades  the  surface  of  the  uterus,  becoming  developed  on  the  placental 
wound,  as  occurred  in  numerous  cases  reported  by  Dr.  Behier. 

Diphtheria  of  the  genital  organs  is  an  affection  frequently  met  with,  espe- 
cially in  hospitals  for  children,  where  diphtheria  is  exceedingly  contagious, 
and  is,  so  to  speak,  established  in  permanence.  In  little  boys,  we  met  with 
excoriations  of  the  gland  and  prepuce  :  in  little  girls,  with  excoriations  of 
the  vulva  and  genito-crural  fold,  so  common  a  sequel  of  measles  :  in  both 
sexes,  excoriations  of  the  anus  constitute  the  door  through  which  the  dis- 
ease enters — these  excoriations  becoming  covered  with  plastic  exudation. 

In  the  medical  expedition,  which,  along  with  Dr.  Ramon,  I  made  in 
1828,  in  the  departments  of  Loiret  and  Loir-et-Cher,*  I  visited  the  com- 
mune of  Chaumont-sur-Tharonne,  situated  between  Romorantin  and  the 
Ferte-Beauharnais,  where  an  epidemic  of  malignant  sore  throat  was  very 
prevaleut,  and  where  several  persons  had  already  been  carried  off  by  it. 
The  daughter  of  the  watchman  of  Chaumont,  servant  at  a  farm-house  some 
distance  from  the  village,  feeling  the  first  symptoms  of  diphtheritic  sore 
throat,  ran  home  in  dismay  to  her  father's  house  in  Chaumont,  and  died 
there  a  few  days  after  her  arrival.  She  occupied  the  same  bed  with  her 
mother,  aged  40,  and  a  young  sister.  The  day  after  her  death,  her  mother 
experienced  dreadful  pains  in  the  vulva  and  lower  part  of  the  abdomen. 
Her  husband  examined  the  affected  parts,  and  it  is  from  him  that  1  obtained 

*  An  account  of  this  expedition  was  published  in  the  "  Archives  Gene'rales  de 
Me"decine,"  for  July,  1830. 


366  DIVERSITY    OF    LOCALIZATION    IN    DIPHTHERIA. 

an  account  of  them.  "  I  looked  and  saw,"  said  he,  to  use  his  own  exact 
words,  "  what  resembled  the  throats  of  our  childreu,  and  which  also  had  a 
very  bad  smell :  in  the  iuside  it  was  gray  and  black,  and  round  about  it 
was  red."  This  woman  died  in  five  days  from  the  time  she  began  to  com- 
plain, and  eight  days  after  the  death  of  her  first  daughter.  Scarcely  had 
a  week  elapsed  ere  the  second  daughter  perished  of  laryngotracheal  diph- 
theria. 

Facts  of  a  similar  nature  were  observed  at  Mezieres  (Loiret).  Malig- 
nant sore  throat  appeared  in  the  family  of  the  watchman  of  the  castle, 
where  a  child  six  years  old  had  died.  Soon  afterwards,  four  daughters  of 
a  man  named  Adam  who  lived  in  the  court  of  the  castle  died  of  diphtheria. 
One  of  them,  seven  years  old,  had  simultaneously  the  hands,  feet,  and  vulva 
invaded  by  pellicular  inflammation  similar  to  that  which  had  possession 
of  the  throat :  she  did  not  die  of  suffocation,  but  sunk  into  a  state  of  pro- 
found adynamia  which  soon  terminated  in  death.  This  case  was  commu- 
nicated to  me  by  Dr.  Carriere,  physician  at  Clery,  to  whom  I  am  also 
indebted  for  the  following  history. 

A  man  named  Montigny,  who  had  seen,  within  a  month,  six  of  his  chil- 
dren die  in  succession  of  malignant  sore  throat,  out  of  seven  attacked,  felt 
the  first  symptoms  of  that  malady,  while  at  the  same  time  the  prepuce 
became  covered  with  false  membrane. 

Dr.  l'Epine,  physician  to  the  prytaneum  of  La  Fleehe,  saw  a  similar  case 
during  the  epidemic  which  prevailed  in  that  establishment.  In  his  paper 
he  says  :  "  Mary,  nursing  sister  in  the  infirmary  of  the  school  of  La  Fleche, 
had  from  the  earliest  days  of  her  illness  presented  very  aggravated  symp- 
toms of  malignant  sore  throat.  The  disease,  after  having  made  great 
progress  on  the  tonsils,  appeared  at  the  anus.  The  anus,  very  much  swol- 
len, painful,  and  of  a  livid  red  color,  was  covered  with  a  diphtheritic 
pellicle,  which  could  only  be  detached  bit  by  bit,  and  very  slowly.  After 
showing  for  several  days  decided  symptoms  of  amendment,  she  fell  into  a 
state  of  extreme  adynamia,  having  very  frequent  and  protracted  fits  of 
syncope.     She  died  on  the  seventeenth  day  of  the  malady." 

Cutaneous  diphtheria  is  still  more  common  than  the  other  forms  of  diph- 
theria which  I  have  just  been  describing.  It  most  commonly  shows  itself 
upon  the  surfaces  to  which  blisters  have  been  applied,  in  the  folds  of  the 
skin  met  with  in  too  fat  children,  upon  chafed  surfaces,  upon  herpetic 
vesicles,  upon  chapped  breasts,  upon  cuts,  upon  excoriations  of  the  scrotum, 
upon  the  slightest  .solutions  of  continuity,  and,  in  a  word,  wherever  the  skin 
is  denuded  of  its  epidermis,  and  wherever  there  is  cutaneous  irritation  aris- 
ing spontaneously  or  from  an  injury.  It  supervenes  in  persons  who  have 
a  diphtheritic  affection  in  some  part  of  the  body,  as,  for  example,  pseudo- 
membranous sore  throat;  or,  its  appearance  may  be  the  first  declaration  of 
the  disease  in  individuals  who  have  been  in  contact  with  diphtheritic 
patients. 

Attention  was  direeled  to  cutaneous  diphtheria  by  Chomel  in  1759;  and 
by  Samuel  Bard  in  an  epidemic  which  he  observed  at  New  York  in  1771. 
The  following  is  the  notice  of  the  affection  given  by  the  American  phy- 
sician : 

"One  of  the  first  families, "  says  he,  "in  which  the  malady  appeared  was 
that  of  Mr.  William  Weddle.  There  were  seven  children  iii  the  house,  all 
of  whom  i'ell  ill  one  after  the  other.      The  four  who  were   firs!    affected,  the 

poungesl  of  the  family,  had  pharyngeal  sore  throat,  and  three  <>f  them  died. 

They  had  no  embarrassment  of  the  respiration,  bul  thai  symptom  was  re- 
placed by  had  ulcers  behind  the  ears.  These  ulcerations  commenced  ^ 
distinct  red  patches,  which  soon  became  unite. I.      They  caused  intense  itch- 


DIVERSITY    OP    LOCALIZATION    IN    DIPHTHERIA.  §67 

ing,  and  profusely  exuded  an  ichor,  so  acrid  as  to  erode  the  neighboring 
parts  in  such  a  way,  that  within  a  few  days  the  erosion  occupied  the  space 
behind  the  ear,  and  extended  down  to  the  neck.  All  the  patients  had  lever, 
particularly  at  night.  One  suffered  from  constant  tenesmus,  a  symptom 
present  in  several  of  those  who  had  difficulty  in  breathing,  but  in  none  did 
it  exist  to  so  remarkable  a  degree  as  in  the  case  referred  to.  Several  had 
ulcerations  behind  the  ear  similar  to  those  now  described  ;  and  some  pa- 
tients seemed  to  be  affected  with  slight  difficulty  of  breathing.  The  ul- 
cerations continued  during  several  weeks,  and  at  various  points  became 
covered  with  a  pellicle  similar  to  that  on  the  tonsils;  and  they  also  became 
very  painful." 

My  attention  was  never  so  much  occupied  with  this  subject  as  dining  the 
medical  expedition  to  which  I  have  referred,  and  regarding  which  I  am  now 
going  to  speak. 

Dr.  Ramon  and  I  were  informed  that  malignant  sore  throat  had  just 
broken  out  at  Nouan-le-Fuzelier,  in  the  department  of  Cher-et-Loir,  a 
village  on  the  road  from  Orleans  to  Bourges,  and  that  it  had  already  de- 
stroyed victims  there.  We  went  thither ;  and  Dr.  Lemenager,  a  physician 
residing  in  the  place,  had  the  goodness  to  go  with  us  to  the  houses  of  the 
patients.  Our  first  visit  was  to  the  house  of  a  woman  named  Josephine 
Pressior.  It  was  situated  at  the  northern  extremity  of  Nouan  ;  and  up  to 
that  time  there  had  been  no  cases  except  in  the  southern  district,  in  a 
hamlet  called  Les  Rois,  a  little  detached  from  the  village.  Josephine  in- 
formed us  that  her  daughter,  a  girl  of  18,  had  had  some  intercourse  with 
an  infected  family  in  the  hamlet  of  Les  Rois,  and  that  soon  afterwards  she 
had  been  attacked  by  pharyngeal  diphtheria.  When  we  saw  this  young 
woman,  she  was  in  the  eighth  day  of  the  malady.  Dr.  Lemenagar  had 
applied  leeches  to  the  neck,  had  three  times  touched  the  back  part  of  the 
mouth  with  a  solution  of  nitrate  of  silver,  and  had  several  times  insufflated 
alum.  He  had  likewise,  through  dread  of  gangrene,  had  a  camphorated 
decoction  of  cinchona  injected  into  the  throat,  and  had  prescribed  alum 
and  quinine  gargles.  On  the  fifth  day  of  the  disease,  a  blister  was  applied 
to  the  nape  of  the  neck :  profuse  suppuration  supervened,  the  abraded  sur- 
face became  covered  with  false  membrane,  and  likewise  an  old  ulcer  on  the 
foot  became  similarly  coated. 

I  found  the  child's  back  in  the  following  condition  :  the  blistered  surface, 
which  originally  was  not  more  than  three  inches  broad,  was  now  more  than 
six ;  it  was  horribly  painful,  and  was  suppurating  profusely ;  it  extended 
over  the  back,  making  irregular  deviations  like  the  marks  called  "points" 
on  a  backgammon  board ;  and  it  was  surrounded  by  a  large  erysipelatous 
areola,  much  more  apparent  below  than  above  or  at  the  sides.  The  part 
denuded  of  epidermis  seemed  to  be,  and  really  was  depressed,  in  consequence 
of  the  surrounding  tumefaction.  It  was  covered  with  superimposed  layers 
of  yellowish-white  fibrinous  deposit,  which  was  thickest  in  the  centre,  and 
gradually  became  thinner  as  it  approached  the  circumference.  In  the 
middle,  the  thickness  of  the  deposit  was  from  two  to  four  lines ;  it  bore  an 
exact  resemblance  to  the  dry  pleuritic  concretions  found  in  the  cavity  of 
the  chest  when  resolution  has  begun,  and  when  the  serous  fluid  which  was 
effused  has  been  almost  entirely  absorbed.  On  raising  some  of  these  con- 
cretions by  means  of  a  very  thin  leaf  of  metal,  we  saw  that  they  adhered 
strongly  to  the  cutaneous  tissue,  and  that  there  wras  a  certain  amount  of 
difficulty  in  detaching  them.  It  ought  to  be  mentioned  that  butter  only 
had  been  used  in  dressing  the  blister. 

The  surrounding  erysipelas  had  a  singular  aspect.  The  nearer  to  the 
excoriated  parts,  the  more  intense  was  the  redness.     At  numerous  points, 


368  DIVERSITY    OF    LOCALIZATION    IX    DIPHTHERIA. 

the  epidermis  was  raised  up  by  small  collections  of  lactescent  serosity,  so 
that  the  skin  was  covered  with  confluent  vesicles  in  the  neighborhood  of 
the  wound :  as  the  distance  from  the  healthy  skin  diminished,  so  also  di- 
minished the  number  of  the  vesicles.  Some  of  the  vesicles  seemed  to  be 
formed  by  the  union  of  several :  there  were  others  which  had  burst,  either 
when  single  or  united,  and  in  their  place  there  was  seen  a  white  mem- 
branous exudation  covering  the  dermis.  These  ulcerations  became  united 
to  others  of  smaller  size,  and  ultimately  they  all  coalesced  with  the  prin- 
cipal ulceration:  in  this  way  the  disease  advanced  step  by  step.  Let  me 
add  the  mention  of  a  fact  which  is  remarkable,  viz.,  that  the  erysipelas 
rarely  spreads  in  the  regions  of  the  head  and  shoulders,  and  is  indeed  sel- 
dom met  with  in  these  situations. 

Josephine  Pressoir,  the  mother,  being  in  the  fields  five  days  before  her 
daughter  fell  ill,  was  seized  with  acute  pain  in  one  of  the  breasts,  in  con- 
sequence, as  she  said,  of  catching  cold.  Inflammation  of  the  mammary 
cellular  tissue  soon  supervened,  and  an  abscess  firmed.  The  pus  found  an 
exit  for  itself:  at  the  most  elevated  part  of  the  tumor,  the  skin  became 
mortified  to  the  extent  of  about  three  lines,  and  thus  the  abscess  opened 
spontaneously.  I  saw  the  woman  the  day  after  this  occurrence  :  the  wound 
was  already  surrounded  with  an  erysipelatous  circle,  and  the  edges  of  the 
ulceration  were  covered  with  a  false  membrane  which  extended  over  the 
integuments  for  a  space  of  from  two  to  three  lines.  The  woman's  daughter 
was  at  this  time  in  the  eighth  day  of  her  diphtheria:  during  all  her  ill- 
ness, she  had  never  discontinued  to  sleep  with  her  mother. 

At  Blettiere,  a  farm  in  the  commune  of  Marcilly-en-Villette,  department 
of  the  Loiret,  five  persons  died  of  pharyngo-traehea]  diphtheria.  P.  A. 
Hure,  aged  ten,  slept  in  the  same  room  and  bed  with  those  who  were  car- 
ried off  by  the  malady.  Very  soon,  a  slight  inflammation  which  he  had 
behind  the  ears  became  aggravated,  the  skin  became  covered  with  false 
membrane,  pellicular  inflammation  extended  over  the  whole  back  ;  and  he 
died  in  a  few  days,  exhausted  by  horrible  pain  and  excessive  suppuration. 
Dr.  Regnaud,  physiciau  at  Ferte-Saint-Aubin  stated  that  he  had  seen 
another  patient  die  at  Marcilly  in  an  exactly  similar  manner  from  cutaneous 
diphtheria,  which  commenced  in  some  ulcerated  pustules  of  porrigo  favosa 
in  the  hairy  scalp,  whence  it  extended  to  the  neck,  back,  and  down  even  to 
the  loins.  He  also  communicated  to  me  the  history  of  a  man  of  Marcilly, 
in  whom  the  skin  of  the  scrotum,  previously  excoriated,  was  the  seat  of  a 
diphtheritic  a  fleet  ion. 

At  Grand-Pied-Blain,  a  grange  in  the  commune  of  Tremblevif,  rather 
less  than  a  quarter  of  a  league  southeast  from  Ferte-Beauharnais,  twelve 
persons  were  attacked  with  malignant  -ore  throat,  and  ten  of  them  died. 
To  the  mother  of  three  of  the  deceased  children,  a  blister  had  been  ap- 
plied as  a  measure  of  precaution — as  a  means  of  preventing  the  disease! 
But  in  a  few  days,  a  frightful  inflammation  took  possession  of  the  blistered 
surface  and  surrounding  parts:  in  a  very  short  time,  the  unfortunate 
woman  was  dead.  I  was  told  that  the  skin  of  the  neck  had  been  attacked 
by  gangrene. 

Similar  events  were  observed  in  the  family  of  Bouzy  at  the  hamlet  l>  - 
Rois,  uear  Nouan-le-Fuzelier.  Cases  had  already  occurred  in  mosl  of  the 
houses  in  the  hamlet  ;  and  a  little  girl  died  el'  the  malady  in  a  room  im- 
mediately adjoining  that  of  Bouzy.  A  young  man  named  Cauqui,  aged 
!'.i,  Blepl  in  the  same  room  with  Bouzy,  his  wife,  and  his  child,  lie  took 
malignant  sore  throat :  Bouzy,  terrorstruck,  applied  a  blister  to  both  anna 
of  his  child  "to  draw  out  the  bad  humors:"  almost  immediately,  the  blis- 
tered surfaces  became  covered  with  false  membrane,  and  the  surrounding 


DIVERSITY    OF    LOCALIZATION    IN    DIPHTHERIA.  369 

skin  became  inflamed.  On  the  fourth  day  of  the  malady,  when  I  first  saw 
this  child,  the  nose  was  obstructed  by  pellicular  exudation,  there  was  an 
extremely  fetid  serous  discharge  from  the  nostrils,  and  the  diphtheria  was 
beginning  to  invade  the  pharynx. 

At  Saint-Loup,  department  of  Loir-et-Cher,  of  twenty-one  persons  at- 
tacked with  diphtheria,  nineteen  died.  An  individual  named  Blaise,  deputy 
of  the  mayor,  and  his  wife,  had  just  left  their  two  children  :  they  themselves 
were  suffering  from  malignant  sore  throat  when  I  was  taken  to  their  house 
by  Dr.  Macaire  of  Menneton.  The  husband  was  already  improving,  thanks 
to  the  topical  treatment  which  had  been  adopted  ;  and  his  wife,  whose  larynx 
had  been  invaded  by  false  membrane,  was  beginning  to  breathe  more  easily, 
but  a  blister  had  been  put  on  the  left  arm,  which  was  in  a  truly  frightful 
state.  The  blistered  surface  was  remarkably  enlarged,  had  the  appearance 
of  being  much  depressed,  was  covered  with  a  blackish-gray  pellicular  exu- 
dation, aud  was  discharging  a  very  fetid  clear  serosity.  The  arm,  forearm, 
and  hand  Avere  swollen  and  had  a  glistening  rosy  color.  It  was  very  diffi- 
cult to  believe  that  the  blistered  surface  was  not  the  seat  of  mortification ; 
but  on  pricking  it  with  a  pin,  I  found  that  beneath  the  false  membrane,  the 
surface  was  exceedingly  sensitive.  I  powdered  the  broken  cutaneous  sur- 
face with  sublimated  calomel.  Next  morning,  the  pain  and  swelling  had 
almost  entirely  disappeared  :  the  same  treatment  was  continued.  Three  days 
from  the  commencement  of  the  treatment,  the  wound  was  quite  cleansed, 
laudable  pus  was  being  secreted,  and  the  false  membrane  had  entirely  dis- 
appeared. All  that  remained  was  a  small  slough,  which  separated  in  twelve 
or  fifteen  days. 

A  boy  had  just  died  of  tracheal  diphtheria  at  a  farm  in  the  department 
of  the  Indre.  Dr.  Bonsargent,  called  in  too  late,  was  unable  to  afford  him 
efficacious  treatment.  But  he  had  ordered  some  leeches  to  be  applied  to 
the  abdomen  of  the  mother,  who  was  complaining  of  pains  in  that  region. 
The  leech-bites  were  soon  inflamed  ;  and  the  skin,  after  becoming  erysipela- 
tous and  denuded  of  epidermis,  was  speedily  covered  with  false  membrane 
so  exceedingly  fetid  as  to  simulate  gangrene. 

Francois  Miniere,  aged  45,  a  district  roadman  of  Ghaumont-sur-Tharonne, 
department  of  Loir-et-Cher,  had  two  children  suffering  from  epidemic  sore 
throat.  One  died  :  the  other  was  cured  by  topical  treatment.  While  mat- 
ters were  thus  going  on,  the  father,  who  had  an  excoriation  at  the  inside  of 
the  metatarso-phalangeal  articulation,  began  to  feel  acute  pain  in  that  sit- 
uation. The  skin  soon  became  erysipelatous  and  denuded  of  epithelium  : 
some  days  later,  there  was  a  foul  ulcer,  with  thick  uneven  edges,  surrounded 
by  a  considerable  amount  of  swelling :  its  surface  was  covered  with  grayish 
false  membrane,  which  could  be  easily  stripped  off.  The  glands  of  the  groin 
and  inside  of  the  leg  were  a  good  deal  swollen.  About  six  grains  of  cal- 
omel were  sprinkled  over  the  affected  parts.  In  thirty-six  hours,  the  ulcer 
had  diminished  one-quarter  in  size,  the  pain  was  less  acute,  the  swelling  had 
disappeared,  and  there  was  no  longer  visible  any  false  membrane.  I  dis- 
continued personally  to  apply  the  calomel,  leaving  some  of  it  for  use  ;  but 
the  patient  lost  it,  and  the  ulcerated  surface  which  had  been  so  speedily  re- 
duced in  size,  remained  stationary  for  a  long  time. 

A  young  boy  of  Marcilly-en-Villette,  by  name  Denis-Lubin  Maitre,  and 
likewise  his  mother,  had  had  for  some  time  diphtheria  of  the  gums,  a  form 
of  the  disease  regarding  which  I  shall  afterwards  have  to  speak  to  you.  He 
died  of  diphtheria,  which  simultaneously  invaded  the  throat  and  hairy 
scalp.  This  boy  had  tinea.  His  brother,  aged  13,  a  cow-herd  at  Colom- 
bier,  commune  of  Menestreau,  came  to  Marcilly  when  his  father  and  sister 
were  ill :  soon  after  his  return  to  Colombier,  ulcerations  which  he  had  on 
vol.  i. — 24 


370  DIVERSITY    OF    LOCALIZATION    IN    DIPHTHERIA. 

his  head  became  horribly  painful,  and  discharged  a  great  quantity  of  fetid 
serosity.  I  got  these  particulars  from  the  boy  himself,  and  from  Madame 
Briolet  of  Cyran  who  attended  upon  him,  and  who  cured  him.  This  patient 
was  the  cause  of  the  epidemic  bi-eaking  out  in  the  place  where  he  resided. 
I  shall  recur  to  this  history,  when  I  make  some  remarks  on  the  contagion 
of  diphtheria. 

At  Paulmery,  near  Selles,  a  young  girl  had  contracted  the  disease :  she 
went  home  to  her  family  at  Barres  (department  of  Indre),  a  farm  situated 
a  league  from  Paulmery,  where  she  very  soon  died.  Her  two  sisters  also 
died.  Their  mother,  who  had  attended  upon  them,  took  diphtheria,  which 
attacked  the  neck  and  the  whole  of  the  right  side  of  the  face :  she  did  not 
die,  but  she  had  a  great  deal  of  suffering  and  a  tedious  recovery. 

At  Gracay  (Indre),  an  unweaned  male  infant  was  seized  with  diphthe- 
ritic sore  throat,  which  was  prevailing  as  an  epidemic.  Up  to  his  death, 
his  mother  suckled  him  :  her  nipple  soon  became  invaded  by  the  special  in- 
flammation, and  covered  with  false  membrane,  the  extension  of  which  was 
arrested  by  appropriate  treatment. 

At  the  same  period,  Dr.  J.  Bourgeois  observed  at  Ferte-Saint-Aubin,  in 
a  family  of  seven  persons,  an  epidemic  of  diphtheria,  which  affected  the  skin 
in  all  the  seven,  and  in  one  little  girl  the  vulva :  in  a  boy  who  died  of 
croup,  the  first  seat  of  the  disease  was  the  thigh,  at  a  point  slightly  excori- 
ated by  the  friction  caused  by  the  edge  of  a  wheelbarrow  in  which  he  had 
been  drawn  by  a  brother,  who  was  carried  off,  seven  days  before  the  former, 
by  laryngeal  diphtheria. 

Since  these  occurrences,  gentlemen,  similar  facts  have  greatly  multiplied, 
and  there  are  few  physicians  who  have  not  met  with  some  such  cases.  You 
have,  yourselves,  observed  a  certain  number  in  the  clinical  wards. 

In  a  female  infant  of  eighteen  months,  who  occupied  bed  No.  18  of  St. 
Bernard's  Ward,  I  showed  you. the  pellicular  affection  behind  the  ears  where 
there  had  been  eczema.  You  recollect  a  little  boy,  four  months  old,  in 
whom  diphtheria  declared  itself  in  the  front  of  the  neck,  upon  red  spots 
which  had  formed  between  the  folds  of  the  skin ;  it  soon  extended  to  the 
ears:  repeated  cauterizations  with  the  perchloride  of  iron  led  to  recovery. 
In  other  cases,  the  surfaces  to  which  blisters  had  been  applied  wire  attacked  : 
and  among  the  cases  of  this  description  was  a  male  child  who  lav  in  bed 
No.  15  of  our  nursery  ward.  He  had  a  blister  on  the  arm,  which  was  the 
cause  of  his  contracting  the  disease  from  a  woman  in  our  wards  who  lav 
close  to  his  cradle,  and  who  had  plastic  stomatitis. 

It  is  hardly  four  years  ago  since  I  was  sent  for  by  a  physician  to  sec  a 
child  with  pharyngeal  diphtheria.  The  progress  of  the  disease  had  become 
arrested  under  the  influence  of  very  energetic  topical  treatment;  but  the 
attending  physician  had  thought  it  necessary  to  apply  a  blister  to  the  front 
of  the  neck.  I  expressed  to  my  colleague  the  fears  which  I  entertained  re- 
garding the  blistered  surface,  which  I  said  there  was  every  reason  to  expect 
would  soon  be  covered  with  plastic  exudation,  which  would  soon  probably 
invade   the    front  of  the   chest.      I    advised    recourse    to  vigorous  measures. 

My  anticipations  were  but  too  completely  realized.  The  \\  hole  of  the  neck 
and  the  front  of  the  chesl  became  involved  in  diphtheritic  disease;  and  the 
little  patient  died,  not  ofcroup,  Imi  of  general  diphtheritic  poisoning. 

Very  recently,  I   was  asked    to  visil    a   girl,  ten  years  old,  who,  for  some 

days,  had  had  behind  the  ears,  diphtheritic  patches, developed  probably  on 
an  eczematic  surface.  The  eczema  had  been  neglected,  from,  I  regrel  to 
say,  the  singularly  mistaken  idea  of  the  attending  physician,  that  it  ought 
not  to  be  interfered  with,  its  existence  being,  in  bis  opinion,  rather  a  favor- 
able than  an  unfavorable  circumstance.       the  throat,  however,  was  in  turn 


DIVERSITY    OF    LOCALIZATION    IN    DIPHTHERIA.  371 

attacked;  and  when  I  saw  the  child,  I  found  both  tonsils  covered  with  false 
membrane,  which — as  well  as  the  cutaneous  deposits — I  hastened  energeti- 
cally to  cauterize.     The  little  girl  recovered. 

What  are  the  characteristics  of  cutaneous  diphtheria?  As  soon  as  it 
effects  a  solution  of  continuity,  pain  is  felt  in  the  part:  forthwith,  there  is 
a  profuse  discharge  of  fetid,  colorless  serosity ;  and  very  soon  the  surface  is 
covered  with  plastic  exudation,  flabby,  grayish,  and  variable  in  respect  of 
thickness.  The  edges  become  swollen,  assume  a  violet-red  hue,  and  appear 
much  raised  above  the  level  of  the  bottom  of  the  sore.  The  disease,  bow- 
ever,  does  not  generally  extend,  and  may  remain  stationary :  sometimes, 
however,  even  when  only  the  epidermis  has  been  removed,  we  see  the  dermis 
become  at  once  covered  with  a  white  plastic  exudation,  similar  to  that  ob- 
served upon  surfaces  to  which  blisters  have  been  applied.  Not  unfrequently, 
erysipelas  appears  around  the  excoriated  part.  The  epidermis  of  the  ery- 
sipelatous surface  is  raised  up  at  numerous  points  by  little  collections  of 
lactescent  serosity,  in  such  a  manner  that  the  skin  in  the  neighborhood  of 
the  sore  is  covered  with  confluent  vesicles:  the  vesicles  gradually  decrease 
in  number  with  the  increase  in  the  distance  between  the  sound  skin  and  the 
sores.  Some  of  the  vesicles  seem  to  have  been  formed  by  the  union  of 
several :  and  others,  simple  or  aggregate,  burst,  when  in  their  place  is  seen 
the  dermis  covered  with  a  white  plastic  exudation  :  these  excoriations  unite 
with  smaller  ones,  and  thus  form  a  junction  with  the  principal :  it  is  in  this 
way  that  the  disease  accomplishes  its  progressive  invasion.  Thus  it  is  that 
diphtheria,  commencing  in  a  slight  excoriation  of  the  hairy  scalp,  or  on  the 
skin  behind  the  ear,  may  invade  the  skin  down  to  the  loins,  as  I  have  seen 
in  several  cases.  The  pellicular  deposit,  at  first  thin,  becomes  gradually 
thicker,  the  layer  formed  last  on  the  skin  constantly  raising  up  those  pre- 
viously secreted,  so  as  at  last  to  constitute  a  coat  of  from  four  to  six  lines 
in  thickness.  The  layers  nearest  the  dermis  preserve  their  consistence  ;  but 
the  more  external  layers,  being  bathed  in  the  serous  discharge,  soften,  pu- 
trefy, change  color,  assuming  a  gray  or  sometimes  blackish  appearance,  and 
exhale  a  dreadful  fetor.  It  is  (as  in  pharyngeal  diphtheria)  very  difficult 
under  such  circumstances,  not  to  believe  that  there  is  extensive  sphacelus. 
I  do  not  say  that  there  are  no  cases  in  which  gangrene  may  not  attack 
parts  affected  with  diphtheria:  this,  in  fact,  does  occur,  and  particularly  in 
diphtheria  of  the  vulva,  as  I  mentioned  when  speaking  to  you  of  the  com- 
plications of  measles.  When  the  disease  spreads  with  rapidity,  or  when  it 
simultaneously  occupies  a  great  many  points,  there  maybe  high  fever;  but 
generally,  there  is  not  much  fever,  and  what  there  is  has  a  hectic  or  suppu- 
rative character. 

The  continuous  mode  in  which  the  invasion  of  diphtheria  takes  place  has 
this  peculiarity,  that  it  generally  advances  from  above  downwards.  Thus, 
for  example,  we  do  not  find  diphtheria  ascending  the  arm  to  the  shoulder, 
or  proceeding  from  the  neck  to  the  scalp ;  but,  on  the  contrary,  we  see  it 
descend  from  the  shoulder  to  the  arm,  from  the  neck  to  the  back,  from  the 
belly  to  the  loins,  and  from  the  nipple  to  the  rest  of  the  breast.  It  juts  out 
irregularly,  affecting  sometimes  the  shape  of  points  in  a  backgammon  table, 
the  surrounding  skin  presenting  a  dull  red  color.  It  is  very  probable  that 
the  propagation  of  the  diphtheritic  inflammation  is  accomplished  by  the 
irritation  induced  by  the  long  contact  of  the  serous  discharge  which  bathes 
the  parts  as  it  runs  downwards,  or  is  retained  by  the  dressings  in  particular 
situations. 

But  this  kind  of  extension  of  the  disease  differs  very  much  from  its  repeti- 
tion, if  I  may  be  allowed  so  to  express  myself.     It  is  enough  that  a  point 


372  DIVERSITY    OF    LOCALIZATION    IN    DIPHTHERIA. 

of  skin  or  mucous  surface  is  the  seat  of  the  pellicular  affection,  to  cause  the 
malady  to  repeat  itself  in  several  other  places  simultaneously,  under  the  in- 
fluence of  any  slight  accideutal  influence.  Thus,  as  I  have  already  said, 
cutaneous  diphtheria  may  develop  itself  in  individuals  suffering  from  pseudo- 
membranous sore  throat,  and  likewise,  diphtheria  primarily  developed  on 
the  skin,  may  become  the  starting-point  of  pseudo-membranous  pharyngeal 
and  laryngeal  affections. 

There  takes  place  what  we  see  occur  in  syphilis.  What  is  it  that  takes 
place  in  that  disease?  At  the  point  of  inoculation,  there  is  produced  the 
specific  ulceration,  the  chancre,  and  at  a  longer  or  shorter  interval  after 
the  sore  is  healed,  the  characteristic  constitutional  symptoms  of  pox  appear. 
In  cutaneous  diphtheria,  matters  proceed  more  rapidly,  but  in  a  similar 
manner.  An  abraded  surface  has  served  as  a  door  of  admission  for  the 
disease,  which  for  some  time,  remains  a  local  affection :  sometimes,  it  may 
be  destroyed  in  its  locality  by  energetic  treatment  at  the  opportune  moment, 
but  too  frequently,  notwithstanding  energetic  treatment,  and  even  when  we 
are  hoping  that  the  progress  of  the  malady  has  been  arrested,  diphtheritic 
exudations  appear  on  other  parts  of  the  body,  particularly  in  the  region  of 
the  pharynx,  the  favorite  seat  of  the  plastic  affection,  and  the  victim  dies 
in  a  profoundly  ansemic  state,  with  the  malignant  symptoms  already  de- 
scribed. Often,  even,  the  patient  sinks  prior  to  the  manifestation  of  any 
new  local  symptoms. 

Cutaneous  diphtheria,  under  which  term  I  include  diphtheria  of  the 
vulva,  vagina,  and  anus,  is  thus,  you  see,  a  much  more  formidable  disease 
than  the  croup-producing  pharyngeal  diphtheria:  it  is  more  formidable 
solely  on  account  of  the  intensity  of  the  inflammation,  which,  from  its  occu- 
pying a  large  surface,  may  lead  to  deepseated  mortification  of  tissues,  often 
the  starting-point  of  general  poisoning  of  the  system,  thus  constituting  that 
malignant  form  of  the  disease  to  which  I  have  directed  your  attention. 

These  facts  are  known,  but  they  are  not  as  yet  sufficiently  known.  I  am 
often  called,  and  you  too,  gentlemen,  will  often  be  called  to  children  suf- 
fering from  pharyngeal  diphtheria,  more  particularly  when  there  is  croup, 
to  whom  blisters  have  been  applied.  Again,  when  you  are  in  hopes  that 
you  have  saved  a  child  by  tracheotomy,  when  the  tracheal  wound  was 
nearly  closed,  and  all  seemed  going  well,  you  will  have  the  grief  to  see 
your  patient  perish  from  malignant  diphtheria,  which  may  have  had  it- 
starting-point  in  an  injurious  proceeding  of  the  relations,  or  sometimes  of 
the  medical  attendants. 

I  cannot,  therefore,  too  often  repeat  to  you:  Take  care  that  yon  do  not. 
for  any  reason  whatever,  apply  blisters  to  patients  suffering  from  croup: 
beware  of  wounds,  beware  of  the  very  smallest  solutions  of  continuity,  and 
of  leech-bites  in  persons  attacked  with  diphtheria.  When  yon  do  find  any 
solutions  of  continuity,  cauterize  them  vigorously  without  ioss  of  time,  with 
the  solid  nitrate  of  silver,  or  the  solid  sulphate  of  Copper :  powder  them 
with  calomel,  white  precipitate,  or  red  precipitate:  with  all  possible  expedi- 
tion, modify  the  morbid  action  of  the  affected  parts,  so  as  to  prevent,  as  far 
as  that  may  he  possible,  the  frightful  symptoms  which  will  otherwise  inev- 
itably declare  themselves. 


DIPHTHERIA    OF    THE    MOUTH.  373 


Diphtheria  of  the  Mouth. 

[Stomaeace. —  Watery  Chancres. — Scorbutic  Gangrene  of  the  (rums. — "  Fe- 
garit"  of  Spanish  Physicians. —  Ulcero-Stomatitis:  Ulcero-Membranous 
Stomatitis. — Diphtheria  of  the  Gum*.']  Of  all  the  manifestation*  of  Diph- 
theria, it  has  the  greatest  tendency  to  remain  confined  to  its  first  locality. — 
May  be  propagated  to  the  Pharynx  and  Larynx  and  produce  Croup. — 
May  lend  to  Gangrene. — May  be  a  manifestation  of  Malignant  Diph- 
theria.— Exceedingly  contagious. — Epidemic. 

Gentlemen:  Diphtheria  of  the  mouth  was  really  not  known  to  the 
physicians  of  our  day  till  after  the  publication  of  Bretonneau's  remark- 
able treatise  on  diphtheria.  In  calling  the  attention  of  his  contemporaries 
to  this  disease,  the  illustrious  physician  of  the  school  of  Tours  remarked 
that  it  was  one  of  the  species  of  stomacace  of  the  older  authors,  and  of  fegarit 
of  the  Spaniards,  names,  he  says,  which,  though  different  in  their  etymol- 
ogy, both  signify  malignant  ulceration  of  the  mouth.*  Van  Swieten  has 
devoted  a  special  paragraph  to  it ;  but  he  misunderstood  its  nature,  regard- 
ing it  as  a  scorbutic  affection.  However,  recalling  the  description  which 
Aretaeus  has  given  of  malignant  ulcers  of  the  tonsils — "tonsillarum  ulcera 
pestifera" — Van  Swieten  recognizes  the  connection  which  exists  between 
the  malignant  aphthse  and  the  Syrian  disease  :  he  admits  that  the  disease 
is  propagated,  not  only  to  the  pharynx,  but  also  to  the  respiratory  organs. 
These  facts  had  fallen  into  oblivion,  when  they  were  again  brought  to  light 
by  Bretonneau,  who  showed  that  pseudo-membranous  stomatitis,  pseudo- 
membranous sore  throat,  and  croup,  are  identical. 

In  1818,  when  the  legion  of  La  Vendee  was  in  garrison  at  Tours,  several 
soldiers  were  attacked  by  a'  particular  affection  of  the  gums  to  which  the 
surgeons  gave  the  name  of  land  scurvy  [scorbid  de  terre].  Within  a  very 
short  time,  nearly  the  entire  legion  was  attacked :  the  number  of  patients 
was  so  great  that  some  had  to  be  removed  from  the  surgical  to  the  medical 
wards,  a  circumstance  which  afforded  Bretonneau  an  opportunity  of  study- 
ing the  disease.  At  first,  he  also  believed  that  the  disease  was  scurvy.  He- 
perceived,  however,  that  the  outbreak  could  not  be  ascribed  to  the  influence 
of  diet  or  locality,  and  that  the  condition  of  the  patients  presented  no  trace 
of  scorbutic  cachexia  :  they  were  strong,  vigorous  men,  in  the  enjoyment 
of  perfect  health,  except  that  they  had  this  particular  affectiou.  This 
scurvy  had,  in  point  of  fact,  stomatitis  as  its  sole  manifestation  :  there  were 
no  ecchymoses,  no  stiff  joints,  no  hemorrhagic  tendency,  except  bleeding 
from  the  gums  :  in  a  word,  there  was  not  found  any  of  the  marvellous  symp- 
toms described  by  authors,  particularly  by  Lind.  Bretonneau  observed  that 
some  of  the  soldiers  affected  with  the  scorbutic  gangrene  took  diphtheritic 
sore  throat,  and  died  of  croup.  This  circumstance  led  him  to  reflect  on 
the  fact,  that  in  other  soldiers  of  the  same  legion  the  tonsils  were  primarily 
affected  by  the  plastic  inflammation,  which  exendeel  to  the  back  part  of  the 
throat  and  to  the  air-passages  :  he  then  came  to  the  conclusion  that  this 
so-called  scorbutic  gangrene  was  nothing  else  than  the  pellicular  disease 
occupying  the  gums,  and  wearing  a  particular  aspect.  At  precisely  the 
same  period,  some  cases  of  croup  occurred  in  the  vicinity  of  the  principal 
barracks  occupied  by  the  legion  of  La  Vendee.    The  physicians  of  the  town 

*  Van  Swieten:  Chapter,  "Dcl'Angine  gangreneuse"  commentary  on  Boer- 
haave's  Aphorism,  816. 


374  DIPHTHERIA    OF    THE    MOUTH. 

affirmed  that~up  to  that  time  they  had  not  met  with  a  single  case  in  the 
entire  course  of  their  practice  :  and  Bretonneau  himself  acknowledged  that 
he  had  only  twice  seen  croup.  Ere  long,  a  real  epidemic  of  the  disease 
scourged  the  town  of  Tours. 

Bretonneau,  having  examined  with  minute  attention  the  numerous  leasee 
which  were  passing  before  him,  very  soon  became  convinced  that  the  stoma- 
titis which  was  then  occurring  was  identical  with  the  disease  called  gan- 
grenous sore  throat.  He  assigned  to  the  disease  certain  characters,  which 
I  shall  now  endeavor  to  describe  to  you. 

After  experiencing  general  discomfort  for  some  days,  or  still  more  fre- 
quently, without  anything  to  announce  the  coming  on  of  the  symptoms, 
there  appear  on  the  free  margin  of  the  gums,  at  the  insertion  of  the  teeth , 
small,  yellowish-white,  oblong,  irregularly  rounded  patches,  forming  a  sort 
of  border  of  not  more  than  a  millimetre  in  breadth.  The  tartar  round  the 
neck  of,  and  on  the  substance  of  the  diseased  teeth,  is  deposited  in  greater 
abundance  than  usual  as  a  grayish,  brownish,  rusty-looking  mud.  The 
gums  are  gradually  destroyed  around  the  sockets  of  the  teeth,  in  conv- 
enience of  which  the  teeth  become  uncovered  and  loose.  The  rusty  color 
to  which  I  have  adverted  is  due  to  the  mixture  of  a  certain  quantity  of 
blood  with  the  peculiar  pseudo-membranous  exudation  from  the  gums. 
The  slightest  touch  causes  the  affected  parts  to  bleed,  and  even  by  gently 
separating  the  lips,  you  will  cause  little  drops  of  blood  to  fall  down..  The 
gums  are  painful,  and  to  a  certain  extent  swollen,  but  they  never  present 
the  blue  fungous  appearance  which  they  have  in  scurvy.  As  the  disease 
advances,  the  false  membranes  extend,  become  livid  or  black,  seem  as  if 
deeply  sunk,  and  are  surrounded  by  a  red  border  encircling  them  like  a 
cushion,  so  that  they  simulate  ill-conditioned  ulcers.  But  there  is  no  ulcer- 
ation ;  and  the  false  membranes  are  easily  detached  from  the  mucous  mem- 
brane which  they  cover.  When,  however,  the  false  membranes  are  removed, 
they  are  speedily  replaced  by  others.  The  lymphatic  glands  of  the  sub- 
maxillary region,  which  from  the  onset  of  the  disease  had  begun  to  be 
swollen  and  painful,  particularly  when  touched,  now  become  more  swollen, 
and  embrace  the  neighboring  parts  in  the  tumefaction. 

A  considerable  flow  of  saliva  and  sanious  serosity  wets  and  stains  the 
linen  of  the  patient:  this  discharge  continues  during  sleep.  The  breath 
exhales  an  intolerably  fetid  odor:  this  fetor,  combined  with  the  appearance 
of  the  affected  parts,  gives  the  disease  a  very  great  resemblance  to  gangrene. 
But  here,  again,  appearances  are  deceitful.  There  is  here  no  more  gangrene 
than  there  is  in  pharyngeal  diphtheria:  nevertheless,  just  as  I  was  careful 
to  tell  you,  that  in  some  rare  instances  pseudo-membranous  sore  throat  leads 
to  sphacelus  of  subjacent  tissues,  so  must  I  state,  that  plastic  stomatitis  may 
lead  to  a  similar  result.  I  must  add,  that  this  consecutive  gangrene  is  a 
much  more  common  sequel  of  buccal  than  of  pharyngeal  diphtheria.  It  is 
far  more  frequently  met  with  in  hospital  than  in  private  practice:  indeed, 
in  the  latter,  I  have  never  yet  seen  it. 

There  i-  ooperiocfof  life  at  which  diphtheria  of  the  mouth  does  not  occur; 
but  it  is  a  rare  affection  among  young  children,  and  exceedingly  rare  amoftg 
infants  at  the  breast.  Bretonneau's  firsl  observations,  ;i-  you  are  aware, 
were  made  on  soldiers,  consequently  upon  adults.  It  i.-.  in  general,  at  the 
socket  of  a  diseased  tooth  that  diphtheria  of  the  mouth  begins,  and  thence 
it  proceeds  to  invade  the  rest  of  the  gums. 

There  is  no  form  of  diphtheria  which  lias  so  strong  a  disposition  as  diph- 
theria of  the  mouth  to  localize  itself  withonl  spreading  to  neighboring  parts. 

Thus,  although  diphtheria  of  the  pharynx  has  a  tendency  to  advance  from 
one  place  to  another,  like  lava  flowing  from  a  crater,  diphtheria  of  the  gums 


DIPHTHERIA    OF    THE    MOUTH.  375 

may  remain  stationary  for  some  months.  It  would,  however,  he  a  mistake 
to  believe  that  it  never  extends.  Not  unfrequently  the  malady  is  commu- 
nicated from  the  gums  to  the  mucous  membrane  of  the  cheeks,  and  inside 
of  the  lips,  forming  a  junction  with  the  white  spots,  which  then  soon  increase 
in  size.  Afterwards,  in  their  turn,  the  veil  of  the  palate  and  the  tonsils 
may  become  implicated,  as  in  cases  observed  by  Bretonneau  ;  the  malady 
may  then  advance  by  the  line  of  march  which  I  have  already  pointed  out, 
invading  the  larynx  and  trachea,  and  at  last  causing  death  by  croup.  I 
shall  now  textually  quote  to  you  one  of  Bretonneau's  illustrations. 

"At  the  end  of  the  epidemic,"  says  Bretonneau,  "eight  children,  between 
nine  and  ten  years  of  age,  who  slept  in  the  same  dormitory  at  the  Orphan 
Asylum,  were  attacked  during  the  same  week  with  scorbutic  gangrene  of 
the  gums.  I  have  noted  a  peculiarity  which  I  am  quite  unable  to  explain, 
and  which  no  circumstance  of  which  I  am  awai-e  offers  any  plausible  ex- 
planation :  all  the  eight  were  affected  on  the  right  side.  From  the  second 
day  of  the  invasion  of  the  disease,  three  had  the  corresponding  tonsil  swollen 
and  covered  with  pellicular  deposit."  "  Is  it  not  possible,"  adds  the  author, 
"  that  the  diphtheritic  inflammation  might  have  rapidly  reached  the  larynx, 
had  not  its  progress  been  arrested  by  the  application  of  strong  hydrochloric 
acid,  the  effect  of  which  was  so  prompt  and  efficacious,  that  in  a  few  hours 
after  it  was  first  applied  the  swelling  of  the  lymphatic  glands  was  sensibly 
diminished  ?"* 

It  is  when  diphtheria  reaches  the  inside  of  the  cheeks  that  it  has  a  ten- 
dency to  terminate  in  gangrene.  After  remaining  confined  to  the  gums  for 
one  or  several  months,  after  remaining  confined  to  the  mucous  membrane 
of  the  mouth  for  a  period  of  which  it  is  impossbile  to  state  the  limits,  an 
oedemato-phlegmonous  swelling  of  the  face  supervenes :  the  skin  of  the  face 
becomes  red,  the  tissues  acquire  considerable  hardness,  and  ere  long  gan- 
grene of  the  mouth,  with  all  its  characteristics,  involves  the  cheek,  as  well 
as  the  gum  which  was  the  starting-point  of  the  evil. 

The  identity  of  buccal  and  pharyngeal  diphtheria  with  croup  has  been 
established  beyond  dispute  by  the  researches  of  Bretonneau.  It  is  fully 
proved  by  the  fact,  that  the  plastic  affection  of  the  gums  may  be  propagated 
to  the  pharynx  and  larynx.  Moreover,  the  case  which  I  quoted  to  you  of 
the  infant  who  died  almost  simultaneously  with  the  mother  from  malignant 
diphtheria,  of  which  the  first  appearance  was  in  the  gums,  also  shows  that 
there  exists  that  complete  identity  in  which  I  believe.  One  of  my  most 
distinguished  colleagues,  Dr.  Jules  Bergeron,  physician  to  the  Hopital 
Sainte-Eugenie,  in  an  interesting  and  conscientious  work,f  while  he  holds 
that  the  disease  he  describes  is  the  same  as  that  observed  by  Bretonneau  in 
1818,  denies  that  ulcerous  stomatitis  is  a  diphtheritic  affection.  He  rests 
his  opinion  upon  two  facts,  viz.,  that  in  none  of  his  cases  of  ulcerous  stoma- 
titis— all  carefully  observed — did  the  malady  ever  propagate  itself  beyond 
the  gums,  and  that  in  none  were  there  any  symptoms  of  toxaemia.  Against 
these  arguments  may  be  placed  the  cases  observed  by  Bretonneau,  in  which 
the  kind  of  propagation  was  seen  of  which  Bergeron  denies  the  occurrence. 
But  by  reading  the-  lucidly  drawn  descriptions  of  Dr.  Bergeron,  it  is 
easy  to  satisfy  oneself  that  the  ulcerous  stomatitis  of  which  he  speaks  was 
very  different  from  the  plastic  stomatitis  of  the  legion  of  La  Vendee  :  the 
single  fact  of  the  existence  of  ulcerations  would  suffice  to  establish  this 

*  Bretonneau:  Des  Inflammations  Speciales  du  Tissu  Muqueux,  et  en  particulior 
de  la  Diphtherite,  p.  127.     Paris,  1826. 

t  BerCtEron  (Jules)  :  Stomatite  ITlcereuse  des  Soldats.  [Recueil  de  Memoires  de 
Medecine  MUitaire.]     Paris,  1859. 


376  NATURE    OF    DIPHTHERIA. 

difference — you  can,  I  say,  find  the  proof  of  the  correctness  of  this  state- 
ment in  Bergeron's  treatise,  and  in  other  works  subsequently  published  on 
the  subject.  In  diphtheria  of  the  gums  or  mouth,  the  plastic  exudatiou 
leaves  uninjured  the  mucous  membrane  which  it  covers;  or,  at  all  events, 
there  is  nothing  like  real  ulceration. 

Apart  from  the  possibility  of  the  propagation  of  the  disease  to  the  pharynx 
and  larynx,  apart  perhaps  from  that  which  shows  itself  as  the  first  symptom 
of  malignant  diphtheria,  plastic  stomatitis  is  identical  in  its  nature  with 
other  diphtheritic  affections.  This  identity  is  further  shown  by  the  con- 
tagiousness of  both  affections.  The  plastic  affection  of  the  gums  is  not  only 
communicated  as  stomatitis,  but  likewise  as  pharyngeal,  or  even  as  malig- 
nant diphtheria. 

Thus,  as  I  have  told  you,  in  the  Tours  epidemic  of  1818,  no  one  could 
recollect  seeing  cases  of  pseudo-membranous  sore  throat  or  croup  prior  to 
the  arrival  of  the  legion  of  La  Vendee,  which  brought  diphtheria  to  the 
town.  I  have  also  told  you  that  the  first  cases  occurred  in  the  neighbor- 
hood of  the  principal  barracks,  which  were  occupied  by  the  soldiers  of  that 
legion.  In  a  family,  one  member  of  whom  was  attacked  with  pseudo-mem- 
branous stomatitis,  some  were  similarly  affected,  while  others  took  pharyn- 
geal diphtheria,  croup,  and  cutaneous  diphtheria.  Such  facts  admit  of 
being  more  easily  ascertained  when  they  occur  in  small  districts,  where 
physicians  can  trace  the  malady  back  to  its  source,  where,  so  to  speak,  they 
at  a  glance  can  understand  what  is  going  on,  and  follow,  step  by  step,  the 
invading  march  of  the  epidemic. 


Xature  of  Diphtheria. — Contagion.— Alteration  of 
the  Blood. — Albuminuria. 

Gentlemen:  At  the  period  when  Bretonneau  wrote  his  treatise  on 
diphtheria,  medicine,  French  medicine  at  least — was  under  the  dominion 
of  the  physiological  doctrines  of  Brotissais  :  his  theory  of  inflammation 
reigned  supreme  throughout  the  entire  domain  of  pathology,  so  that  in  al! 
diseases,  inflammation  was  regarded  as  the  only  element  of  which  it  was 
necessary  to  take  account.  Pinel,  however,  had  shown  that  in  different  or- 
ganic tissues,  inflammation  underwent  very  characteristic  changes:  the 
illustrious  author  of  the  Nosographie  Philosophique  had  already  thrown  a 
great  deal  of  light  upon  the  history  of  diseases,  and  given  a  new  impulse  to 
the  spirit  of  observation.  Bretonneau,  proceeding  further  than  Pinel,  in 
his  turn  .-bowed,  that  the  various  inflammatory  alteration-,  and  the  phe- 
nomena which  accompany  them,  do  not  exclusively  depend  upon  the  spe- 
cialty of  the  affected  tissues:  he  demonstrated  in  his  remarkable  works  on 
diphtheria  and  dothiuenteria  that  the  specific  character  of  the  inflamma- 
tion, much  more  than  its  intensity,  and  much  more  than  the  nature  of  the 
tissue  in  which  it  is  seated,  exerts  an  influence  upon  the  functional  disturb- 
ance produced  by  each  inflammatory  Lesion:  it  is,  he  said,  to  the  specific 
character  of  the  inflammation  that  the  duration,  severity,  and  danger  of 
most  pyrexiae  are  attributable. 

The  malady  winch  we  are  now  studying  was  not  regarded  as  an  excep- 
tion to  the  absolute  rule  which  it  was  attempted  to  lav  down.  In  pseudo- 
membranous sore  throat  ami  in  croup,  nothing  was  seen  hut  an  inflamma- 
tion ofthethroal  or  larynx,  which  it  was  deemed  essential  to  treat  by  anti- 
phlogistic measures.  Sere,  unquestionably,  the  inflammatory  element  may 
play  its  part:  hut  this,  so  far  from  being  the  chief  part,  i-  quite  subordi- 
nate;  exactly  a-  in   small-pox,  and  measles,  a-   well  afi  in  other  disea.-c.-,  it 


NATURE    OF    DIPHTHERIA.  377 

is  subordinate  to  the  nature  of  the  presiding  cause,  which  imposes  on  it  its 

peculiar  stamp. 

There  is,  however,  an  essential  difference  between  the  diseases  which  I 
have  just  named  and  diphtheria:  this  difference  consists  in  the  greater  im- 
portance which  in  diphtheria  attaches  to  the  local  affection.     In  small-pox 

lor  example,  we  look  at  the  pustules  chiefly  in  relation  to  their  diagnostic 
and  prognostic  significance,  but  in  diphtheria,  we  regard  the  local  manifes- 
tations from  the  treatment  point  of  view.  In  diphtheria,  it  is  just  as  in 
malignant  pustule,  in  which  malady,  by  making  a  direct  attack  upon  the 
local  affection,  we  stop  the  progress  of  the  general  disease  of  which  the  pus- 
tule is  the  first  manifestation.  So  is  it  also  in  diphtheria  :  by  energetically 
treating  the  local  affection,  as  soon  as  it  shows  itself,  we  arrest  its  progress, 
and  prevent  the  occurrence  of  ulterior  symptoms.  I  shall  return  to  this 
point,  when  I  come  to  discuss  the  subject  of  treatment. 

Whatever  local  manifestations,  and  whatever  general  forms  diphtheria 
may  assume,  it  is  always,  in  its  essential  nature,  the  same  disease :  it  is  the 
same  disease  whether  it  affect  the  mucous  membranes  or  the  skin ;  whether 
it  appear  as  a  pharyngeal,  laryngeal,  or  bronchial  affection,  as  stomatitis, 
as  plastic  coryza,  or  as  a  cutaneous,  vulvar,  anal,  or  preputial  affection,  it 
is  the  same.  The  diversity  of  aspect  presented  by  the  local  affections  de- 
pends solely  upon  the  diversity  in  the  nature  of  the  tissues  iu  which  the 
morbid  action  shows  itself:  the  different  manifestations  all  originate  in  one 
sole  cause.  The  indisputable  correctness  of  this  statement  is  shown  by 
what  takes  place  in  epidemics,  when  we  see  diphtheria  transmitted  from 
person  to  person,  assuming  a  variety  of  forms,  and  exhibiting  great  di- 
versity in  its  localization  ;  when,  for  instance,  we  see  a  patient  who  is  af- 
fected with  diphtheria  of  the  gums  communicate  to  other  persons  pseudo- 
membranous sore  throat,  croup,  cutaneous  diphtheria,  or  some  other  form 
of  the  pellicular  disease.  Dr.  Guersant  mentions  a  case  in  which  diph- 
theria of  the  prepuce  in  a  child  was  the  starting-point  of  pseudo-mem- 
branous sore  throat  in  the  brother  and  the  father. 

Looking  at  the  great  differences  which  there  are  in  the  symptoms  pre- 
sented by  the  different  forms  of  the  disease,  it  might  seem  that  that  form 
which  kills  by  attacking  the  air-passages — simple  or  genuine  diphtheria, — 
and  that  which  kills  by  general  poisoning — malignant  diphtheria — are  in 
their  nature  very  distinct  from  one  another.  But  it  is  not  so,  gentlemen  ; 
under  this  diversity  of  form,  just  as  amid  the  variety  of  the  local  affections, 
it  is  always  the  same  disease  which  we  encounter:  it  is  always  diphtheria, 
just  as  it  is  always  small-pox,  whether  the  form  be  confluent  or  distinct, 
mild  or  malignant.  The  transformations  which  the  disease  undergoes  in 
accordance  with  the  nature  of  the  epidemic  depend  on  I  know  not  what — 
on  a  something  which  we  agree  to  call  the  character  of  the  epidemic  \_genie 
qjidemique']  :  this  diversity  of  form  met  with  in  the  same  epidemic  depends 
upon  the  natural  or  acquired  peculiarity  of  the  individual.  From  this 
point  of  view,  the  comparison  which  I  have  made  between  diphtheria  and 
small-pox  appears  to  me  all  the  more  appropriate,  that,  besides  the  simple 
and  malignant  forms  of  which  I  have  spoken,  the  pellicular  disease  assumes 
an  aspect  which  is  analogous  to  the  relation  which  modified  small-pox  bears 
to  small-pox.  Indeed,  in  some  epidemics,  individuals  are  seen  to  take  sore 
throats,  which,  in  respect  of  anatomical  characters,  seem  to  be  of  the  com- 
mon membranous  kind,  such  as  result  from  herpes  of  the  pharynx,  or  even 
simple  sore  throat ;  while  they  are  in  reality  diphtheritic  sore  throats,  modi- 
fied in  a  remarkable  manner.  That  which  makes  my  comparison  thoroughly 
appropriate,  that  which  proves  the  identity  of  the  nature  of  the  different 
forms  of  diphtheria  is,  that  each  of  them,  in  passing  from  one  individual 


378  NATURE    OF    DIPHTHERIA. 

to  another,  may  declare  itself  under  a  particular  form  :  modified  diphthe- 
ritic sore  throat,  for  example,  may  give  either  simple  or  malignant  diph- 
theria, just  as  modified  small-pox  may  give  distinct  or  confluent  small-pox ; 
and  vice  versa.  At  the  meeting  of  the  Medical  Society  of  the  Parisian 
Hospitals,  held  on  the  25th  August,  1858,  my  honorable  colleague  Dr. 
Alphonse  Guerard  stated  the  following  circumstances,  which,  within  a 
period  of  about  six  weeks,  he  had  recently  observed  in  one  family.  A  child 
died  of  laryngeal  croup:  two  days  afterwards,  two  young  girls  took  ery- 
thematous sore  throat,  and  were  attended  by  our  lamented  brother,  Dr. 
Gillette.  Some  days  later,  the  father,  aged  forty-five,  a  patient  of  Dr. 
Guerard,  took  a  pseudo-membranous  pharyngeal  sore  throat.  Two  other 
children  of  the  family  were  next  attacked,  one  with  simple,  and  the  other 
with  membranous  sore  throat. 

A  similar  history  was  communicated  by  Dr.  Henri  Roger  to  Dr.  Peter, 
who  has  published  it  in  his  inaugural  thesis. 

"  G.,  aged  two  months,  was  seized  with  membranous  sore  throat  on  the 
17th  May,  which  proved  fatal  on  the  22d.  During  the  evening  of  the 
21st,  the  mother,  a  woman  twenty-two  years  of  age,  had  general  discomfort 
and  fever.  There  was  also  sore  throat;  and  within  twenty-four  hours,  a 
whitish  speck  appeared  on  the  right  tonsil.  On  the  following  day,  false 
membrane  was  observed  on  both  tonsils.  The  submaxillary  glands  were 
engorged,  and  chaps  round  the  nipple  were  covered  with  pellicular  deposit. 
During  the  following  days,  the  general  and  local  symptoms  became  more 
severe.  Ultimately,  there  was  a  gradual  and  slow  amendment.  At  the 
beginning  of  June,  the  false  membranes  had  completely  disappeared  ;  but 
there  was  an  abscess  in  the  right  tonsil.  The  woman  was,  however,  quite 
well  by  the  11th  June. 

"The  child's  nurse,  a  woman  aged  33,  was  seized  with  sore  throat,  which 
was  severe,  but  not  pseudo-membranous.  In  this  case,  the  malady  con- 
tinued for  thirteen  days — that  is,  from  the  23d  May  to  the  4th  June. 

"The  father  of  the  child  G.,  a  man  of  35  years  of  age,  had  a  simple  sore 
throat  of  average  severity,  which  lasted  four  days — that  is,  from  the  25th 
to  the  29th  June. 

"The  child's  grandfather  and  grandmother,  who  went  daily  to  see  their 
children,  particularly  the  grandmother,  who  had  attended  upon  them,  had 
very  mild  sore  throats. 

"A  lady  residing  in  the  neighborhood,  a  friend  of  the  family,  who  came 
often  to  the  house,  was  attacked  by  laryngitis. 

"The  cook,  a  woman  above  forty,  had  no  symptom  of  sore  throat."* 

Dr.  Peter  follows  up  this  group  of  eases  with  some  remarks  in  which  1 
cordially  concur.  He  then,  in  contrast  with  the  cases  just  quoted,  in  which 
tli>-  severity  of  the  cases  diminished  progressively  in  transmission  from  chil- 
dren to  adults,  mentions  another  series  "I'  case8,  in  which  there  was  an  in- 
verse progress  of  the  malady,  in  which  it  passed  from  adults  to  a  child, 
and  from  that  child  to  an  oldish  man.  The  following  i-  the  history  of  the 
disease  in  the  family  in  question. 

The  husband  of  the  female  servant  was  the  first  who  took  ill:  he  com- 
municated pseudo-membranous  sore  throat  to  his  wife:  she  recovered.  Sb 
davs  later,  the  child  of  the  master  of  the  house,  twenty-six  months  old.  wa- 

attacked  by  pharyngeal  diphtheria  :  then,  on  the  twelfth  day.  the  larynx 
was  invaded;  and  next  day,  when  Dr.  Gillette  did  me  the  honor  to  consult 
with  me  on  the  case,  the  croup  was  for  advanced.     In  the  evening,  Dr. 


•   Peter  (Michel) :   Recbercbes  sur  la  Diphthente  etleCroup      Paris,  1859. 


CONTAGION    OF    DIPHTHERIA.  370 

Peter  performed  tracheotomy  ;  but  this  did  riot  save  the  child,  who  died 
"ii  r lit-  fourth  day  after  the  operation. 

It  was  from  this  child,  when  he  was  attending  upon  him,  that  our 
lamented  brother  Gillette  took  diphtheria,  from  the  consequent  croup  of 
which  he  died,  without  tracheotomy  having. been  tried,  as  the  pseudo-mem- 
branous exudation  had  reached  the  bronchial  tubes. 

Diphtheria,  then,  is  pre-eminently  a  specific  disease,  the  different  local 
and  general  tonus  of  which,  constituting  merely  varieties  of  a  species,  are 
attributable  to  the  action  of  the  same  morbific  principle,  a  specific  morbid 
poison  :  in  a  word,  it  is  a  pestilential  disease.  Like  all  diseases  of  an  un- 
questionably specific  character,  it  is  contagious  ;  and  perhaps  is  inoculable. 
The  cases,  however,  which  have  been  brought  forward  in  proof  of  the  pos- 
sibility of  inoculating  diphtheria,  particularly  those  communicated  to  the 
Hospitals'  Medical  Society  by  Dr.  Bergeron,  are  very  open  to  be  called  in 
question,  and  the  experiments  performed  with  a  view  to  arrive  at  a  rigor- 
ous demonstration  of  facts  have  as  yet  been  barren  of  results.  I  am  not 
speaking  of  the  experiments  made  on  animals,  for  it  is  admitted  that  in 
respect  of  inoculation  in  the  human  subject,  no  conclusions  can  be  derived 
from  experiments  made  on  animals  :  I  am  only  referring  at  present  to  the 
inoculation  of  the  disease  from  man  to  man.  In  1828,1  tried  ineffectually 
to  inoculate  myself  with  diphtheria,  by  means  of  punctures  on  the  left  arm, 
tonsils,  and  veil  of  the  palate,  made  with  a  lancet  moistened  by  contact 
with  a  false  membrane  which  I  had  just  removed  from  a  diphtheritic  sore. 
Dr.  Peter,  in  the  excellent  work  which  I  have  already  quoted  several  times, 
states  that  upon  three  occasions  he  repeated  the  same  experiment  on  him- 
self without  obtaining  any  result.  In  the  first  instance,  when  performing 
tracheotomy  on  a  child,  he  received  on  the  surface  of  the  cornea  of  the  left 
eye,  a  semi-liquid  pseudo-membranous  exudation,  which  for  a  moment  cov- 
ered the  globe  of  the  eye,  and  the  most  fluid  part  of  which  insinuated  itself 
under  the  eyelids  :  he  did  not  wash  the  eye,  yet  no  consequences  followed 
the  occurrence  described.  On  the  second  occasion,  he  made  three  punc- 
tures in  the  lower  lip,  with  a  lancet  moistened  with  semi-fluid  diphtheritic 
exudation  :  he  experienced  no  derangement  of  health  from  the  proceeding. 
On  the  third  occasion,  this  dai'ing  experimenter  painted  the  tonsils,  the 
pillars  of  the  veil  of  the  palate,  and  the  back  of  the  pharynx  by  means  of 
a  dossil  of  charpie  soaked  in  diphtheritic  matter  :  again  the  result  was 
negative.  It  therefore  seems  possible,  gentlemen,  from  these  experiments, 
that  diphtheria  is  not  more  inoculable  than  measles,  scarlatina,  and  hoop- 
ing-cough, maladies  the  contagious  character  of  which  no  one  doubts. 

If  any  one,  in  times  past,  has  for  a  moment  denied  the  contagious,  char- 
acter of  diphtheria,  forgetting  the  observations  of  our  predecessors,  among 
others  those  of  Rosen,  and  long  before  him,  those  of  Cortesius,  and  De 
Wedel,  no  one  in  the  present  day  could  dispute  that  it  is  contagious.  Bre- 
tonneau,  in  his  treatise  on  diphtheria,  called  attention  to  this  point,  and 
again,  in  a  more  special  manner,  returned  to  the  subject,  in  his  last  work, 
which  appeared  in  the  "  Archives  Generates  de  Medeciue"  for  the  year 
1855.  Numerous  facts  are  therein  collected  from  the  history  of  epidemics 
in  all  quarters.  Nevertheless,  it  is  not  always  easy  to  perceive  the  manner 
in  which  the  disease  has  been  transmitted  from  one  place  to  another.  In 
some  instances,  however,  one  can  trace  it  back  to  its  origin  ;  and  that  can 
be  done  in  the  following  case,  the  history  of  which  is  undoubtedlty  au- 
thentic. 

The  epidemic  of  diphtheria  which  prevailed  at  Fresnay-le-Ravier,  arron- 
dissement  of  Xevers,  in  1858,  had  as  its  starting-point  a  child  who  had  been 


380  ALBUMINURIA    IN    DIPHTHERIA. 

brought  from  Paris.  That  child  died,  also  the  infant  of  the  nurse,  and  the 
nurse  herself.     The  scourage  then  broke  out  in  the  village. 

Once  diphtheria  enters  a  house,  it  has  an  undoubted  tendency  to  propa- 
gate itself  by  contact  from  individual  to  individual.  How  frequently  we 
see  almost  all  the  children  in  a  family  attacked  in  succession,  while  the 
father,  mother,  and  attendants  on  the  sick  are  also  brought  more  or  less 
under  the  influence  of  the  disease!  I  have  given  you  examples  of  this; 
and,  as  you  are  aware,  the  medical  profession  has  paid  a  heavy  tribute  in 
life  to  the  contagious  power  of  this  frightful  disease.  I  have  already  men- 
tioned Valleix,  Henri  Blache,  and  Gillette,  to  which  list,  too  long  though 
it  be,  there  remain,  I  doubt  not,  other  names  to  be  added. 

It  appears,  then,  that  the  question  of  the  contagious  character  of  diph- 
theria is  at  present  generally  answered  in  the  affirmative.  It  was  lately 
under  discussion  in  the  Hospitals'  Medical  Society,  and  the  subject  of  an 
excellent  communication  by  Dr.  Henri  Roger,  in  which  his  object  was  to 
establish,  on  the  basis  of  a  series  of  authentic  and  rigorously  observed  cases, 
not  only  the  contagious  character  of  diphtheria,  but  likewise  the  duration 
of  the  incubation  of  the  diphtheritic  poison.  From  these  researches,  it 
seems  that  the  period  of  incubation  generally  ranges  between  two  and  seven 
days  :  you  must  bear  in  mind,  however,  that  in  consequence  of  the  impossi- 
bility of  inoculating  diphtheria,  this  statement  must  be  regarded  as  only  a 
near  approximation  to  the  truth. 

I  have  told  you,  that  diphtheria,  in  its  malignant  form,  kills  after  the 
manner  of  septic  diseases,  by  a  sort  of  general  and  complete  poisoning  of 
the  system.  This  poisoning  shows  itself  during  life  by  the  local  and  gen- 
eral symptoms  which  I  have  described :  it  is  characterized  by  a  peculiar 
alteration  in  the  blood,  which  is  found  on  necroscopic  observation ;  also 
by  albuminuria,  a  functional  disturbance,  met  with  in  a  great  number  of 
septic  diseases,  such  as  variola,  scarlatina,  dothiuenteria,  and  cholera  ;  and 
finally,  it  is  characterized  by  paralytic  complications,  to  which,  from  their 
great  importance,  I  mean  to  dedicate  an  entire  lecture. 

The  alteration  of  the  blood,  to  which  I  to-day  call  your  attention,  was  first 
pointed  out  by  my  young  colleague,  Dr.  Millard,  in  his  excellent  inaugural 
thesis  ;*  and  it  has  more  recently  been  discussed  in  Dr.  Peter's  work,  pub- 
lished in  1859.  At  the  autopsy  of  six  persons  who  died  of  croup  compli- 
cated with  plastic  coryza,  a  complication  which  I  mentioned  as  occurring 
in  malignant  diphtheria,  Dr.  Millard  five  times  met  with  this  alteration  of 
the  blood,  which  till  then  had  not  been  described  by  any  one.  I  must  add 
that  Dr.  Millard  states  that  the  sixth  case  was  too  imperfectly  observed  to 
justify  a  negative  conclusion  in  respect  of  it.  This  alteration  of  the  blood 
consists  in  a  very  marked  change  in  its  color:  in  place  of  being  of  a  more 
or  less  deep  red,  it  is  brown.  Dr.  Millard  compares  this  to  the  juice  of 
plums,  and  to  the  juice  of  liquorice  :  he  say-  it  stains  the  fingers  almost  as 
much  as  sepia.  \h\  Peter  compares  it  to  water  colored  by  soot.  The  vis- 
cera and  mucous  membranes  being  impregnated  with  it,  present  a  dirty 
hue,  which  is  quite  characteristic.  This  blood  is  turbid,  and  somewhat 
muddy:  the  clots  formed  are  soft,  and  somewhat  resemble  the  overcooked 
juice  of  the  grape  [rfoint  trop-cniW],  The  arteries,  instead  of  being  found 
empty  alter  death,  as  is  generally  the  case,  contain  nearly  as  much  blood 
as  the  veins. 

I  have  now  reached  the  subject  of  albuminv/ria.  Gentlemen,  several  years 
ago,  an  English  physician,  Dr.  Wade,  of  Birmingham,  announced  thai  he 

had  found  alhumen    in  the   urine  of  diphtheritic  patients,  and   also  that  its 


■    Millard:  Bur  la  Trach6otomie  dans  le  Croup.     Paris,  1858. 


ALBUMINURIA    IN    DIPHTHERIA.  381 

presence  was  a  frequent  phenomenon  iii  mortal  cases.  He  supported  his 
own  experience  by  quoting  that  of  his  colleagues,  mentioning  thai  this  fact 
had  been  observed  by  several  physicians,  and  among  others  by  Dr.  James, 
who  published  an  interesting  account  of  an  epidemic  of  croup  in  the  "Med- 
ical Times."  Dr.  Wade  states  that  in  consequence  of  his  having  commu- 
nicated his  observations  to  the  Royal  Medical  and  Chirurgical  Society, 
confirmatory  cases  were  at  once  brought  forward  by  Dr.  Bobbins  and  others. 
This  discovery,  from  having  been  originally  published  in  the  "Midland 
Quarterly  Journal  of  Medical  Science,"  a  periodical  little  circulated  on 
this  side  the  Straits  of  Dover,  remained  for  a  long  time  unknown  in 
France.  Like  everybody  else,  I  was  ignorant  of  the  discovery,  when  there 
fell  into  my  hands  an  unpublished  paper,  by  Dr.  Abeille,  who  was  the  first 
to  my  knowledge  to  mention  diphtheria  among  the  diseases  in  which  we 
may  meet  with  albuminuria.  Since  that  time,  I  have  lost  no  opportunity 
of  looking  for  albumen,  which  I  have  several  times  found  in  the  urine  of 
diphtheritic  patients  in  the  clinical  wards,  and  did  not  fail  to  notice  in  my 
clinical  lectures  during  1857.  In  a  lecture  delivered  on  the  23d  June,  1858, 
Dr.  G.  See,  ignorant  of  the  researches  of  the  English  physicians  and  of  Dr. 
Abeille,  in  a  more  particular  manner  called  general  attention  to  the  fre- 
quency of  albuminuria  occurring  in  malignant  sore  throat,  and  in  croup 
both  before  and  after  tracheotomy.  He  stated  that  in  his  wards  in  the 
Children's  Hospital,  the  urine  of  all  the  diphtheritic  patients  Avas  examined 
for  albumen  every  day,  and  that  at  least  in  one-third  of  the  cases,  it  was 
found  in  notable  quantity.  It  is,  therefore,  as  Dr.  Wade  originally  stated, 
and  as  I  have  verified  before  you,  very  common  to  find  albumen  in  the 
urine  of  diphtheritic  patients. 

The  phenomenon  has  been  explained  in  several  ways.  Some  have  looked 
on  the  cause  as  possibly  of  a  complex  character,  thinking  that  the  presence 
of  albumen  in  the  blood  might  depend  in  some  cases  upon  passive  transient 
congestion  of  the  kidneys  produced  by  asphyxia  in  croup,  and  the  conse- 
quent stasis  of  the  blood.  This  theory  is  very  open  to  objections,  even  in 
the  exceptional  cases  to  which  attempts  have  been  made  to  apply  it.  With 
the  majority  of  physicians,  I  believe  that  the  occurrence  of  albumen  in  the 
urine  of  diphtheritic  patients  is  dependent  upon  the  general  state  of  the 
system  :  we  find  here,  but  cannot  explain  why,  the  same  condition  we  meet 
in  such  septic  diseases  as  small-pox,  scarlatina,  and  dothinenteria.  In 
some  cases,  albumen  is  found  in  the  urine  from  the  very  onset  of  the  dis- 
ease ;  the  quantity  obtained  by  treatment  with  heat  and  nitric  acid 
varies  considerably  in  the  same  individual  from  one  day  to  another : 
sometimes,  its  appearance  is  intermittent.  You  may  remember  a  case  of 
this  kind  which  occurred  in  a  young  woman  who  lay  in  bed  No.  9  of  St. 
Bernard's  Ward,  the  history  of  which  I  shall  bring  before  you  in  relation 
to  the  subject  of  diphtheritic  paralysis ;  you  will  remember  that  the  varia- 
tions in  the  quantity  of  albumen  which  we  found  in  the  urine  of  this  patient 
did  not  in  any  way  correspond  with  the  increase  or  decrease  of  the  para- 
lytic symptoms,  and  that  it  was  useless  to  attempt  to  form  a  prognosis  from 
what  was  seen  in  the  test-tube.  In  point  of  fact,  howrever  interesting  this 
phenomenon  may  be,  it  is  impossible  in  the  present  state  of  our  knowledge 
to  arrive  at  any  absolute  induction  from  it.  It  is  quite  correct  to  say,  in 
general  terms,  that  in  severe  cases  of  diphtheria,  albuminuria  is  usually 
met  with  :  but  the  exceptions  to  this  rule  are  numerous.  Again,  we  some- 
times meet  with  albuminuria  in  slight,  and  find  that  it  is  absent  in  serious, 
cases.  An  attempt  has  been  made  to  explain  by  albuminuria  the  paralytic 
affections  regarding  which  I  am,  forthwith,  going  to  address  you.  I  may 
remark,  however,  that  albuminuria  is  not  a  constant  symptom  in  that  class 


382  PARALYSIS    IN    DIPHTHERIA. 

of  cases;  and  also,  that  the  paralytic  affections  incident  to  diphtheria  do 
not  admit  of  comparison  with  the  symptoms  of  disturbance  of  the  nervous 
system  which  supervene  in  the  course  of  acute  or  chronic  albuminuria, 
which  are  characterized  by  convulsions  or  coma,  and,  with  the  exception 
of  amaurosis,  never  by  paralysis.  One  word  more  on  this  subject.  Al- 
though Dr.  Wade  states  that  he  has  never  seen  dropsy  accompany  diph- 
theritic albuminuria,  dropsical  affections  are,  according  to  Dr.  G.  See, 
sometimes  met  with,  though  much  more  rarely,  he  says,  than  in  scarlatina. 
For  my  part,  I  have  met  with  but  few  examples :  and  so  far  as  I  can  make 
a  statement  on  such  a  point  from  memory,  I  should  say  that  I  have  not 
met  with  this  anasarca  in  one  case  in  twenty. 

To  sum  up  :  The  presence  of  albumen  in  the  urine  of  diphtheritic 
patients,  whether  the  disease  be  in  the  form  of  pseudo-membranous  sore 
throat,  croup,  or  cutaneous  diphtheria,  is  a  frequent  occurrence,  but  one 
which  in  the  actual  state  of  our  knowledge  has  only  a  limited  signification 
in  relation  to  prognosis  and  treatment.  It  is,  however,  impossible,  to  deny 
that  it  is  the  expression  of  a  great  disturbance  of  the  organism,  produced 
by  the  morbific  principle  which  engenders  diphtheria. 


Paralysis  i>~  Diphtheria. 

Not  a  Neiv  Disease. —  The  Mild  Form. — Symptoms. — Paralysis  of  the  Veil  of 
the  Palate,  of  the  Senses,  Limbs,  and  of  the  Muscles  of  Organic  Life. — 
Death  by  Suffocation,  by  Strangling. —  The  Aggravated  Form. — Ata.ro- 
adynamic  Symptoms. —  The  Gravity  of  the  Paralysis  bears  neither  any 
Relation  to  the  Intensity  or  Duration  of  ih<-  Pseudo-membranous  Affec- 
tion, nor  to  the  Albuminuria. —  This  hind  of  Paralysis  is  the  Result  of 
Poisoning. —  Treatment. 

Gentlemen  :  AVe  stopped  for  a  long  time  when  going  round  St.  BernardV 
Ward  beside  a  young  woman  who  was  stretched  out  on  an  easy-chair,  whence 
it  was  impossible  for  her  to  raise  herself.  This  patient,  who  occupied  bed 
Xo.  10  of  that  ward,  had  been  struck  with  paralysis  three  months  previ- 
ously. Under  our  own  eyes  we  saw  the  gradual  development  of  the  symp- 
toms. She  now  presents  a  remarkable  example  of  the  paralysis  consecutive 
to  diphtheria,  an  affection  which  certainly  is  not  new,  but  which  has  not,  till 
very  recently,  been  accurately  studied. 

This  case,  which  gives  me  an  opportunity  of  addressing  you  to-day  on 
this  subject,  is  so  interesting,  that  I  do  not  hesitate  to  lay  it  before  you  with 
some  minuteness  of  detail.  The  patient,  aged  28,  came  into  the  clinical 
wards  on  the  6th  August,  1859.  Eight  days  previously  she  had  had  feel- 
ings of  general  discomfort,  and  had  suffered  from  severe  headache:  she  also 
had  had  fever,  sore  throat,  ami  profuse  sweating:  on  the  day  following  ~h< 
had  vomiting  and  loss  of  appetite. 

There  was  a  special  circumstance  connected  with  this  young  woman  which 
it  is  important  to  note:  she  had,  only  fifteen  days  before  the  seizure  now 

described,  left  our  wards,  where  .die  had  been  under  treatment  for  lumbago: 
she   had,  during   that   period,  occupied    the  bed  adjoining  that  of  a  woman 

with  diphtheria,  whose  infant  had  died  from  croup.  It  was  probably  from 
them  that  she  contracted  the  disease  which  brought  her  hack  to  the  Hdtel- 
Dieu. 

At  the  morning  visit  on  the  7th  August,  I  saw  thai  there  was  very  ex* 
tensive  phi-tic  gore  throat  :  the  uvula  and  tonsils  were  entirely  covered  with 
false  membranes,  and  presented  more  than  on,'  grayish-white  surface.     I 


PARALYSIS    IN    DIPHTHERIA.  333 

immediately  cauterized  the  affected  parts  with  hydrochloric  acid.  I  pre- 
scribed insufflations  of  alum,  and  directed  them  to  be  used  several  times 
during  the  twenty-four  hours:  also  u  julep,  containing  six  grammes  [93 
grains],  of  the  perchloride  of  iron  ;  and  also  the  powder  of  cinchona  in  in- 
fusion of  coffee. 

Next  day  I  was  shown  a  very  thick  false  membrane  which  had  been 
detached  from  the  throat:  this  diphtheritic  deposit  was  in  length  two  cen- 
timetres and  a  half,  and  in  breadth  one  centimetre.  On  the  free  surface 
traces  w«.re  visible  of  the  cauterization  of  the  previous  evening,  and  at  the 
part  where  the  eschar  adhered  to  the  mucous  membrane,  the  latter  was 
furrowed  by  Hue  red  arborizations.  In  the  cavity  of  the  mouth  the  false 
membrane  was  less  abundant,  and  was  found  only  on  the  uvula  and  poste- 
rior pillars  of  the  veil  of  the  palate.  The  cervical  glands,  particularly  those 
of  the  right  side,  were  engorged.  On  examining  the  urine  we  found  that  it 
contained  a  considerable  quantity  of  albumen.  The  julep  with  perchloride 
of  iron  was  continued,  and  the  quantity  of  the  latter  was  increased  to  eight 
grammes  [two  drachms  and  four  grains]  :  I  then  introduced  into  the  throat 
water  strongly  charged  with  tannin,  using  the  apparatus  constructed  in 
accordance  with  the  suggestions  of  Dr.  Sales-Girons  for  the  inhalation  of 
medicated  waters. 

During  the  night  of  the  8th  and  9th  August  the  patient  was  seized  with 
a  fit  of  difficult  bi-eathing,  which  made  it  necessary  to  call  the  pupil  on  duty, 
who  removed  from  the  pharynx  a  thick  false  membrane,  which  was  the 
cause  of  the  attack.  From  the  date  of  this  occurrence  the  false  membrane 
became  from  day  to  day  thinner  and  less  extensive.  On  the  11th,  after 
having  removed  a  very  thin  layer,  I  cauterized  with  hydrochloric  acid  the 
surface  which  had  been  covered  by  false  membrane  ;  and  on  the  16th  there 
only  remained  a  few  small  white  spots.  The  diphtheria  seemed  to  be  per- 
manently stopped.  Nevertheless,  the  perchloride  of  iron  was  taken  to  the 
extent  of  ten  grammes  [155  grains]  a  day  up  to  the  23d  of  August,  after 
which  it  was  discontinued. 

The  urine,  however,  when  treated  by  heat  and  nitric  acid,  still  yielded  a 
considerable  precipitate  of  albumen.  To  state  at  once  all  that  refers  to  this 
symptom,  from  15th  August  to  the  12th  September,  though  great  variations 
occurred  in  the  amount  of  albuminous  precipitate,  there  was  a  progressive 
diminution,  and  on  the  12th  September  I  noted  on  the  report-sheet  that 
there  was  "  very  little  albumen  in  the  urine ;"  but  within  a  few  days  it 
reappeared  in  as  great  abundance  as  at  first.  This  recrudescence  of  the 
albuminuria  coincided  with  the  manifestation  on  the  14th  of  the  special 
nervous  symptoms  on  which  I  am  going  to  make  some  remarks.  For  three 
days  the  albuminous  precipitate  was  very  abundant :  on  17th  September 
there  was  none,  but  on  the  18th  there  was  a  slight  trace :  this  reappearance 
of  albumen  was  very  transient,  and  by  the  20th  September  the  albuminuria 
had  finally  ceased. 

From  the  12th  August — the  malady  being  then  in  its  ninth  day — the 
uvula  was  quite  free  from  false  membrane,  but  on  the  right  tonsil  there  was 
some,  and  on  the  left,  an  exceedingly  slight  trace :  elsewhere,  there  was 
none.  But  a  symptom  existed  which  claimed  my  serious  attention :  this 
was  a  nasal  tone  of  voice,  indicating  incipient  paralysis  of  the  veil  of  the 
palate:  from  day  to  day,  this  snivelling  increased.  On  the  15th,  on  trying 
the  strength  of  the  patient,  by  Dr.  Burq's  dynamometer,  I  found  that  the 
pressure  of  the  right  hand  was  27,  aud  of  the  left,  22  kilogrammes.  Three 
days  later,  the  paralysis  of  the  veil  of  the  palate  had  increased  :  drinks  and 
liquid  food  returned  by  the  nose.  On  20th  August,  the  young  woman  com- 
plained of  general  weakness,  and  of  formication  in  the  feet:  she  marked  on 


384  PARALYSIS    IN    DIPHTHERIA. 

the  dynamometer  23  kilogrammes  by  the  right,  and  20  by  the  left  baud. 
On  the  23d,  the  hands  were  benumbed,  and,  like  the  feet,  were  the  seat  of 
formication  :  she  could  not  walk  without  stumbling.  On  the  25th,  I  as- 
certained that  she  was  in  an  anaesthetic  state.  I  could  prick  her  without 
her  being  aware  of  it.  On  applying  the  sesthesimeter  to  the  dorsal  surface 
of  the  left  forearm,  she  did  not  feel  distinctly  the  two  points  of  the  instru- 
ment when  six  centimetres  apart  from  one  another.  The  arms  wore  ex- 
tended, and  the  hands  were  in  a  state  of  constant  tremulous  motion.  Not 
only  were  fluids  swallowed  with  difficulty,  but  even  solid  food  caused  pain 
in  passing  the  isthmus  of  the  fauces — to  use  the  expression  of  the  patient — 
the  morsels  remained  sticking  in  the  throat.  For  some  days,  this  dysphagia 
went  on  increasing  in  severity."  On  31st  August,  new  symptoms  arose. 
When  this  unfortunate  young  woman  was  breathing,  we  heard  a  slight 
whistling  sound  during  inspiration,  like  that  produced  in  persons  suffering 
from  what  is  called  cedema  of  the  glottis.  From  the  previous  evening,  she 
had  been  suffering  much  from  difficulty  of  breathing,  and  the  inspirations 
were  54  in  the  minute.  On  examining  the  chest  by  auscultation  and  per- 
cussion, we  found  no  abnormal  condition.  On  2d  September,  the  lips  and 
tongue  were  affected  with  paralysis.  The  patient  felt  numbness  and  formi- 
cation, and  she  had  difficulty  in  articulating.  The  difficulty  in  speaking 
increased,  as  well  as  the  dyspnoea.  The  gums  were  insensible,  and  the  teeth 
ceased  to  feel  the  food  which  they  masticated.  I  then  had  recourse  to  elec- 
tricity, which  I  caused  to  be  applied  to  the  anterior  and  lateral  parts  of  the 
neck;  and  likewise  over  the  epigastric  region,  having  a  suspicion  that  the 
dyspnoea  was  referable  to  the  diaphragm,  which  was  paralyzed  like  the 
other  muscles.  On  the  fifth  day  of  this  treatment,  the  patient  told  me  that 
she  could  swallow  and  breathe  more  easily.  She  was,  however,  very  far 
from  having  got  rid  of  her  untoward  symptoms.  On  11th  September,  her 
sight  became  affected.  Vision  was  dim  ;  she  could  not  read,  and  the  letters 
looked  as  if  in  confusion.  The  difficulty  of  articulating  had  become  still 
more  marked:  the  hands,  but  not  the  feet,  continued  to  be  benumbed. 

It  was  at  this  period,  let  me  remind  you,  that  the  albumen  reappeared  in 
considerable  quantity  in  the  urine  after  having  greatly  diminished  :  it  was 
also  at  this  period,  that  is  to  say  about  the  14th  of  September,  that  the  pa- 
tient was  seized  during  the  visit  with  the  nervous  symptoms  to  which  I  have 
already  alluded  :  she  had  been  complaining  since  the  morning  of  a  tremu- 
lous movement  of  the  hands.  Just  as  I  was  leaving  her  bed,  I  perceived 
her  all  at  once  become  affected  with  violent  convulsive  movements  in  both 
arms,  the  eyelids,  and  muscles  of  the  eye:  the  globe  of  the  eye  was  turned 
upwards.  These  convulsions  lasted  for  more  than  an  hour,  consciousness 
remaining  perfect  during  the  whole  time.  This  woman  had  never  had  pre- 
viously any  nervous  attack.  I  prescribed  the  following  potion:  mint  water 
SO  grammes  [aboul  22  fluid  drachms]  ;  syrup  of  ether,  40  grammes  [about 
11  fluid  drachms];  musk,  1  gramme  |  15'  grains].  Next  day, she  was  very 
calm.     During  the  night  of  the  L§th  and  i6th,  the  convulsions  returned, 

affecting  on  this  occasion  the  muscles  of  the  face  and  jaw.      At  the  visit,  I 

observed  great  dyspnoea,  and  much  difficulty  in  articulating:  there  was, 

however,  less  dysphagia.  The  left  leg  was  much  weaker  than  the  right,  and 
bent  under  the  weighl  of  the  body.    There  was  no  lossof  power  in  the  \\\^r\- 

extremities,  but  they  continued  to  he  the  .-.at  of  formication.  <  hi  22d 
September,  both  legs  were  affected  with  feebleness,  and  to  such  a  degree  as 
to  render  both  walking  and  standing  impossible:  the  evacuation  of  the 
bowels  was  accomplished  with  ureal  difficulty.     The  degree  of  feebleness 

and  accompanying   Dumbness   was   variable.      Thus,  while  on   the   22d,  the 

patient  was  quite  unaware  of  the  existence  of  her  toes,  next  day  that    die- 


PARALYSIS    IN    DIPHTHERIA.  385 

agreeable  state  had  passed  away.  There  was,  however,  a  decided  increase 
iii  the  weakness  of  the  legs.  On  the  20th  September,  she  was  completely 
paraplegic:  there  was  vesical  tenesmus,  then  difficulty  in  micturition — a 
true  paralysis  of  the  bladder.  The  dyspnoea,  difficulty  in  passing  urine,  and 
impeded  articulation  gradually  diminished;  and  to-day  you  have  seen  the 
patient  breathe,  swallow,  and  speak  with  ease.  The  employment  of  elec- 
tricity was  continued  ;  it  was  applied  in  succession  to  the  parts  affected  with 
paralysis.  From  1st  October,  the  numbness  of  the  legs  began  to  diminish; 
and  they  gradually  recovered  their  power.  On  the  7th,  the  patient  could 
get  up  and  sit  on  the  side  of  her  bed,  although  she  was  still  unable  to  walk. 
On  the  11th,  in  tottering  fashion,  she  began  to  take  a  few  steps:  when  she 
walked,  she  did  not  feel  the*  ground  under  her  feet. 

It  was  difficult,  gentlemen,  in  this  case,  not  to  recognize  the  relation  be- 
tween the  paralytic  symptoms  which  we  saw  develop  themselves  under  our 
own  eyes,  and  the  diphtheria  with  which  the  young  woman  was  still  af- 
fected when  they  showed  themselves.  If  cases  always  presented  themselves 
to  physicians  in  this  clear  form,  it  is  probable  that  diphtheritic  paralysis 
could  not  have  escaped  notice :  for  assuredly  the  malady  is  not  new,  as 
some  have  supposed. 

What  has  happened  in  connection  with  it,  has  happened  in  relation  to 
many  other  morbid  conditions.  Albuminuria,  which  we  have  only  been 
acquainted  with  for  a  few  years,  is  now  quite  commonly  met  with.  I  may 
say  the  same  in  respect  of  leucocythemia :  indeed  this  example  is  particu- 
larly striking,  for  though  the  affection  was  till  the  other  day  quite  un- 
known, there  is  now  not  an  hospital  in  which  cases  of  it  are  not  met  with. 
Albuminuria  and  leucocythemia  are  not  new  affections,  nor  are  they  more 
common  now  than  in  former  times,  but  in  the  present  day,  they  are  recog- 
nized when  met  with,  whereas  formerly,  they  occurred  without  attracting 
attention :  the  researches  of  Bright  drew  our  attention  to  the  former,  and 
the  latter  has  been  brought  under  our  notice  by  Bennett,  Virchow,  E. 
Vidal,  and  Magnus  Huss.  Precisely  the  same  thing  has  occurred  in  respect 
of  the  paralysis  attendant  upon  diphtheria.  As  it  does  not  in  general  su- 
pervene till  a  period  somewhat  remote  from  the  manifestation  of  the  local 
characteristics  of  the  pellicular  malady,  it  is  easy  to  see  how  its  origin  and 
cause  have  not  always  been  understood. 

When  we  refer  to  the  historical  records  which  have  come  down  to  us, 
descriptive  of  the  Mai  Egyptiaque — very  ancient  records  dating  back  to  the 
times  of  Aretseus,  we  find  only  exceedingly  slight  references  to  the  consecu- 
tive paralysis.  Some  distinctly  mention  the  extreme  debility  which  fol- 
lows diphtheria,  but  strictly  speaking  no  one  says  anything  of  paralysis. 
Its  existence,  however,  was  categorically  stated  by  three  authors — Ghisi, 
Chomel,  and  Samuel  Bard — at  the  middle  and  end  of  last  century.  All 
the  three  completely  establish  the  correlation  of  paralysis  with  diphtheria. 
The  case  related  by  Ghisi,  in  his  second  medical  letter  upon  the  epidemic 
sore  throat  which  prevailed  at  Cremona  in  1747  and  1748,  is  that  of  his 
own  son,  a  child  a  little  under  eight  years  of  age.  The  following  are  the 
concluding  sentences  of  the  narrative: 

"Leaving  to  the  patience  and  skill  of  M.  Ch.  Scotti,  doctor  in  surgery, 
the  treatment  of  large  ulcers  occupying  both  tonsils,  and  part  of  the  veil  of 
the  palate  and  uvula,  I  also  intrusted  to  him  the  treatment  of  a  large  pain- 
ful tumor,  which,  at  the  very  time  that  the  interior  of  the  throat  had  got 
nearly  well,  began  to  point  externally  and  to  form  an  abscess  a  little  below 
the  angle  of  the  jaw,  under  the  mastoid  muscle.  I  left  to  nature  the  cure 
of  the  strange  consequences  of  the  disease,  consequences  which  had  been  re- 
marked in  many  ivho  had  already  recovered,  and  which  continued  for  about 
vol.  i. — 25 


386  PARALYSIS    IN    DIPHTHERIA. 

a  month  after  recovery  from  the  sore  throat  and  abscess.  During  that 
period,  the  child  spoke  through  his  nose;  and  food,  particularly  that  which 
was  least  solid,  returned  through  the  nares,  in  place  of  passinsr  down  the 
gullet." 

Also  in  1748,  Chomel,  a  French  physician,  observed  in  two  patients, 
paralysis  consequent  upon  gangrenous  sore  throat.  In  one  of  these  cases, 
it  was  unquestionably  the  same  paralysis  of  the  veil  of  the  palate  which 
Ghisi  pointed  out.  "  The  patient,"  says  Chomel.  "  had  not  quite  com- 
menced convalescence  at  the  forty-fifth  day  of  the  disease,  having  still  diffi- 
culty in  articulating,  speaking  through  the  nose,  and  having  the  uvula  pen- 
dulous." In  the  other  case,  however,  the  complications  were  different  from 
paralysis  of  the  veil  of  the  palate :  "  the  patient  became  squint-eyed  and 
deformed  ;  but  day  by  day,  as  his  strength  returned,  he  regained  his  natural 
appearance." 

Samuel  Bard,  who  has  written  an  account  of  the  epidemic  sore  throat 
which,  in  1771,  prevailed  in. the  town  and  province  of  New  York,  describes 
the  case  of  a  little  girl,  two  and  a  half  years  old,  who  recovered  from  an 
attack  of  suffocative  sore  throat,  and  cutaneous  diphtheria  consequent  upon 
the  application  of  blisters ;  but  who  retained  paralysis  of  the  veil  of  the 
palate  and  weakness  of  the  legs.  "The  larynx.'"  says  Dr.  Bard,  "retained 
a  special  sensibility  in  respect  of  liquids:  whenever  she  attempted  to  drink, 
she  was  seized  with  a  fit  of  coughing,  yet  she  was  able  to  swallow  solid  food 
without  anv  difficulty.  These  symptoms  passed  off,  with  the  exception 
of  weakness  and  aphonia,  which  continued  tor  some  time  longer.  In  the 
second  month,  she  could  with  difficulty  walk  alone,  or  raise  her  voice  above 
a  whisper." 

These  cases  had  remained  unknown.  Bretonneau,  even,  in  his  treatise  on 
diphtheria,  gave  a  translation  of  Ghisi's  letter  and  Samuel  Ward's  obser- 
vations without  stopping  to  notice  the  point  now  before  us.  My  illustrious 
master's  attention  had  not  then  been  called  to  the  subject :  in  the  epidemic 
with  which  he  had  just  been  engaged,  he  had  not  seen  any  cases  of  diph- 
theritic paralysis;  nor  did  he  remember  to  have  met  with  any  cases  prior  to 
1843.  The  first  patient  in  whom  he  met  with  it  was  Dr.  Herpin,  a  surgeon 
to  the  hospital  of  Tours.  Bretonneau  published  tin-  case,  exactly  as  it 
was  communicated  to  him  by  Dr.  Herpin,  in  his  paper  on  the  means  of 
preventing  the  development  and  progress  of  diphtheria,  which  appeared  in 
the  "Archives  Generates  de  Medecine"  for  January  and  September,  1855. 
From  that  time  the  occurrence  of  paralysis  as  a  sequal  of  diphtheria  was 
a  fact  completely  established  in  the  minds  of  the  physicians  of  the  school 
of  Tours  ;  but  at  Paris,  the  subject  was  almost  unnoticed,  or  at  least  it  was 
not  till  long  after  its  existence  had  been  pointed  out,  that  the  relationship 
between  the  paralytic  affections  and  the  disease  which  produced  them  was 
fully  appreciated. 

Bight  years  ago,  I  and  others  were  .-truck  by  the  frequency  with  which 
paralysis  of  the  veil  of  the  palate  occurred  in  persons  who  had  had  diph- 
theria. The  patients,  adult-  and  children,  had  a  nasal  tone  of  voice,  and 
great  difficulty  in  swallowing.  In  endeavoring  to  explain  these  cae 
imagined  that  the  paralysis  depended  upon  a  special  modification  of  the 
veil  of  the  palate  produced  by  the  plastic  inflammation,  a  modification  in 
virtue  of  which  the  muscular  fibre  constituting  pari  of  thai  structure,  fox 
a  certain  time,  loses  it-  normal  contractility.  This  was  the  explanation  given 
by  my  friend  Dr.  Lasegue  and  me  in  our  paper  on  the  Bubjecf  published  in 
the  "Union  M6dicale"  for  9th  October,  1854  A-  thai  paper  referred  only 
to  paralysis  of  the  veil  of  the  palate,  our  explanation  was  to  a  certain  ex- 
tent admissible,  for  one  could  compare  what  happened  in  diphtheritic  sore 


PARALYSIS    IN    DIPHTHERIA.  387 

throat  with  what  .sometimes  occurs  in  purely  inflammatory  sort-  throat,  in 
which  we  also  meet  with  this  consecutive  paralysis;  and,  speaking  in  more 
general  terms,  with  what  occurs  in  all  muscular  tissue  which  has  been  for  a 
time  the  scat  of  simple  or  rheumatic  inflammation.  Long  before  that 
period,  however,  I  had  seen  other  cases  of  diphtheritic  paralysis,  both  local 
and  general,  affecting  the  eyes  and  the  tongue;  but  I  had  seen  them  with- 
out being  able  to  explain  their  nature,  without  having  laid  hold  of  the  re- 
lation of  the  disturbed  innervation  to  the  disease  in  which  they  originated. 
Thus,  in  1833,  a  remarkable  case  came  under  my  observation  when  I  was 
doing  temporary  duty  in  these  wards  for  Recamier.  The  facts  of  the  case 
were  carefully  reported  by  my  lamented  friend  Dr.  Thirial. 

The  patient  was  a  young  woman,  twenty-two  years  of  age,  who  was  ad- 
mitted as  a  patient  into  the  Hotel-Dieu  ou  the  13th  June.  The  superior 
and  inferior  extremities  were  both  completely  paralyzed.  With  the  right 
arm,  she  could  hardly  perform  slight  extension  movements :  the  fingers 
were  retracted,  flexed  in  the  palm  of  the  hand,  and  when  an  attempt  was 
made  to  extend  them,  pain  was  excited.  The  paralysis  of  the  left  arm  was 
neither  so  generally  diffused,  nor  in  any  part  so  complete.  The  patient 
was  wholly  unable  to  move  the  right  inferior  extremity  ;  and  she  was  nearly 
as  much  paralyzed  in  the  left,  with  this  exception,  that  she  could  push  it 
out  and  slightly  draw  it  back,  in  consequence  of  power  remaining  in  the 
muscles  of  the  pelvis. 

There  was  a  certain  amount  of  difficulty  in  voiding  the  urine  and  fieces. 

Notwithstanding  the  almost  total  loss  of  the  general  motor  power  of 
both  sides  of  the  body,  sensation  remained  intact  in  the  paralyzed  limbs. 
The  heat  of  the  parts  was  a  little  below  the  natural  standard,  but  they 
were  perfectly  sensible  to  the  contact  of  the  hand,  and  to  differences  of 
temperature. 

The  organs  of  the  senses,  as  well  as  the  mental  faculties,  were  not  im- 
paired in  the  slightest  degree.  Speech  was  free :  my  questions  were  an- 
swered with  remarkable  correctness  and  precision.  The  pulse  was  natural. 
There  was  not  much  appetite,  but  digestion  was  good. 

This  young  woman  was  an  inhabitant  of  a  village  in  the  department  of 
Haute-Marne,  whence  she  had  come  to  Paris  for  treatment.  She  stated 
that  she  had  been  confined  on  the  14th  February,  consequently  four  months 
before  she  was  received  into  the  Hotel-Dieu.  Parturition  was  perfectly 
propitious ;  but  about  fifteen  days  after  delivery,  she  was  seized  with  sore 
throat  possessing  the  character  of  pseudo-membranous  sore  throat,  from 
winch  she  was  very  ill,  and  in  great  danger.  The  village  doctor  under 
whose  care  she  had  been,  had  first  taken  blood  from  the  feet,  then  applied 
(on  different  occasions)  sixty  leeches,  and  afterwards  blistered  the  calves  of 
the  legs  :  he  did  not  however  employ  any  topical  treatment.  The  patient 
stated  that  the  surfaces  to  which  the  blisters  had  been  applied  became  cov- 
ered with  false  membrane:  this  statement,  as  Thirial  has  remarked,  put 
beyond  doubt  the  nature  of  the  sore  throat. — its  serious  and  contagious 
character. 

Notwithstanding  the  insufficiency,  let  me  add,  in  spite  of  the  absurdity 
of  this  treatment,  the  patient  had  the  good  fortune  to  get  better ;  but  it 
was  not  till  after  the  lapse  of  a  considerable  time  that  convalescence  began. 
Indeed,  she  stated  that  she  had  not  commenced  getting  up  till  about  the 
10th  April,  that  is  to  say,  not  till  more  than  six  weeks  from  the  begin- 
ning of  the  diphtheritic  attack. 

The  first  time  that  she  tried  to  stand  or  walk,  she  observed  a  certain 
awkwardness  in  the  movements  of  the  right  leg :  she  could  not  maintain 
the  erect  position,  nor  make  a  few  steps  without  the  aid  of  a  staff.     The 


388  PARALYSIS    IN    DIPHTHERIA. 

physician  to  whom  she  complained  of  these  symptoms,  paid  little  attention 
to  them,  ascribing  them  to  debility,  the  natural  consequence  of  so  long  an 
illness.  It  is  probable  that  a  similar  error  has  in  times  past  been  often 
committed,  and  that  to  a  certain  extent  the  commission  of  this  error 
explains  the  silence  observed  in  reference  to  paralysis  in  diphtheria.  Our 
patient,  some  days  after  making  her  complaints,  began  to  suffer  from  very 
disagreeable  formication  in  the  weak  leg,  and  to  experience  considerable 
and  increasing  difficulty  in  moving  it.  In  a  word,  at  the  end  of  a  fort- 
night, there  was  complete  paralysis  of  the  right  inferior  extremity;  and  the 
left  arm  became  afterwards  similarly  affected.  After  some  time,  the  for- 
mication was  felt  over  the  whole  of  the  left  side  of  the  body :  and  soon 
afterwards,  the  motor  power  began  to  diminish  simultaneously  in  the  upper 
and  lower  extremity.  About  the  end  of  May,  the  patient  ceased  to  be  able 
to  stand,  even  with  the  assistance  of  a  support,  and  was  thenceforth  obliged 
to  keep  her  bed.  After  remaining  in  this  condition  for  a  fortnight,  the 
patient's  family  resolved  to  send  her  to  Paris  for  treatment.  Thus  it  was 
that  she  came  into  the  Hotel-Dieu  in  the  condition  which  I  have  just 
described  to  you. 

This,  gentlemen,  was  assuredly  a  case  exceedingly  well  characterized, 
and  seems  to  be  one  which  in  the  present  day  nobody  ought  to  have  mis- 
taken. Nevertheless,  notwithstanding  the  various  hypotheses  successively 
suggested  by  the  numerous  physicians  following  the  clinic,  both  as  to  the 
nature  and  seat  of  the  disease,  the  true  diagnosis  of  this  woman's  case 
escaped  me  during  the  whole  time  she  was  under  my  treatment  in  hospital, 
which  was  two  complete  months.  At  the  end  of  that  period,  being  three 
months  after  the  setting  in  of  the  paralytic  symptoms,  the  recovery  was 
perfect.  No  one,  I  repeat,  seized  the  relation  between  this  woman's  paral- 
ysis and  her  antecedent  diphtheria,  during  the  time  she  was  in  our  wards. ' 
As  for  myself,  I  never  should  have  got  at  the  correct  diagnosis,  had  I  not 
at  a  later  period  met  with  similar  cases. 

In  1846,  my  honorable  colleague,  Dr.  Vosseur,  summoned  me  to  see  with 
him  the  female  child  of  a  joiner  living  in  the  Impasse  des  Feuillantines, 
Rue  Saint-Jacques.  The  child  had  paralysis  of  the  veil  of  the  palate  ;  .die 
also  had  strabismus;  and  a  leg  and  arm  were  paralyzed.  At  first,  I  sup- 
posed that  it  was  a  case  of  hemiplegia  depending  upon  a  tubercular  lesion 
of  the  brain.  In  a  fortnight,  the  child  died  :  before  death,  the  paralysis 
had  extended  to  the  whole  body. 

These  cases,  however,  were,  like  the  first,  a  dead  letter  to  me.  Yet  I 
was  acquainted  with  the  case  described  by  Dr.  Herpin  of  Tours.  Breton- 
neau  narrated  it  to  me,  and  said  that  it  was  a  case  of  diphtheritic  paral- 
ysis. The  statement  seemed  to  me  incredible.  I  refused  to  see  anything 
more  in  the  case  than  a  coincidence;  and  when,  in  1851,  Dr.  Lasegue  and 
I  published  our  work  on  paralysis  of  the  veil  of  the  palate,  1  was  quite 
satisfied  witli  the  explanation  which  I  there  gave  of  that  affection ;  I  did 
not  perceive  that  in  its  nature  paralysis  of  the  veil  of  the  palate  was  simi- 
lar to  paralysis  of  the  limbs,  sight,  &C.  It  was  not  till  about  the  year 
1852,  that,  enlightened  by  new  cases,  better  studied  and  better  interpreted, 
I  understood  diphtheritic  paralysis  as  Bretonneau  understood  it.  Prom 
that  time,  whenever  an  opportunity  occurred,  I,  in  my  turn,  called  the 
attention  of  my  colleagues  t"  this  important  subject  ;  and  in  this  place, 
since  1855,  I  have  pointed  out  to  you  cases  of  this  kind.  These  cases  1 
shall  to-day  recall  to  your  recollection. 

In   1852,  I  saw,  along  with  my  colleagues   Drs.   Beylard,  Olliffe,  and 

Bigelow,  an   American    young    lady    who    had    frightful    diphtheria,    which 
invaded  the  pharynx,  nasi  I  fossa,  and  internal  surface  of  the  eyelids.      For 


PARALYSIS    IN    DIPHTHERIA.  389 

three  weeks,  the  patient's  life  was  in  the  balance.  She  recovered  :  but 
during  the  course  of  her  illness,  she  fell  into  an  extraordinary  state  of 
adynamia.  Before  her  attack,  she  was  in  blooming  health,  and  had  a 
remarkably  fresh  complexion  ;  but,  from  the  third  day  of  her  membran- 
ous sore  throat,  she  became  as  pale  as  the  palest  of  chlorotic  women,  and 
in  addition  to  this  deprivation  of  color,  the  skin  presented  a  bloated 
appearance.  Being  at  that  time  ignorant  of  the  connection  of  albumin- 
uria with  diphtheria,  I  did  not  examine  the  urine.  Notwithstanding,  I 
repeat,  the  severity  of  the  symptoms,  the  patient  recovered ;  that  is  to  say, 
the  pseudo-membranous  affections  completely  disappeared  ;  but  we  soon 
had  other  very  formidable  morbid  symptoms  to  contend  against.  "We  first 
had  paralysis  of  the  veil  of  the  palate  and  of  the  pharynx,  which  consti- 
tuted an  almost  complete  obstacle  to  deglutition :  whenever  the  girl  tried 
to  take  any  kind  of  liquid,  it  was  at  once  returned  by  the  nose.  For  some 
time  it  was  necessary  to  give  aliment  only  in  the  solid  form,  and  nourish 
her  with  chocolate  prepared  with  water,  and  meat  broth.  At  the  same  time, 
it  was  necessary  to  plug  the  nose  in  such  a  way  that  the  column  of  air 
contained  in  the  nasal  fossa?,  by  presenting  an  obstacle  to  the  return  of  the 
food,  should  perform  the  office  of  the  veil  of  the  palate.  This  contrivance 
proved  successful. 

To  this  paralysis  of  the  veil  of  the  palate,  which  was  also  characterized 
by  a  nasal  tone  of  voice,  there  was  added  paralysis  of  the  visual  apparatus. 
The  patient  became  amblyopic  and  ultimately  amaurotic.  The  arms  be- 
came affected  ;  and  along  with  loss  of  motor  power,  there  was  loss  of  sen- 
sation. Subsequently,  the  inferior  extremities  became  paralyzed.  Six 
weeks  after  recovery  from  the  pseudo-membranous  affection,  the  paralysis 
was  so  general  that  the  patient  was  unable  to  stir,  and  so  was  compelled 
to  remain  in  bed.  Four  months  elapsed  before  she  could  walk  in  her  room 
supported  by  two  persons,  or  carry  the  spoon  to  her  mouth  and  take  her 
food  without  assistance.  It  required  a  year  to  complete  her  recovery.  She 
is  now  in  perfect  health. 

I  related  the  particulars  of  this  case  to  my  friend  Dr.  Blache,  as  well  as 
to  several  of  my  hospital  colleagues  :  it  recalled  to  their  recollection  some 
other  cases  of  a  similar  nature  which  till  then  had  not  arrested  their  atten- 
tion. Some  time  afterwards,  Dr.  Faure  called  me  in  to  consult  with  him 
in  the  case  of  a  child,  a  girl  between  four  and  five  years  of  age,  who  was 
recovering  from  a  diphtheritic  affection.  She  had  paraplegia  of  the  same 
description  as  that  of  my  young  American  lady,  writh  this  difference,  that 
there  was  a  sort  of  alternation  in  the  paralytic  symptoms  :  for  example, 
an  arm  would  be  affected  now,  and  by  and  by  a  leg.  At  the  same  time 
that  Dr.  Faure  consulted  me  in  this  case,  he  published  an  accouut  of  it  in 
the  "  Union  Medicale."  This  case  dates  back  for  about  five  or  six  years. 
The  recovery  was  very  rapid. 

In  1858,  I  was  asked  by  Dr.  Arnal  to  meet  him  in  consultation  on  the 
case  of  an  exchange  agent.  Dr.  Arnal  informed  me  that  his  patient,  after 
having  been  attacked  with  paralysis  of  the  veil  of  the  palate,  experienced 
considerable  feebleness  of  vision,  then  paraplegia,  paralysis  of  the  upper 
extremities  :  the  muscles  of  the  neck  became  unable  to  support  the  head 
in  its  natural  position  ;  and  finally,  there  was  anaphrodisia.  In  listening 
to  the  patient's  replies  to  my  questions  regarding  his  case,  I  observed  a 
nasal  tone  of  voice,  and  an  aggregate  of  paralytic  affections  which  led  me 
to  think  that  the  symptoms  depended  on  antecedent  diphtheria.  This  was 
the  truth. 

Nowadays,  that  is  to  say,  since  the  publication  of  Bretonneau's  paper  in 
the  "  Archives,"  diphtheritic  paralysis  has  been,  so  to  speak,  the  order  of 


390  PARALYSIS    IN    DIPHTHERIA. 

the  day,  and  has  been  discussed  in  several  inaugural  theses  ;  particularly 
in  1858,  in  his  thesis  by  Dr.  Perate,  and,  in  1859,  by  Dr.  Pery,  who  spe- 
cially devoted  his  inaugural  dissertation  to  the  subject.  However,  the 
most  extended  work  which  has  yet  been  devoted  to  diphtheritic  paralysis  is 
that  which  Dr.  Maingault  presented  to  the  Medical  Society  of  the  Hospi- 
tals. The  author  has  collected  above  fifty  cases,  six  of  which  were  seen 
by  himself;  and  upon  this  collection  of  cases  is  based  the  treatise  which  he 
has  recently  published.* 

For  some  time  past,  numerous  cases  of  this  kind  have  occurred  in  the 
hospitals,  particularly  in  the  Children's  Hospital,  as  well  as  in  Parisian 
private  practice,  and  at  various  places  in  France.  The  existence  of  the 
affection  has  been  pointed  out  in  the  reports  made  on  the  epidemics  of 
pseudo-membranous  sore  throat  which  have  prevailed  in  the  departments. 
Within  the  last  few  months,  I  have  shown  you  several  examples  in  our 
wards  :  and  Dr.  E.  Moynier  has  given  an  account  of  some  others."}" 

The  great  number  of  cases  now  observed,  no  doubt  arises  from  cases  not 
being  allowed  to  pass  unnoticed,  in  consequence  of  the  zealous  manner  in 
which  attention  has  been  drawn  to  the  affection;  but  they  have  also  really 
been  more  common  of  late,  a  circumstance  which  is  perhaps  explained  by 
diphtheria  in  recent  years  having  assumed  a  peculiar  physiognomy  which 
it  did  not  formerly  possess,  and  which  is  characteristic  of  the  toxic  form 
of  the  disease.  Be  that  as  it  may,  there  is  not  now  a  physician  who  has 
not  heard  of  diphtheritic  paralysis.  Let  me  endeavor  to  give  you  a  sketch 
of  the  principal  features  of  the  affection. 

There  are  two  distinct  forms  of  diphtheritic  paralysis,  one  of  which  is 
severe  and  the  other  mild.  In  the  severe  form,  which,  thank  God,  is  very 
rare,  the  patients  sink  under  adynamic  and  ataxic  symptoms :  in  the  mild 
form,  generally  speaking,  recovery  takes  place,  and  in  the  exceptional  cases 
in  which  death  occurs,  it  is  the  result  of  an  accident,  depending  it  is  true 
upon  paralysis,  but  proving  mortal  from  a  mechanical  cause,  the  patient, 
for  instance,  dying  from  the  alimentary  bolus  having  got  impacted  in  the 
bronchus,  as  occurred  in  a  case  lately  described  by  my  friend  and  colleague. 
Dr.  Tardieu. 

In  its  mild  form,  diphtheritic  paralysis  has  characteristics  which  I  shall 
now  point  out. 

Sometimes,  paralysis  of  the  veil  of  the  palate  supervenes  towards  the  close 
of  an  attack  of  pseudo-membranous  sore  throat,  before  the  complete  re- 
covery of  the  patient,  as  happened  in  the  case  of  our  female  patient  of  bed 
No.  9,  St.  Bernard's  Ward  ;  but,  generally,  the  period  of  its  occurrence  is 
after  the  disappearance  of  the  false  membrane,  a  week  or  a  fortnight,  or 
even  a  month  after  apparent  recovery  from  a  pharyngeal  diphtheria.  It 
declares  itself  by  a  nasal  tone  of  the  voice,  such  as  might  he  attributed  to 
destruction  or  great  swelling  of  the  palatine  veil.  The  patient  to  whom  I 
have  referred  spoke  slowly,  and  articulated  with  difficulty.  There  was  at 
the  same  time  some  dysphagia:  fluids,  which  were  swallowed  with  much 
more  difficulty  than  solids,  were  in  part  rejected  by  the  nose.  When,  how- 
ever, the  paralysis  affects  not  only  the  veil  of  the  palate,  hut  also  the 
muscles  of  the  pharynx,  (here  is  greater  difficulty  in  swallowing,  and  the 
passage  of  the  alimentary  bolus  is  difficult  in  proportion  to  the  smallness  of 
its  volume  ;  sometimes  it  gets  into  the  air-passages,  where  it  produces  conse- 

*  Maingault:  Do  In  Paralyaie  Diphthenque,  Rocherches  Cliniquea  but  Lea 
Ciiusc-,  la  Nature,  el  le  Traiteinent  de  Cette  AJection.     Paris,  I860. 

;  Moynier  :  Compte  Rendu  public"  par  la  "Gazette  des  B6pitaux,"  numiros  dea 
15,  22  novembre  et  ler  d6oembre,  1859. 


PARALYSIS    IN    DIPHTHERIA.  391 

quences  which  T  have  just  referred  to,  and  to  which  I  shall  have  to  return. 
A  peculiarity  observed  in  this  class  of  patients  by  Dr.  Maingault,  and 
noticed  in  a  work  which  he  published  anterior  to  the  appearance  of  that 
which  I  have  just  spoken,*  and  pointed  out  also  by  Dr.  Duchennc  of 
Boulogne — is  that  they  can  neither  blow  out  a  lighted  candle,  inflate  the 
cheeks,  suck,  nor  gargle.  To  explain,  gentlemen,  the  mechanism  of  the  dif- 
ficulty of  swallowing,  and  of  the  different  phenomena  which  I  am  going  to 
point  out  to  you,  would  carry  me  beyond  the  limits  of  a  clinical  lecture: 
this  mechanism  has  been  fully  discussed  by  Dr.  Maingault  in  his  thesis. 

Upon  examining  the  pharynx  of  the  patient,  the  veil  of  the  palate  is 
seen  to  be  hanging  down,  in  such  a  way  as  to  half-close  the  posterior  cavity 
of  the  mouth :  in  place  of  rising  and  falling  as  usual  with  a  frequent  oscil- 
latory movement  when  the  tongue  is  held  down  by  a  spoon,  it  remains 
almost  immovable.  It  does  not  contract  when  an  attempt  is  made  to  excite 
it  by  the  point  of  a  bistoury  or  pen  :  its  sensibility,  naturally  so  exquisite 
that  its  slightest  titillatiou  produces  nausea,  is  completely  blunted  :  it  may, 
without  causing  any  suffering,  be  pricked,  or  cauterized  with  hydrochloric 
acid  or  nitrate  of  silver. 

The  palatine  veil  is  generally  the  first  part  affected  with  diphtheritic 
paralysis :  this  might  be  anticipated,  for  in  addition  to  the  general  cause, 
there  is  in  operation  the  local  condition — the  inflammation  of  which  the 
pharynx,  tonsils,  uvula,  and  veil  of  the  palate  are  the  seat — which  has  an 
influence  in  producing  the  local  paralysis.  It  is,  indeed,  a  recognized  fact, 
as  I  have  already  said,  that  inflammation,  when  it  invades  a  muscle,  carries 
with  it  such  a  modification  of  the  vital  properties  of  that  muscle,  as  to 
diminish  or  even  destroy  its  contractility.  Taking  this  fact  alone  into 
account,  the  explanation  which  I  gave,  in  1851,  of  paralysis  of  the  veil  of 
the  palate,  was  admissible ;  but  at  that  time  I  had  only  looked  at  one  side 
of  the  question,  and  later  observations  showed  me  that  the  inflammation 
plays  but  a  subordinate  part,  though  undoubtedly  it  has  a  great  predis- 
posing influence  in  bringing  the  muscular  structure  under  the  operation  of 
the  general  cause  which  produces  diphtheritic  paralysis  in  other  parts  of 
the  body.  So  well  sometimes,  and  by  no  means  rarely,  is  the  principal 
part  performed  by  this  general  cause,  that  the  paralysis  of  the  veil  of  the 
palate  does  not  supervene  till  long  after  recovery  from  the  sore  throat,  at  a 
time,  therefore,  when  the  inflammation  being  completely  at  an  end,  could 
no  longer  be  an  agent. 

Not  only  is  the  veil  of  the  palate  generally  the  part  which  is  first  affected 
by  diphtheritic  paralysis,  but  it  is  also  a  part  to  which  I  have  often  seen 
the  paralysis  limited.  Sometimes  the  paralysis  sets  in  all  at  once  and  in  a 
general  manner,  attacking  simultaneously,  for  instance,  the  veil  of  the 
palate,  the  limbs,  and  different  organs ;  or  perhaps  the  paralysis  of  the  veil 
of  the  palate  has  only  preceded  by  a  few  days  the  affections  which  we  are 
now  about  to  study  ;  or  finally,  but  this  is  a  much  less  usual  occurrence, 
the  paralysis  of  the  veil  of  the  palate  may  have  almost  entirely  passed 
away,  when  other  parts  become  paralyzed. 

A  circumstance  which  clearly  shows  that  diphtheritic  paralysis  depends 
on  a  general  cause,  and  that  paralysis  of  the  veil  of  the  palate  cannot  be 
entirely  explained  by  the  plastic  inflammation  of  which  the  veil  was  the 
seat,  is,  that  paralysis  may  strike  the  palatine  veil  consecutively  to  cutane- 
ous diphtheria,  as  well  as  consecutively  to  pseudo-membranous  sore  throat, 
as  has  been  seen  by  my  friends  and  colleagues  Dr.  Barthez  and  Dr.  N.  Gue- 

*  Maingault:  Sur  la  Paralysie  du  Voile  du  Palais  a  la  suite  d'Angine.  \_Thise 
d$  Pay-is,  1854.] 


S92  PARALYSIS    IN    DIPHTHERIA. 

neau  de  Mussy,  as  also  by  myself  in  a  recent  case.  This  is  a  point  of  the 
greatest  importance,  for  it  demonstrates  both  the  special  character  of  the 
symptoms  and  the  specificity  of  the  nature  of  diphtheritic  paralysis. 

The  case  to  which  I  refer  occurred  in  a  gentleman  sent  to  me  from  Laval 
by  my  honorable  colleague,  Dr.  Garreau.  During  last  February  this  patient 
took  diphtheria,  which  was  then  epidemic  in  Laval.  Two  members  of  his 
family,  a  child  and  a  servant,  had  taken  the  disease :  in  him  the  seat  of  the 
pellicular  affection  was  a  surface  on  the  front  of  the  chest,  to  which  a  blis- 
ter had  been  applied  for  the  relief  of  angina  pectoris,  from  which  he  suffered 
much.  Four  or  five  days  after  the  application  the  vesicated  surface  ulcer- 
ated, and  became  covered  with  false  membrane :  the  sore,  which  was  ex- 
ceedingly painful,  took  five  weeks  to  cicatrize.  During  the  month  which 
followed  there  was  no  sign  of  constitutional  disturbance,  the  general  health 
seemed  unexceptionable,  and  the  patient  was  getting  ready  to  start  for 
Croisic,  when  the  symptoms  supervened  which  led  to  my  being  consulted. 

Without  any  discoverable  cause  he  began  to  experience  slight  difficulty 
in  walking,  and  some  diminution  of  the  muscular  power  of  the  arms.  He 
had  also  difficulty  in  swallowing,  and  complained  of  constantly  having  a 
sensation  in  the  throat  of  the  presence  of  a  bulky  foreign  body  :  food,  espe- 
cially fluid  food,  was  swallowed  with  difficulty,  and  excited  violent  parox- 
ysms of  coughing.  The  sensibility  of  the  skin  wras  blunted,  and  there  was 
formication  in  the  feet,  legs,  and  hands.  The  patient  did  not  feel  his  toes 
come  in  contact  with  the  sole  of  his  shoe :  he  could  scarcely  hold  his  hat, 
put  in  a  button,  or  carry  a  spoon  to  his  mouth,  indeed,  the  mouth  went  to 
the  spoon  rather  than  the  spoon  to  the  mouth.  Micturition  and  defecation 
were  performed  under  the  influence  of  the  will,  but  the  patient  had  almost 
no  consciousness  of  the  passage  of  the  excrementitious  matters.  He  had 
also  dimness  of  vision,  a  considerable  amount  of  amblyopia,  which  had  sen- 
sibly diminished  when  I  saw  him  in  June.  The  paralytic  symptoms  had 
then,  however,  rather  increased.  The  urine,  treated  by  heat  and  nitric 
acid,  gave  no  albuminous  precipitate.  There  was  no  pain  in  any  part  of 
the  body,  and  the  mental  faculties  were  not  impaired  in  any  degree. 

The  gentleman  informed  me  that  at  the  time  he  was  suffering  in  the  man- 
ner described,  there  were,  to  his  knowledge,  several  persons  at  Laval  who 
were  similarly  affected.  Among  other  cases,  he  mentioned  to  me  that  of  a 
workman,  in  whom  the  symptoms  had  supervened,  as  in  his  own  cast.',  after 
the  application  of  a  blister,  and  the  vesicated  surface  becoming  covered 
with  false  membrane. 

Gentlemen,  I  beg  you  to  observe,  in  corroboration  of  what  I  have  said 
as  to  the  secondary  part  which  the  inflammation  of  the  throat  plays  in  the 
production  of  the  paralysis  of  the  veil  of  the  palate,  that  in  the  case  which 
I  have  just  described,  that  form  of  paralysis  occurred  though  there  had 
been  no  sore  throat. 

Generally,  however,  when  the  paralysis  is  consecutive  to  cutaneous  diph- 
theria, it  commences  in  the  extremities. 

The  patients  complain  of  numbness,  and  of  formication  extending  from 
the  fingers  to  the  continuity  of  the  Limbs.  The  sensation  of  formication  is 
most  felt  when  the  patients  make  a  muscular  effbrl  :  it  is  accompanied  by 
a  feeling  of  cold  in  the  feet  and  hands,  and  of  weight  in  the  Limbs.  Their 
tactile  sensibility  is  blunted,  and  sometimes  the  anaesthesia  becomes  com- 
plete: you  may  pinch  them  and  prick  them  without  occasioning  pain. 
This  anaesthesia  may  extend  to  the  entire  cutaneous  surface;  but,  usually, 
aniesthesia  and  analgesia  exist  only  in  certain  parts  of  the  body,  precisely 
a-  in  hysterical  paralysis.  The  extremities  seized  are  generally  the  inferior; 
and  in  some  cases  the  patients  either  cannot  feel  at  all.  or  feel  very  Lmper- 


PARALYSIS    IN    DIPHTHERIA.  393 

fectly  that  on  which  they  tread  :  they  tell  you  that  it  seems  as  if  they  were 
walking  on  cotton,  or  on  a  very  thick  woollen  carpet.  Some  of  them  can- 
not walk  without  danger  of  falling,  unless  their  eyes  are  open.  This  is  what 
is  observed  in  other  kinds  of  paralysis.  When  the  hands  become  affected 
the  person  loses  the  consciousness  of  holding  anything  in  them,  and  is  un- 
able to  seize  small  objects,  such  as  needles  and  pins.  Paralysis  of  the  nerves 
of  sensation,  I  repeat,  begins  generally  in  the  inferior  extremities,  whence 
it  afterwards  extends  to  other  parts  of  the  body;  but  cases  have  been  no- 
ticed in  which  the  superior  extremities  only  were  affected:  in  some  alto- 
gether exceptional  cases  hyperesthesia  occurs. 

Along  with  the  manifestations  of  paralysis  of  the  nerves  of  sensation, 
paralysis  of  the  motor  power  in  different  degrees  also  shows  itself.  The 
only  sign  of  its  presence  may  be  the  weakness  which  the  patients  exhibit, 
particularly  when  they  try  to  walk  rather  quickly,  or  to  go  up  or  down  a 
stair.  But  these  symptoms  do  not  remain  thus  limited  :  the  feebleness  goes 
on  increasing,  walking  becomes  more  and  more  difficult,  and  at  last,  to 
stand  is  an  impossibility  :  the  individuals  become  bedridden  :  the  paral- 
ysis may  ultimately  so  increase  as  to  make  it  impossible  for  the  patients  to 
raise  their  legs.  By  the  aid  of  the  dynamometer,  the  degree  of  the  weak- 
ness of  the  superior  extremities  can  to  a  certain  extent  be  ascertained. 
You  have  seen  that  vigorous  subjects,  who  when  in  their  ordinary  health 
ought  to  produce  from  50  to  55  kilogrammes  of  pressure  on  Dr.  Birrq's 
dynamometer,  are  unable  to  show7  more  than  twenty,  or  perhaps  not  more 
than  twelve  or  ten.  The  diminution  of  motor  power  goes  on,  till  the  pa- 
tients are  unable  to  extend  their  arms,  which  are  in  a  state  of  constant 
tremor  :  the  paralysis  still  increases,  the  power  to  use  the  hands  is  lost, 
and  the  individual  requires  to  be  fed  by  another's  hand. 

Like  the  affections  of  the  sensory  nervous  system,  those  of  the  motor 
generally  begin  in,  and  sometimes  remain  limited  to,  the  inferior  extremi- 
ties. In  most  cases,  however,  the  superior  extremities  are  attacked  in  their 
turn,  and  subsequently,  the  muscles  of  the  trunk  and  neck  may  become 
affected.  My  friend,  Dr.  Faure,  who  was  the  first  to  point  out  the  fact, 
has  accurately  described  it.  "  The  general  carriage  of  the  body,"  says  he, 
"has  gi-eatly  altered  :  the  whole  of  the  upper  part  of  the  trunk  is  thrown 
back  :  the  head,  on  the  contrary,  falls  down  in  front  on  the  chest ;  all  the 
muscular  masses  of  the  neck  and  back  are  powerless  :  sometimes  the  pa- 
tients are  unable  to  raise  the  head  when  asked  to  do  so,  and  if  the  whole 
body  is  turned  backwards,  the  head  immediately  drops  down  like  an  inert 
mass."*  The  intercostal  muscles  and  diaphragm  are  sometimes  struck 
with  this  form  of  paralysis  :  and  the  great  dyspnoea  of  our  patient  of  Xo. 
9  St.  Bernard's  "Ward,  which  for  a  short  time  alarmed  us  so  much,  had  no 
other  cause  than  this.  In  that  woman,  too,  whose  case  presented  a  com- 
plete picture  of  all  the  symptoms  we  are  now  studying,  you  saw  the  muscles 
of  the  face,  lips,  and  tongue  become  affected. 

The  appearance  of  persons  with  paralysis  of  the  muscles  of  the  trunk, 
and  the  embarrassed  utterance  which  exists  when  the  tongue  and  lips  are 
implicated  is  similar  to  that  of  idiots;  but  the  precision  with  which  they 
reply  when  interrogated  demonstrates  the  clearness  of  their  mental  faculties. 

Mutability  of  symptoms  is  a  peculiarity  which  seemed  to  have  been  first 
pointed  out  in  the  case  of  the  little  girl  of  four  years  of  age  whom  I  saw 
with  Dr.  Faure,  of  whom  I  have  just  been  speaking  to  you,  a  peculiarity 
to  which  I  call  your  attention,  which  I  have  often  noted,  and  the  presence 
of  which,  in  the  case  which  is  the  subject  of  the  present  lecture,  you  have 

*  "Union  Me"dicale,"  3d  February,  1857. 


394  PARALYSIS    IN    DIPHTHERIA. 

had  an  opportunity  of  observing.  Thus,  you  will  see  paralysis  diminish 
in  one  limb,  and  simultaneously  increase  in  another.  The  numbness,  for 
example,  which  the  patient  has  been  experiencing  in  one  leg,  will  suddenly 
cease,  and  become  greater  in  the  other  leg  :  to-day,  the  right  hand  will  not 
give  a  dynamometric  pressure  of  more  than  10  or  12  kilogrammes,  and 
to-morrow  its  power  will  have  augmented,  while  that  of  the  left  will  have 
diminished  :  then  the  parts  which  were  first  affected  are  a  second  time 
attacked,  and  become  more  affected.  This  strange  peculiarity,  this  muta- 
bility, does  not  exist  in  paralysis  dependent  upon  a  lesion  of  the  nervous 
centres  appreciable  at  the  autopsy,  but  is  met  with  in  other  diseases,  par- 
ticularly in  hysteria  :  it  is  also  seen  in  the  paralysis  consecutive  to  acute 
diseases,  as  has  been  pointed  out  by  Dr.  Gubler  in  a  remarkable  paper 
which  was  read  before  the  Hospitals'  Medical  Society.* 

The  muscles  of  organic  life  are  not  exempt  from  the  influence  of  the 
disease  :  I  have  already  stated  that  the  diaphragm  may  be  affected  :  the 
muscular  coat  of  the  intestine,  particularly  of  the  rectum,  is  that  most  fre- 
quently implicated.  There  is,  as  a  consequence,  obstinate  constipation,  as 
I  have  often  seen.  In  one  of  the  cases  reported  by  Dr.  Sellerier,  and  com- 
municated on  the  18th  September  to  the  Medical  Society  of  the  department 
of  the  Seine,  there  was  first  retention  and  then  incontinence  of  the  fseces. 

In  some  cases,  the  palsy  strikes  the  bladder:  there  is  dysuria  and  vesical 
tenesmus:  the  individuals  urinate  from  engorgement:  when,  on  the  contrary, 
the  sphincter  is  paralyzed,  there  is  incontinence  of  urine. 

Virile  debility,  amounting  sometimes  to  complete  anaphrodisia,  exists  in 
the  majority  of  patients  affected  with  diphtheritic  paralysis,  as  I  have  ascer- 
tained by  questioning  them  on  the  subject.  Some  of  you  will  remember  a 
young  man,  of  whom  I  shall  afterwards  have  to  speak,  who  occupied  bed 
No.  19  in  St.  Agnes's  Ward:  loss  of  virile  power  was  one  of  the  first  symp- 
toms to  which  this  patient  called  my  attention.  You  can  understand  that 
in  women  it  is  difficult  to  ascertain  the  existence  of  anaphrodisia. 

The  senses  of  smell,  taste,  and  hearing  are  affected  in  some  cases,  but  the 
affection  of  special  sensation  which  is  most  commonly  met  with  is  dimness 
of  vision:  my  colleague  Dr.  Blacfie  and  I  have  met  with  numerous  exam- 
ples. On  the  15th  of  June  last,  I  was  consulted  in  the  case  of  a  girl  of 
nine  years  of  age,  who  had  been  attended  at  Vichy,  during  an  attack  of 
pseudo-membranous  sore  throat,  by  my  honorable  colleague  Dr.  Alquie. 
In  rather  less  than  a  fortnight  after  recovery  from  this  malady,  the  tone  of 
the  child's  voice  was  nasal,  but  the  paralysis  was  limited  to  the  veil  of  the 
palate;  some  time  later,  she  experienced  general  debility,  which  attracted  the 
notice  of  the  parents  from  her  not  entering  with  her  accustomed  ardor  into 
her  usual  games.  She  was  brought  into  my  consulting-room,  when  I  found 
that  the  feebleness  was  excessive.  On  trying  her  strength  by  Dr.  Burq'e 
dynamometer,  I  scarcely  obtained  a  pressure  of  3  or  4  kilogrammes:  I  also 
ascertained  that  she  was  presbyopic.  In  a  few  days  the  patient's  mother 
again  called  me  in:  the  first  remark  she  made  was  that  her  daughter  could 
HO  longer  see  distant  more  distinctly  than  near  objects,  and  that  instead  of 
placing   the  book  far  from  her,  she  was  now  unable  to  read  unless  she  held 

it  two  or  three  centimetres  from  her  nose:  the  presbyopia  had  been  succeeded 
by  myopia. 

Presbyopia  and  myopia  are  observed  then  in  very  many  of  those  who 

have  paralysis  as  a  sequel  of  diphtheria.  The  most  common  of  these  tWO 
indications  of  feebleness  of  sight    is   presbyopia.      A  child  whom   1  sent  to 


G-ublkr  :   Des  Paralysies  dans  leura    Rupporte,  avec  lea  Maladies  A-iguea,  &o. 
[Archives  Qinirales  de  Mtdecine,  I860.] 


PARALYSIS    IN    DIPHTHERIA.  395 

my  friend  Dr.  Follin  that  he  might  make  an  examination  of  the  eyes  with 
the  ophthalmoscope,  could  not  read  No.  10  of  Jtcger,  that  is  to  say,  the  aub- 
title  of  the  "  Moniteur  dea  Hopitaux." 

Feebleness  of  vision  advances  in  some  cases  to  complete  blindness,  which, 
however,  ceases  after  a  longer  or  shorter  interval.  This  transient  amaurosis 
is  sometimes  one  of  the  first  symptoms  of  diphtheritic  paralysis. 

Upon  investigating  these  cases  of  temporary  disturbance  of  the  visual 
apparatus,  we  find  that  there  is  no  appreciable  structural  change  in  the 
choroid  membrane,  the  retina,  or  the  centre  of  the  eye.  This  is  the  conclu- 
sion arrived  at  by  Dr.  Follin,  whose  great  experience  and  talent  shown  in 
the  solution  of  the' problem  now  before  us,  is  known  to  all  of  you.  Dr. 
Follin  believes  that  the  impaired  vision  depends  upon  paralysis  of  certain 
muscles  of  the  eye.  You  are  aware  of  the  part  which  many  physiologists 
assign  to  the  action  of  the  internal  muscles  of  the  eye  in  accommodating 
the  organ  to  different  distances :  if  this  theory,  by  many  considered  very 
open  to  objection,  be  accepted,  paralysis  of  some  of  these  muscles  would  oc- 
casion a  defect  in  the  accommodating  power,  and  lead,  according  to  circum- 
stances, either  to  presbyopia  or  myopia.  Whether  the  internal  muscles  of 
the  eye  do  or  do  not  play  the  part  thus  assigned  to  them  in  producing  those 
visual  affections  of  diphtheritic  patients  of  which  I  have  been  speaking, 
another  explanation  than  that  now  stated  can  be  given  of  the  amaurosis  and 
amblyopia.  Recollect  how  common  it  is  for  albuminuria  to  be  coincident 
with  diphtheritic  paralysis:  recollect  that  although  you  do  not  always  find 
albumen  in  the  urine  of  diphtheritic  patients  with  visual  affections,  you  do 
find  it  as  a  rule:  moreover,  I  need  not  remind  you  that  amaurosis,  ambly- 
opia, and  presbyopia  are  not  unusual  concomitants  of  albuminuria.  It  is 
allowable,  therefore,  to  believe  that  in  some  cases  belonging  to  the  class 
now  before  us,  the  existence  of  albuminuria  ought  to  be  taken  into  account, 
and  that  everything  must  not  be  ascribed  to  paralysis  of  the  muscles  of  the 
eye. 

The  existence  of  paralysis  of  the  muscles  of  the  eye  is  nevertheless  beyond 
question:  on  it  depends  the  fall  of  the  eyelid,  and  the  strabismus  so  fre- 
quently met  with,  which  when  present  in  one  eye  only  produces  double 
vision. 

All  the  affections  of  which  I  have  been  speaking — paralysis  of  the  veil 
of  the  palate,  of  the  extremities,  of  the  muscles  of  the  trunk  and  face,  as 
well  as  the  impaired  vision — continue  for  a  certain  time,  but  at  last  com- 
pletely cease.  Death,  however,  as  I  have  been  careful  to  tell  you,  even 
when  the  diphtheritic  palsy  has  assumed  the  mild  form,  may  result  from 
intercurrent  complications.  I  have  already  alluded  to  the  case  observed 
by  my  friend  Dr.  Tardieu,  my  colleague  at  the  Lariboisiere  Hospital,  and 
published  by  his  pupil  M.  Roeher  in  the  "Union  Medicale"  for  1st  October, 
1859.  In  that  case,  death  arose  from  asphyxia  following  the  passage  into 
the  left  bronchus  of  the  alimentary  bolus.  Dr.  Peter  mentions  in  his 
memoir  a  similar  case  in  a  child  of  eight  years  of  age. 

Perhaps  there  is  reason  for  astonishment  that  such  accidents  are  not 
more  common,  when  we  see  how  frequently  there  is  difficulty  of  degluti- 
tion in  patients  affected  with  diphtheritic  paralysis.  Our  patient  of  St. 
Bernard's  Ward  escaped  being  a  victim  to  this  terrible  complication  ;  but 
you  recollect  that  it  was  necessary  for  some  time  to  take  very  great  pre- 
cautions in  respect  of  his  taking  food.  Notwithstanding  these  precautions, 
we  had  on  several  occasions  to  encounter  suffocative  attacks  from  the 
aliments,  solid  and  liquid,  having  a  tendency  to  get  into  the  air-passages. 

When  diphtheritic  paralysis  assumes  the  severe  form,  regarding  which  I 
am  now  going  to  speak,  the  termination  is  fatal :  death  supervenes  in  the 


396  PARALYSIS    IN    DIPHTHERIA. 

midst  of  terrible  nervous  symptoms,  against  which  the  resources  of  medi- 
cine are  impotent. 

You  have  observed  a  case  of  this  description  in  St.  Agnes's  Ward.  The 
patient  was  a  man  of  twenty-five  years  of  age,  who  on  admission,  stated 
that  he  had  been  ill  for  four  days.  I  found  that  he  had  pseudo-membran- 
ous pharyngeal  sore  throat,  which  seemed  to  be  on  the  way  towards  recovery 
on  the  twelfth  day  from  that  on  which  he  was  admitted  to  the  hospital. 
When  alarmed  at  the  persistence  of  albuminuria,  a  paralytic  affection  of 
the  veil  of  the  palate  supervened.  Forty-eight  hours  later,  the  inferior 
extremities  were  affected :  great  weakness  made  walking  difficult :  and  at 
the  same  time,  there  were  observed  loss  of  appetite,  dysphagia,  aud  the 
reappearance  of  a  white  spot  on  the  throat.  Nine  days  later,  there  was  a 
very  large  quantity  of  albumen  in  the  urine,  and  the  legs  were  (Edematous. 
Respiration  was  considerably  oppressed,  and  I  detected  oedema  of  the 
lungs.  The  debility  went  on  increasing;  and  the  patient  died  twenty  days 
after  the  beginning  of  the  paralytic  symptoms,  and  a  month  after  his  arrival 
at  the  Hotel-Dieu. 

I  was  asked,  four  months  ago,  by  Dr.  Surbled  of  Corbeil  to  see  a  man 
of  52  years  of  age  who  had  contracted  diphtheria  from  one  of  the  members 
of  his  family.  After  having  been  ill  for  eight  days,  he  seemed  to  have 
recovered,  when  he  began  to  have  a  nasal  voice,  and  to  experience  some 
difficulty  in  swallowing.  His  inferior  extremities  soon  became  feeble :  this 
feebleness  went  on  increasing,  and  the  superior  extremities  in  their  turn 
became  similarly  affected.  The  motor  paralysis  was  accompanied  by 
numbness  and  formication,  and  was  followed  by"  an  affection  of  the  breath- 
ing: when  I  saw  the  man,  he  had  considerable  dyspnoea.  The  symptoms 
went  on  increasing  in  severity  till  death  took  place  three  months  from 
the  date  of  the  commencement  of  his  diphtheritic  sore  throat. 

The  little  girl  whom  I  saw  in  1848  with  Dr.  Dewulf  likewise  died  from 
this  severe  form  of  diphtheritic  paralysis;  she  was  carried  off  by  cerebral 
symptoms,  the  nature  of  which  I  misunderstood  at  the  time  of  tlieir  occur- 
rence, for  I  then  attributed  them  to  a  tubercular  lesion  of  the  encephalon. 
_  The  following  case,  reported  by  Dr^  Millard,  is  very  remarkable.  A 
little  girl  of  nine  years  of  age  was  admitted,  on  22d  March,  to  the 
Children's  Hospital,  Rue  de  Sevres.  Consequent  upon  an  attack  of  mem- 
branous sore  throat,  which  had  commenced  six  weeks  previously,  and  had 
continued  for  ten  days,  she  retained  a  very  nasal  tone  of  voice,  and  some 
dysphagia,  particularly  a  difficulty  in  swallowing  liquids,  which  returned 
by  the  nose.  General  debility  made  it  painful  for  her  to  walk  or  stand, 
and  imparted  a  character  of  uncertainty  to  her  movements.  She  remarked 
to  her  mother  that  her  sight  had  become  so  indistinct  that  she  was  qo 
longer  able  to  thread  a  needle.  She  was  in  low  spirits,  and  had  little 
appetite.  There  was  neither  diarrhoea  nor  fever  ;  but  for  eight  days,  sin- 
had  hail  a  little  cough. 

On    the   23d  March,  the  alteration  in  the  voice  was  verified  :   mi   causing 

the  child  to  open  the  mouth  by  telling  her  to  pronounce  the  exclamation 
— ah/  it  was  observed  that  the  veil  of  the  palate  remained  completely 
immovable.     It  still,  however,  retained  its  sensibility,  bul  on  tickling  the 

uvula,  nausea  was   excited.      Sighl    was   sensibly  enfeebled,  and    the    pupils 

were  small  and  contracted.  <>l>jeei-  held  out  to  her,  she  grasped  slackly, 
and  easily  allowed  them  to  escape  from  her  grasp.  Her  uncertain,  totter- 
in-  Btep suggested  the  idea  of  incomplete  paraplegia.     There  was  no  change 

in  the  general  sensibility.      The  urine  did  not  contain  albumen. 

For  the  (irst  two  days  of  her  residence  in  hospital,  .-he  was  moping,  with- 
out appetite,  and  without  energy  :  afterwards,  when  she  became  accustomed 


TARALYSIS    IN    DIPHTHERIA.  397 

to  her  new  abode,  she  went  into  the  garden,  and  regained  her  spirits  and 
some  strength.  There  was,  however,  no  improvement  in  respect  of  the 
paralysis  of  the  veil  of  the  palate.  She  was  put  on  a  tonic  regimen,  and 
took  daily  a  gramme  [15^  grains]  of  extract  of  cinchona  in  infusion  of 
coffee. 

On  28th  March,  she  went  to  mass  in  the  morning,  breakfasted  with  appe- 
tite, and  received  a  visit  from  her  relations  :  when  they  left  her,  they  were 
enchanted  with  her  improved  condition.  She  went  to  vespers  with  her 
companions,  when,  at  4  o'clock,  she  was  seized  with  cerebral  symptoms, 
which  at  first  gave  rise  to  the  belief  that  she  had  fainted :  she  sunk  down, 
without  cry  or  convulsion,  the  countenance  at  the  same  time  becoming 
altered.  Dr.  Millard  saw  her  at  five  o'clock.  She  was  then  lying  on  her 
back:  the  face  was  flushed,  the  skin  was  hot,  and  the  pulse,  128:  she  com- 
plained of  intense  headache.  The  mental  faculties  were  not  impaired. 
There  existed  neither  contractions,  convulsions,  nor  paralysis :  but  there 
was  strabismus,  and  a  persistence  of  the  nasal  tone  of  voice.  There  was  a 
deep  sonorous  cough,  without  any  sign  of  pulmonary  lesion  appreciable  by 
auscultation  or  percussion.  From  the  previous  evening,  it  was  noted,  that 
she  had  been  constipated.  Being  in  doubt  as  to  the  diagnosis,  Dr.  Millard 
ordered  the  hair,  which  was  profuse,  to  be  cut  immediately,  for  leeches  to 
be  applied  behind  the  ears,  a  purgative  enema  to  be  administered,  and 
sinapisms  to  be  shifted  about  over  the  surface  of  the  lower  limbs.  During 
the  evening,  general  convulsions  supervened  :  the  child  uttered  piercing 
cries,  and  passed  a  restless  night.  The  leeches  had  bled  to  the  extent  that 
was  desired,  and  the  result  of  the  enema  was  an  abundant  evacuation. 

At  the  visit  next  morning,  the  visage  was  pale,  and  the  pulse,  which 
remained  at  128,  was  a  little  compressible,  and  less  resistant  than  on  the 
previous  evening.  The  pupils  were  naturally  dilated,  and  the  weakness 
of  vision  and  strabismus  continued  to  be  very  decided.  The  patient  com- 
plained of  pain  in  the  head.  Intelligence  remained  unaffected.  The 
breathing  was  oppressed  and  sighing,  without  there  being  any  appreciable 
sign  of  pulmonary  lesion.  Calomel  combined  with  scammony  was  pre- 
scribed :  forty  centigrammes  [7-f-  grains]  of  calomel  and  ten  grammes 
[nearly  155  grains]  of  scammony  were  ordered  to  be  mixed  and  divided 
into  five  equal  parts,  one  of  which  she  was  to  take  every  hour.  At  four  in 
the  afternoon,  the  child  was  in  the  agonies  of  death,  and  in  an  hour  expired, 
without  having  had  convulsion  or  contorsion,the  intelligence  remaining  clear 
to  the  last. 

No  organic  lesion  of  any  consequence  was  observed  at  the  autopsy, 
except  congestion  at  the  base  of  the  lungs,  and  in  the  left  lung  two  tuber- 
cles each  of  the  size  of  a  filbert  nut. 

Thus,  gentlemen,  the  affection  of  the  respiration,  such  as  we  observe  in 
malignant  fevers,  the  vomiting,  the  delirium,  the  convulsions,  the  ataxo- 
adynamic  phenomena,  and  the  general  exhaustion,  are  the  symptoms  amid 
which  persons  sink  under  the  severe  form  of  diphtheritic  paralysis,  symp- 
toms which  bear  witness  to  \he  malignity  of  the  disease  by  which  they 
are  stricken,  and  which  acts  upon  the  essential  powers  of  life. 

The  absence  of  albumen  in  the  urine  of  the  patient  whose  case  I  have 
just  detailed  is  a  circumstance  possessed  of  some  interest.  I  have  told  you 
that  albuminuria  ought  to  be  taken  into  account  in  considering  the  causes 
which  produce  the  disorders  of  the  nervous  system  as  manifested  in  the 
visual  apparatus,  in  muscular  paralysis,  and  convulsions,  such  as  our 
patient  of  bed  No.  9  had,  or  such  as  those  of  a  more  formidable  character 
which  occurred  in  the  case  of  the  little  girl  of  Dr.  Millard;  yet  in  the 
latter  case,  there  was  no  albuminuria  to  associate  with   the  nervous  phe- 


398  PARALYSIS    IN    DIPHTHERIA. 

nomeua.  Physicians  who  have  made  this  subject  a  matter  of  special 
inquiry,  Dr.  Maingault  in  particular,  have  come  to  the  conclusion  that 
diphtheritic  paralysis  may  supervene  in  patients  who  have  not  had  albu- 
minuria at  any  stage  of  their  diphtheria,  as  in  Dr.  Millard's  case,  and  in 
that  of  our  female  patient  in  St.  Bernard's  Ward.  Although  I  have  been 
in  the  habit  of  every  day  attentively  examining  the  urine,  and  finding 
remarkable  variations  in  the  quantity  of  albumen  which  it  contained,  I 
have  hardly  ever  perceived  any  coincidence  between  a  diminution  of  albu- 
men and  the  variations  in  the  paralytic  symptoms.  Moreover,  Dr.  Main- 
gault has  justly  remarked,  that  the  nervous  affections  which  occur  in  the 
course  of  Bright's  disease  are  convulsive  and  comatose  in  their  character, 
and  bear  no  resemblance  to  those  now  under  discussion.  With  the  excep- 
tion of  amaurosis,  so  often  met  with  in  persons  having  albuminuria,  no  one 
has  observed  paralytic  manifestations  in  Bright's  disease. 

Diphtheritic  paralysis,  then,  does  not  depend  on  albuminuria  ;  and  it  is 
still  more  deserving  of  notice,  that  it  bears  no  relation  to  the  intensity. 
extent,  or  continuance  of  the  characteristic  local  manifestations  of  the  dis- 
ease. It  is  no  doubt  most  commonly  as  a  sequel  to  the  severe  form  of 
diphtheria,  to  sore  throat  complicated  with  membranous  coryza,  to  glandu- 
lar engorgements  of  evil  omen,  and  to  plastic  exudations  on  different  parts 
of  the  body,  that  paralysis  occurs  ;  but  on  the  other  hand,  it  is  by  no  means 
unusual,  in  the  present  day,  for  strange  disorders  of  innervation  to  show 
themselves  in  persons  who  have  had  diphtheria  in  apparently  its  mildest 
form.  Dr.  Maingault  has  mentioned  a  certain  number  of  cases  of  this 
kind — cases  in  which  paralytic  affections,  more  or  less  general,  and  more 
or  less  persistent,  followed  pellicular  disease  stationed  on  the  pharynx  and 
occupying  a  very  limited  surface  :  in  some  of  the  cases,  it  is  true,  the  false 
membranes  had  obstinately  resisted  cauterization,  but  in  the  majority,  they 
had  quickly  disappeared  under  that  treatment. 

Perhaps  I  have  recalled  to  the  recollection  of  some  of  you  the  history  of 
the  patient  who  occupied  bed  No.  9  of  St.  Agnes's  Ward,  and  who  furnished 
us  with  an  example  of  diphtheritic  paralysis  supervening  after  an  exceed- 
ingly mild  attack  of  pseudo-membranous  sore  throat.  The  patient  was  a 
man  aged  twenty-four  years  of  age,  of  vigorous  constitution,  and  by  occu- 
pation a  discharger  of  barges.  A  month  before  coming  into  our  wards,  he 
was  seized,  consequent  upon  a  chill,  with  shivering,  fever,  and  very  acute 
sore  throat.  At  first,  he  remained  at  home  without  any  treatment,  and 
then  went  to  the  Beaujon  Hospital,  where  he  was  placed  in  Dr.  Gubler's 
wards.  My  colleague,  whose  experience  in  a  matter  of  this  kind  cannot 
be  called  in  question  by  any  one,  diagnosed  the  case  to  be  one  of  common 
membranous  -ore  throat — guttural  herpes.  The  urine,  which  was  carefully 
examined,  did  not  contain  albumen.  Kecovery  was  rapid.  Some  days 
late)-,  however,  this  man'.-  voice  was  nasal,  his  deglutition  was  difficult  :  and 
if  he  drunk  hurriedly,  the  fluid  was  returned  through  the  nose.  lie  never- 
theless asked  permission  to  leave  the  hospital,  ami  resume  his  ordinary 
occupations.      The    paralysis   of  the  veil    of  the    palate   continued,   and    he 

complained  of  a  constant  feeling  of  cold.  Eighl  days  afterwards,  he  ex- 
perienced a  sensation  of  painful  numbness :  on  the  following  day,  the  Left 

hand  was  seized,  and  in  eighl  days  more,  the  feet    and    hands  were  affected 

with  paralysis:  the  progress  of  the  disease  was  slow  and  uncertain.  You 
recoiled  the  condition  in  which  we  found  him  on  hi.-  arrival  al  the  Hotel- 
Dieu,  a  month  after  the  commencement  of  his  attack  of  sore  throat,  that 

is,  about  three  weeks  after  the  appearance  .if  (he  paralytic  symptoms.     He 

tottered  ai  every  step,  and  did  not  feel  the  ground   under  his  teet,  bo  that 

to  prevent   himself  from  falling,  h«'  was  obliged  to  look  at   his  feet  when  he 


PARALYSIS    IN    DIPHTHERIA.  399 

walked.  He  showed  by  the  right  hand  a  pressure  of  20  kilogrammes  on 
Dr.  Burq's  dynamometer,  and  by  the  left,  21  kilogrammes:  a  man  of  his 

age  and  of  ordinary  strength  ought  to  show  a  pressure  of  55  or  GO  kilo- 
grammes. 1  found  that  anaesthesia  and  analgesia  existed  on  the  entire  sur- 
face of  the  body :  the  right  side  of  the  face  was  rigid  :  there  was  neither 
strabismus  nor  amblyopia:  the  mind  was  unimpaired.  This  individual 
told  us  that  he  had  completely  lost  venereal  desire  and  had  had  no  erections 
for  a  month.  The  functions  of  the  bladder  and  rectum  were  regularly  per- 
formed. Digestion  was  not  at  fault.  I  instituted  tonic  treatment,  and 
gave  iron  and  quinine.  At  a  later  period,  I  prescribed  syrup  of  the  sul- 
phate of  strychnia,  and  afterwards  returned  to  the  ferruginous  medicines. 
When  the  patient,  in  accordance  with  his  own  wish,  left  our  wards,  after  a 
residence  of  about  two  months,  he  had  obviously  regained  some  strength  : 
on  the  evening  before  he  went  home,  he  produced,  by  the  dynamometer,  a 
pressure  of  between  32  and  34  kilogrammes. 

Here  then,  we  had  a  case  of  sore  throat  presenting  all  the  appearances  of 
guttural  herpes,  which  led  to  paralytic  symptoms,  absolutely  similar  to 
those  which  supervene  as  sequela?  of  the  most  severe  diphtheria.  But  the 
question  may  be  raised :  was  this  a  case  of  real  pharyngeal  herpes  ? 
While  it  assumed  the  herpetic  form,  was  it  not  under  the  same  morbific  in- 
fluence which,  at  the  same  epoch,  led  to  pure  diphtheritic  sore  throat  in 
other  cases  ?  Upon  a  former  occasion  I  told  you  that  the  manifestations 
of  diphtheria  are  exceedingly  variable.  Comparing  that  which  takes  place 
in  this  disease  with  that  which  takes  place  in  small-pox,  which  is  sometimes 
confluent  and  sometimes  distinct,  and  which  occasionally  exhibits  only  one  or 
two  pustules — when  we  see  what  takes  place  in  scarlatina,  the  specific  erup- 
tion of  which  may  be  absent — we  can  quite  well  understand  that  the  mani- 
festations of  diphtheria  may  be  very  different  from  one  another,  and  yet 
the  cause  of  the  disease  be  the  same — that  while  the  morbific  seed  is  the 
same,  the  produce  varies  with  the  soil  in  which  it  is  sown.  In  illustration 
of  this  proposition,  I  quoted  cases  from  Dr.  Peter's  work,  which  seem  to  prove 
the  existence  of  this  diversity  of  outward  form  in  diphtheria. 

If  the  skeptical  can  only  see  in  this  a  coincidence,  it  must  be  admitted 
that  the  coincidence  is  at  least  a  very  remarkable  one.  Looking  to  such 
cases,  and  to  others  of  a  similar  description  which  I  have  quoted  to  you, 
we  are  entitled  to  ask,  not  only  whether  common  membranous  sore  throats 
followed  by  paralytic  affections — cases  like  that  of  our  patient  of  bed  No. 
19  St.  Agnes's  Ward — wrere  not  really  diphtheritic  sore  throats  ;  but  also, 
whether  sore  throats  of  apparently  the  most  simple  character  may  not  give 
rise  to  paralysis  of  the  veil  of  the  palate,  as  I  lately  observed  in  two  cases  ? 
One  of  the  patients  to  whom  I  refer  was  a  man  of  50  years  of  age,  and  the 
other  a  young  girl  of  15,  a  patient  of  my  friend  Dr.  Leon  Gros.  Do  not 
these  cases  of  apparently  simple  sore  throat  originate  in  the  same  cause 
as  severe  diphtheria,  especially  when  they  occur  during  diphtheritic  epi- 
demics ?  If  it  be  so,  we  can  quite  well  understand  how  paralytic  affection.^ 
may  supervene  after  simple,  just  as  after  diphtheritic  sore  throats. 

I  do  not  wish  you,  however,  to  believe  that  simple  sore  throats  never 
bring  in  their  train  paralysis  identical  with  that  which  occurs  as  a  sequel 
to  diphtheria.  Facts  accurately  observed  by  able  clinical  physicians  show 
that  irrespective  of  the  epidemic  influence  of  diphtheria,  simple  inflamma- 
tory sore  throats  may  be  the  starting-point  of  that  peculiar  form  of  general 
paralysis  which  we  have  been  studying;  but  while  I  admit  this,  I  wish  to 
state  most  positively  that  though  it  is  very  common  to  meet  with  paralysis 
as  a  sequel  of  diphtheria,  it  is  exceedingly  rare  to  see  it  following  simple 
sore  throat,  which  is  perhaps  the  most  common  of  all  acute  diseases. 


400  PARALYSIS    IN    DIPHTHERIA. 

It  now  remains  for  me  to  endeavor  to  interpret  the  facts  which  I  have 
laid  before  you.  What  is  the  nature  of  diphtheritic  paralysis  f  Can  it  be 
associated  with  any  appreciable  lesion  of  the  nervous  centres?  Assuredly 
not.  It  would  be  inadmissible  to  suppose  that  upon  a  persistent  anatom- 
ical lesion  could  depend  symptoms  so  variable  and  mutable.  We  could 
not  suppose  it  possible  for  such  complete  recovery  to  take  place  from  these 
paralytic  affections,  if  they  depended  upon  softening,  hemorrhage,  or  any 
other  organic  affection  of  the  brain  or  spinal  cord.  Autopsies,  have,  be- 
sides, sufficiently  cleared  up  this  subject ;  and  I  have  myself  had  opportu- 
nities of  ascertaining  after  the  death  of  the  patients,  that  there  was  nothing 
appreciable  in  the  state  of  the  encephalon  or  spinal  marrow  or  their  enve- 
lopes, to  explain  the  symptoms  during  life. 

There  takes  place  then,  in  diphtheritic  paralysis,  something  analogous  to 
that  which  occurs  in  certain  cachexia. 

When  we  detect  albuminuria  in  a  diphtheritic  patient,  the  first  idea 
which  suggests  itself  is  to  attribute  to  that  condition  the  disturbances  of 
innervation  which  we  met  with.  I  will,  gentlemen,  repeat  to  you  a  remark 
which  I  have  just  made,  that  on  the  one  hand  the  nervous  symptoms  con- 
secutive to  diphtheria,  except  the  indistinctness  of  vision  also  experienced 
by  persons  suffering  from  Bright's  disease,  the  nervo-paralytic  symptoms 
bear  no  resemblance  to  the  convulsions  and  coma  of  uraemia  :  on  the  other 
hand,  I  again  repeat,  that  in  a  large  proportion  of  the  cases  of  diphtheritic 
paralysis,  not  the  slightest  trace  of  albumen  can  be  detected  in  the  urine 
at  any  stage  of  the  disease.  We  must,  therefore,  seek  elsewhere  for  our 
interpretation. 

Graves  (in  his  clinical  lectures)  wishing  to  point  out  the  relations  which 
exist  between  different  diseases,  mentions  numerous  well-known  facts  which 
present  a  great  analogy  to  those  we  are  now  studying.  He  states  that  an 
entire  crew  after  eating  of  a  species  of  conger-eel,  were  seized  with  nervous 
symptoms  similar  to  those  induced  by  lead  poisoning.  Some  men  died  in 
a  state  of  violent  delirium :  those  who  survived  were  affected  with  general 
paralysis.  In  some  cases  the  affection  was  permanent :  in  others,  recovery 
took  place  at  the  end  of  three  or  four  months.  Three  or  four  months  ! 
mark  well  the  duration,  for  it  is  absolutely  the  same  as  that  of  diphtheritic 
paralysis.  Werloff,  and  Foster  speak  of  paralytic  affections  following 
maladies  caused  by  eating  some  other  kinds  offish. 

Cases  similar  in  their  nature  to  these  now  mentioned  are  not  rare  in 
pathology.  When  lecturing  upon  urticaria,  I  stated  that  paralytic  :i(K<- 
t ions  sometimes  supervene  in  persons  attacked  bjfebris  urtieata.*  They 
are  observed  still  more  frequently  as  sequehe  of  other  diseases.  In  syphilis, 
irrespective  of  paralysis  depending  upon  specific  tumors  of  the  encephalon 
and  spinal  cord,  and  osseous  growl  lis  of  the  cranium  and  vertebral  canal, 
there  occur  other  paralytic  affections  which  cannot  hi'  traced  t<>  any  appre- 
ciable lesion.  The  correctness  of  (his  statement  is  proved  by  the  case  of  a 
man  who  is  now  lying  in  bed  No.  22  of  St.  Agncs's  Ward.  This  individ- 
ual, who  is  suffering  from  constitutional  syphilis  of  old  standing,  complains 
of  numbness,  formication,  weakness,  and  a  feeling  of  excessive  cold  in  the 
right  leg,  to  which  these  symptoms  are  confined  :  there  is  nothing  abnormal 
in  the  state  of  the,  arm,  face,  or  any  part  of  the  right  side,  except  the  lee. 

But  it  is  still  more  usual  for  these  paralytic  all'ections  to  occur  as  sequelSB 
of  severe  fevers.      You  rememlier,  gentlemen,  a  woman  who  lay  in  bed  No. 

29  of  St.  Bernard's  Ward,  who,  two  years  ago,  became  paraplegic  consequent 

upon   an   attack   of  small-pox.      Such   occurrences   are   frequent    after   that 
*  Seo  p.  217  of  tins  volume. 


PARALYSIS    IN    DIPHTHERIA.  401 

exanthematous  fever.  The  rachialgia  which  announces  the  beginning  of 
tin'  attack,  as  well  as  the  paralysis  of  the  inferior  extremities,  and  the 
retention  of  urine  which  accompany  the  lumbar  pains,  are,  as  1  formerly 
argued,  phenomena  of  this  same  class.     The  paralytic  symptoms  which 

manifest  themselves  after  the  termination  of  the  eruptive  fever  are  likewise 
referable  to  a  similar  cause. 

Borne  of  y»>u,  gentlemen,  I  doubt  not,  still  recollect  the  two  patients  of 
St.  Bernard's  Ward  who,  consequent  on  typhoid  fever,  were  struck  with 
paraplegia.  In  one  of  my  lectures  on  dothinenteria  I  called  your  attention 
to  paralytic  cases  of  this  description,  when  speaking  of  the  disorders  of  the 
nervous  system  which  may  impede  the  progress  of  convalescence  from  that 
fever.  I  stated  to  you  that  these  paralytic  affections,  which  sometimes 
become  general,  involving  the  nerves  of  motion  and  sensation,  attack  the 
organs  of  seeing  and  hearing — the  patients  being  blind  and  deaf — and  also 
localize  themselves  in  the  inferior  extremities,  the  bladder,  and  rectum. 
There  is  a  remarkable  similarity  between  such  complications  of  dothinen- 
teria and  those  observed  in  diphtheria :  the  similarity  is  all  the  more  strik- 
ing from  the  circumstance  that  the  paralysis  consequent  on  dothinenteria 
sometimes  affects  the  veil  of  the  palate. 

Paralytic  seizures  also  supervene  during  the  course  of,  and  after  recovery 
from,  typhus  and  cholera  ;  and,  in  a  word,  in  connection  with  diseases  which 
lead  to  serious  disturbance  of  the  organism  and  greatly  shatter  the  nervous 
system.  Clinical  experience  shows  us  that  we  can  only  regard  as  secondary 
causes  of  these  seizures  the  prolonged  suffering  of  the  patient,  the  state  of 
debility  and  anaemia  into  which  he  has  fallen,  whether  as  the  result  of  the 
fever  itself,  or  of  exhaustion  from  hemorrhages  and  profuse  fluxes,  or  from 
having  been  condemned  to  a  rigorously  low  diet ;  and  that  they  must  be 
looked  upon  as  direct  consequences  of  a  morbific  cause.  They  arise  from 
an  organic  and  functional  modification  imparted  to  the  entire  nervous  sys- 
tem by  this  morbific  cause,  which,  having  acted  primarily  and  directly,  acts 
during  the  whole  continuance,  and  even  after  the  cessation  of  the  malady. 

Here  then,  gentlemen,  we  have  to  do  with  poisons  as  in  the  cases  cited 
by  Graves :  we  have  also  to  do  with  contagion-germs  which  produce  symp- 
toms analogous  to,  but  not  identical  with  those  we  observe  in  diphtheritic 
paralysis.     Similar  effects  follow  the  taking  of  mineral  poisons. 

When  I  come  to  lecture  on  specificity,  I  shall  remind  you  that  poisoning 
with  lead  also  produces  disturbing  effects  on  the  innervation,  and  that  among 
them  paralysis  occupies  an  important  place :  I  shall  describe  to  you  the 
symptoms  experienced  by  persons  employed  in  manufactories  of  vulcanized 
caoutchouc :  I  shall  speak  to  you  of  the  effects  of  inhaling  sulphuret  of 
carbon,  and  among  the  symptoms  produced  by  that  substance,  which  have 
been  so  admirably  described  by  Dr.  A.  Delpech  (the  first  to  make  them 
known  to  us),  I  shall  call  your  attention  to  diminution  of  muscular  power, 
partial  paraplegia,  dimness  of  sight,  and  dulness  of  hearing — in  a  word,  to 
various  forms  of  paralysis.* 

Well,  then,  diphtheritic  paralysis  belongs  to  the  same  category :  its  real 
cause  is  poisoning  of  the  system  by  the  morbific  principle  which  generates 
the  malady  on  which  the  paralysis  depends :  it  originates  in  disturbance  of 
the  nervous  system,  in  the  modality  to  which  it  is  subjected,  a  modality 
with  which  we  are  at  present  unacquainted,  and  with  the  nature  of  which 
we  shall  always,  perhaps,  remain  in  ignorance. 

*  Delpech:  Memoire  sur  les  Accidents  que  developpe  chez  les  Ouvriers  en  Caou- 
chouc  1 'Inhalation  du  Sulfure  de  Carbone  en  Vapeur.     Paris,  1856. 

Nouvelles  Recherches  sur  l'Intoxication  Speciale  que  determine  le  Sulfure  de  Car- 
bone.     [Annates  d'Hygihne.     Paris,  18G3.] 
vol.  i.— 26 


402  TREATMENT    OF    DIPHTHERIA    AND    CROUP. 

It  would  be  difficult  to  formulate  the  treatment  of  diphtheritic  paralysis. 
In  general  terms  I  may  say  that  tonic,  strengthening  remedies  are  every- 
thing. .You  therefore  see  me  prescribe  cinchona  in  all  its  forms,  also  vari- 
ous bitters  aud  ferruginous  medicines  :  you  see  me  insist  on  the  necessity  of 
a  substantial  and  restorative  diet.  According  to  the  case  I  have  to  treat, 
I  stimulate  the  functions  of  the  skin  by  using  aromatic  lotions,  dry  frictions, 
or  sulphurous  baths.  When  the  symptoms  are  on  the  wane,  preparations 
of  mix  vomica  have  seemed  to  me  to  be  of  real  service,  by  supplying,  at  the 
proper  time,  an  excitant  of  muscular  contractility.  Sea-water  baths  are 
also  indicated  as  a  means  of  inducing  perfect  convalescence ;  and  I  believe 
that  a  well-regulated  application  of  hydropathy  might  prove  exceedingly 
useful  for  the  same  purpose. 


Treatment  of  Diphtheria  and  Croup. 

The  Antiphlogistic  Treatment  ought  to  be  absolutely  rejected.  —  Alterative 
Treatment:  Mercurials  useful  as  Topical  Agents:  their  inconveniences: 
alkalies,  particularly  bicarbonate  of  soda,  of  very  doubtful  benefit. —  Chlo- 
rate of  Potash  useful  in  cases  of  average  severity. — Emetic  Treatment:  its 
Inconveniences  greater  than  its  Advantages. — Serious  Consequences  pro- 
duced by  Blisters. —  Topical  Method  of  Treatment  by  Astringents  <md 
Caustics  is  Best  Treatment  of  Diphtheritic  Affections. — Caiheterism  of 
the  Larynx. — Indispensable  Necessity  of  sustaining  the  vital  powers  of  the 
patients  by  Food  and  Tonic  Medicines. 

Gentlemen:  When  it  became  universally  admitted  by  physicians,  that 
pellicular  affections  were  of  the  nature  of  inflammation,  when  croup  was 
regarded  as  the  result  of  inflammation  of  the  mucous  membrane  of  the 
larynx,  it  seemed,  at  the  first  view  of  the  matter,  to  be  both  rational  and 
easv,  to  extinguish  in  its  site  that  inflammation,  in  general  of  very  limited 
extent.  Certainly,  if  we  only  take  into  account  the  local  lesion,  a  diph- 
theritic patch  on  the  skin,  even  though  it  cover  the  surface  to  which  a  large 
blister  has  been  applied,  is  apparently  of  trifling  importance:  when  we 
examine  the  throat  of  a  person  attacked  by  pseudo-membranous  disease, 
we  find  that  the  swelling  of  the  tonsils  is  very  moderate,  and  the  plastic 
exudation  at  first  very  limited  in  extent.  No  doubt,  it  might  be  supposed 
that  a  local  disease  so  circumscribed,  and  giving  rise,  in  the  first  instance, 
to  so  insignificant  an  amount  of  febrile  reaction  would  readily  yield  to  a 
pretty  energetic  antiphlogistic  treatment,  as  other  less  extensive  and  lev- 
intense  inflammations  do  not  resist  such  measures. 

Local  bleeding  by  leeches  and  cupping,  as  well  as  general  bleeding,  seem 
therefore  to  he  indicated  as  the  appropriate  means  to  he  employed  For  the 
purpose  of  promptly  subduing  inflammations  which  set  in  with  so  peaceful 
an  aspect.  Here,  theory  has  been  found  to  he  at  fault,  as  it  very  often 
is  when  applied  to  practice.  It  cannot  be  doubted,  gentlemen,  that  euta- 
neous  diphtheria,  pseudo-membranous  sore  throat,  and  croup,  are  inflam- 
mations: in  common  with  all  others,  1  accept  that  proposition  as  the  truth: 
but  I  do  not  think  that  a  dominating  influence — the  specific  character  of 
the  inflammation — has  been  sufficiently  taken  into  account.  I  shall  tell 
you  when  1  come  to  speak  of  the  very  important  question  of  specificity  that 
septic  maladies  are  personal  maladies,  Over  which  the  treat  men  I  which  may 

he  called  physiological  has  generally  little  effect.  The  progress  of  the 
majority  of  this  class  of  cases  is  unpropitious.  When  once  the  small-pox 
pustule  is  developed,  whatever  may  he  the  degree  of  intensity  in  the  accom- 


TREATMENT    OF    DirilTHERIA    AND    CROUP.  403 

panying  inflammation,  all  the  antiphlogistic  resources  of  medicine  will 
prove  incapable  of  preventing  il  from  running  through  its  appointed  stages: 
to  arrest  its  progress,  the  pustule  must  be  otherwise  destroyed.  To  take 
an  illustration  from  an  affection  which  presents  a  striking  analogy  to  that 
we  are  now  studying:  when  the  malignant  pustule  is  once  developed,  gen- 
eral bleeding,  depletion  by  leeches  or  cupping,  however  often  repeated, 
and  however  much  blood  is  taken,  have  no  effect  in  stopping  its  progress : 
on  the  contrary,  they  may  do  a  great  deal  of  mischief  to  the  patient. 

So  it  is  in  diphtheria.  By  the  admission  even  of  those  who,  taking  a 
middle  view,  consider  that  in  some  cases  antiphlogistic  measures  are  useful, 
they  never  cure  the  disease.  In  my  opinion,  this  modified  belief  of  some 
physicians  in  the  utility  of  antiphlogistic  ti'eatment  is  very  open  to  be  called 
in  question.  Nay,  let  me  at  once  add,  that  a  long  experience  has  shown 
me  that  it  is  not  only  useless,  but  essentially  injurious  in  septic  diseases, 
which  have  an  inherent  tendency  to  produce  prostration. 

The  remarks  which  I  have  made  on  the  antiphlogistic,  are  ecpually  appli- 
cable to  the  alterative  treatment,  which  is  in  fact  its  adjunct.  Mercury 
and  its  preparations  occupy  the  first  place  among  alterative  medicines. 
Mercurials,  as  you  are  aware,  are  regarded  as  the  most  powerful  anti- 
phlogistic^ in  the  materia  medica,  and  they  are  perhaps  even  more  potent 
in  that  respect  than  bloodletting.  You  have  seen,  a  hundred  times,  the 
effects  which  we  have  obtained  from  them  in  inflammations  of  serous  mem- 
branes :  you  are  aware  that  in  these  affections,  so  very  formidable  from 
their  extent,  seat,  and  concomitant  fever,  their  beneficial  influence  has  been 
lauded.  Well !  mercurial  preparations — calomel  given  internally,  and 
cutaneous  frictions  with  Neapolitan  ointment* — have  been  tried  in  Eng- 
land, Germany,  America,  and  France,  as  antiphlogistic  remedies  in  the 
treatment  of  diphtheritic  affections,  pseudo-membranous  sore  throat,  and 
croup.  The  results,  I  must  say,  have  often  been  successful.  Without  any 
other  treatment,  calomel  administered  at  short  intervals,  in  fractional 
doses,  according  to  Dr.  Law's  plan,  has  cured  a  certain  number  of  cases. 

This  announcement,  gentlemen,  may  seem  a  contradiction  to  my  propo- 
sition in  reference  to  the  dangers  of  antiphlogistic  treatment:  and  here  it  is 
that  the  question  becomes  very  complex.  In  point  of  fact,  calomel  and 
the  other  mercurial  preparations  involve  an  argument  wdiich  tells  in  twTo 
ways.  Mercury  has  two  modes  of  action:  it  has  a  general  action  on  the 
economy,  in  which  case  it  is  an  alterative  medicine,  an  antiphlogistic:  it 
has  also  an  exclusively  topical  action.  When  you  prescribe  lotions  for  the 
skin  of  eau  phagedenique  (a  solution  of  corrosive  sublimate),  when  you  irri- 
gate the  eye  with  mercurial  collyria,  when  you  apply  to  the  eyelids  red 
precipitate  and  protochloruret  of  mercury  in  the  dry  state  or  mixed  with 
lard,  when  you  fumigate  with  the  red  sulphuret  of  mercury,  when  you  do 
any  of  these  things,  you  institute  a  treatment  essentially  local;  and  it  is 
only  in  an  indirect  manner  that  general  results  are  obtained.  The  treat- 
ment which  you  employ  is  substitutive.  It  is  only  after  the  lapse  of  some 
time,  and  by  perseverance  in  the  treatment,  that  the  mercury  acts  on  the 
blood,  and  modifies  its  composition  in  the  manner  of  alterative  medicines. 
As  a  topical  application,  protochloride  of  mercury  has  seemed  to  me  to  be 
of  real  service  in  diphtheritic  affections.  When  applied  to  the  sores  which 
are  the  seat  of  the  pseudo-membranous  exudations,  it  modifies  their  char- 

*  The  "  onguent  Napolitain,"  called  also  "  onguent  mercuriel  double,"  is  made  by 
mixing  with  washed  prepared  lard  an  equal  weight  of  pure  mercury;  and  then 
triturating  them  together  till  the  latter  is  killed,  or  in  other  words  till  the  metal  is 
so  minutely  divided  that  no  globules  can  be  seen. — Translator. 


404  TREATMENT    OF    DIPHTHERIA    AND    CROUP. 

acter  in  a  beneficial  manner;  and  if  it  has  done  good  in  pseudo-membranous 
sore  throat,  it  is  by  its  local  action.  When  given  to  a  patient  with  pha- 
ryngeal diphtheria  in  fractional  doses — say  5  centigrammes  [five-sevenths 
of  a  grain]  mixed  with  5  grammes  of  sugar  [77-|  grains],  and  divided  into 
20  packets,  of  which  one  is  taken  every  hour — it  mingles  with  the  saliva, 
and  in  this  state  traverses  the  pharynx,  touching  the  morbid  surfaces,  and 
modifying  them  in  the  same  way  that  it  modifies  diphtheritic  sores  on  the 
skin.  I  do  not,  however,  dispute  that  this  medicine  may  have  a  general 
action,  for  I  know  that  it  produces  decided  effects  when  absorbed  in  its 
passage  through  the  alimentary  canal :  it  modifies  the  blood,  augmenting 
its  fluidity,  and  so  changing  its  state,  that  the  secretions  becomes  less  plastic. 
So  far,  indeed,  am  I  from  denying  the  constitutional  action  of  this  medi- 
cine, that  I  have  a  great  dread  of  it;  and  I  believe  that  the  topical  action 
is  that  alone  which  is  of  use.  When  the  treatment  is  restricted  to  frequent 
mercurial  frictions,  a  special  dyscrasia  of  the  blood  is  speedily  produced, 
phenomena  depending  on  that  dyscrasia  occur,  salivation  is  induced;  but, 
nevertheless,  the  diphtheria  is  not  cured.  It  is  not  necessary  to  say  more 
to  show  you  that  the  mercurial  treatment  has  its  dangers  from  its  constitu- 
tional effects.  From  its  effects  varying  with  the  peculiarities  of  individuals, 
there  is  a  risk  of  their  passing  the  limits  within  which  it  is  wished  to  restrain 
them;  and  in  these  circumstances  the  inconveniences  of  the  antiphlogistic 
treatment  are  likely  to  be  discovei'ed,  for  if  it  do  not  at  once  aggravate  the 
disease,  it  may  prolong  convalescence  by  increasing  the  debility  into  which 
the  patient  has  been  thrown  by  the  disease. 

I  have  now  to  speak  to  you  of  other  alterative  medicines.  Some  years 
ago,  Dr.  Marchal,  of  Calvi,  published  several  cases,  which  seemed  to  prove 
that  the  bicarbonate  of  soda  was  useful  in  the  treatment  of  diphtheria. 
He  thus  restored  the  reputation  of  the  alkaline  treatment,  which,  lauded 
for  a  time,  had  soon  fallen  into  discredit.  Both  the  external  and  internal 
use  of  the  subcarbonate  of  ammonia  had  been  lauded  by  Reehou,  but  never- 
theless this  medicine,  so  difficult  and  sometimes  so  dangerous  to  employ, 
had  been  abandoned.  Chamerlat  prescribed  gargles  of  hydrochlorate  of 
ammonia,  and  Mouremans  has  reported  a  case  of  pseudo-membranous  laryn- 
gitis cured  by  bicarbonate  of  soda.*  The  alkaline  treatment  had  become 
almost  completely  neglected,  when  Dr.  Marchal  restored  it  to  credit.  Other 
practitioners  in  their  turn  came  forward  to  proclaim  successes  which  they 
had  obtained  with  it,  some  of  which  were  real  though  purely  accidental, 
while  others  were  doubtful,  or  very  open  to  be  called  in  question.  In  this 
way,  general  attention  was  directed  to  the  treatment  of  diphtheria  by  bicar- 
bonate ol'soda,  and  by  and  by,  enthusiasm  mingling  in  the  discussion,  it  was 
soon  believed  by  some  that  in  this  medicine  had  been  discovered  a  specific 
for  diphtheria,  and  even  for  croup.  Calm  reflection,  however,  explained 
the  marvellous  results  which  were  announced,  and  reduced  them  to  their 
real  value.  In  fact,  it  was  easy  to  see  that  in  the  cases  in  which  the  alka- 
lies were  said  to  have  cured  pseudo-membranous  affections,  the  cases  were 
of  that  kind  from  which  spontaneous  recovery  is  usual,  such  as  scarlatino- 
membranous  affections,  and  such  accidental  membranous  affections  as  occur 
during  chronic  diseases.  This  is  of  itself  sufficienl  to  deprive  the  facts  of 
their  value.  There  is  always  something  seductive  in  a  theory:  1  myself 
put  forth  one  when  I  wrote  that  there  was  ground  for  hoping  that  some  ad- 
vantage mighl  be  derived  from  the  alterative  and  anaplastic  action  of  bi- 
carbonate of  soda  iii  modifying  the  general  diathesis  which  seems  to  preside 


*  Encyclopedic  des  Sciences  M6dicalea  pour  I 'an  nee  L889. 


TREATMENT    OF    DIPHTHERIA    AND    CROUP.  405 

over  the  development  of  diphtheritic  affections.*  The  general  action  of 
alkalies,  the  peculiar  state  of  the  blood  which  they  produce,  is  an  undoubted 
fact  demonstrated  by  our  predecessors — by  (Allien  among  others;  but  this 

alkaline  cachexy  (for  SO  it  has  been  called)  is  not  produced  till  the  use  of 
the  alkalies  has  been  long  continued,  and  however  protracted  the  duration 
of  the  diphtheritic  attack,  it  never  lasts  long  enough  for  the  anaplastic 
influence  of  the  alkaline  treatment  to  come  into  operation.  This  treatment, 
far  from  producing  the  benefits  which  have  been  attributed  to  it,  is  the 
source  of  serious  evils:  it  is  open  to  the  same  objections  as  the  alterative 
treatment,  the  dangers  of  which  I  have  just  been  pointing  out.  The  topical 
influence,  however,  of  the  bicarbonate  of  soda  remains  to  be  noticed:  it  has 
been  thought  that  its  solvent  action  assists  in  softening  and  detaching  the 
false  membrane.  I  was  formerly  a  believer  in  this  topical  influence,  and 
there  are  physicians  who  have  still  this  faith,  which  additional  experience 
has  taught  me  to  relinquish :  the  modifications  induced  in  the  diphtheritic 
secretions  by  alkaline  solutions  are  far  from  being  such  as  they  seemed  to 
me  when  first  I  made  them  the  subject  of  observation. 

Chlorate  of  potash,  gentlemen,  is  another  medicine  which  has  recently 
attracted  much  attention.  This  salt,  discovered,  as  you  are  aware,  by 
Berthollet,  at  the  end  of  last  century,  entered  the  domain  of  therapeutics 
about  the  year  1796.  In  1819,  Chaussier  proposed  it  as  a  remedy  in  croup. 
It  had  completely  fallen  into  oblivion,  when  Dr.  Blache,  repeating  the  ex- 
periments made  in  1847  by  Hunt  and  West  with  this  medicine  in  the  treat- 
ment of  gangrene  of  the  mouth  and  pseudo-membranous  stomatitis,  was  led 
to  try  it  in  the  treatment  of  pseudo-membranous  sore  throat  and  croup. 
Dr.  Isambert,  when  interne  of  Dr.  Blache,  studied  with  care  and  intelli- 
gence the  numerous  trials  made  with  this  medicine  at  the  Children's  Hos- 
pital, and  made  them  the  subject  of  his  inaugural  thesis.f  The  first  results 
obtained  in  the  treatment  of  membranous  sore  throat,  though  less  satisfac- 
tory than  in  the  treatment  of  ulcero-membranous  stomatitis,  were,  never- 
theless, encouraging.  The  chlorate  of  potash,  no  doubt  attained  a  vogue 
far  beyond  its  merits,  but  the  cases  accumulated  from  all  quarters  justified 
its  being  regarded  as  capable  of  rendering  some  service  in  diphtheritic  sore 
throat,  though  not  entitling  it  to  be  looked  on  as  a  very  efficacious  remedy. 
With  Dr.  Isambert,  I  admit  that  the  beneficial  results  obtained  in  cases  of 
average  severity  are  shown  not  only  by  real  and  ultimate  success,  but  also 
by  an  action  upon  the  mucous  membrane  of  the  pharynx,  altogether  special 
and  in  a  certain  sense  elective,  an  action  analogous  to  that  which  is  ob- 
served in  pseudo-membranous  stomatitis  ;  but  I  deny  that  it  does  any  good 
in  cases  of  severer  type.  When  such  cases  have  been  treated  solely  by  it, 
I  have  always  observed  failure  ;  but  when  employed  conjointly  with  other 
measures,  its  operation  has  appeared  to  me  to  be  beneficial,  though  I  can- 
not make  an  absolute  affirmation  to  that  effect.  This  remark  applies  to 
pseudo-membranous  sore  throat,  but  is  still  more  applicable  to  pseudo- 
membranous laryngitis.  No  doubt,  from  time  to  time  recoveries  occur  in 
cases  of  croup  treated  by  chlorate  of  potash  ;  but  these  cases  are  in  no 
respect  conclusive,  as  its  use  in  them  has  generally  been  combined  with 
other  measures,  particularly  with  emetics,  to  which  solely  the  cure  may 
sometimes  be  ascribed.  As,  however,  this  drug  is  supposed  to  have  a  gen- 
eral influence  on  the  system,  and  to  prevent  plastic  exudation,  and  as  its 
employment  does  not  induce  bad  consequences  like  those  caused  by  alkalies 

*  Trousseau  et  Pidoux  :  Traite  de  Therapeutique. 

f  Isambert:  Etudes  Chimiques,  Physiologiques,  et  Cliniques,  sur  l'Emploi 
Therapeutique  du  Chlorate  de  Potasse,  specialement  dans  les  Affections  Diphther- 
itiques.     Paris,  1856. 


406  TREATMENT    OF    DIPHTHERIA    AND    CROUP. 

and  mercurials,  there  is  no  reason  why  it  should  not  he  given  in  obstinate 
eases.  You  must  not,  however,  too  much  rely  on  its  virtues,  and  you  must 
not  employ  it  to  the  exclusion  of  other  treatment  of  established  efficacy 
within  certain  limits. 

I  ought  also  to  mention  the  treatment  by  bromide  of  potassium  employed 
in  doses  of  from  5  to  10  centigrammes;  and  by  bromine,  a  medicine  by  the 
use  of  which  Dr.  Ozanam  states  that  he  has  obtained  the  most  remarkable 
success.*  In  consideration  of  the  brilliant  results  announced  by  the  in- 
ventor of  this  treatment,  and  also  taking  into  account  that  he  follows  a 
different  system  of  treatment  from  that  which  I  pursue,  and  one  which  in- 
spires distrust,  it  is  necessary  to  maintain  a  prudent  reserve.  As  the  treat- 
ment of  pseudo-membranous  affections  is  everywhere  being  experimentally 
investigated  on  a  large  scale,' there  is  nothing  to  prevent  trials  being  made 
with  bromine  as  well  as  with  other  drugs. 

Bromine  and  its  compounds  are  not  the  only  substances  to  which  a  cer- 
tain amount  of  specific  virtue  has  been  attributed.  You  will  recollect  that 
the  sulphuret  of  potassa  was  warmly  recommended  by  Lobstein,  and  Pro- 
fessor Fritz,  of  Magdeburg,  in  cases,  however,  in  which  the  diagnosis  was 
doubtful ;  and  it  was  also  vaunted  by  Dr.  Maunoir  of  Geneva  ;  and  subse- 
quently, mention  was  made  of  it  by  Drs.  Rilliet  and  Barthez.f  It  is  not 
now  employed.  The  same  may  be  said  of  polygala  senega,  which  at  one 
time  enjoyed  likewise  a  great  reputation,  but  which,  owing  its  good  effects 
to  emetic  and  purgative  properties,  must  be  placed  along  with  the  thera- 
peutic agents  of  that  class,  regarding  which  I  have  forthwith  to  address 
you. 

But  before  I  proceed  to  do  so,  I  wish  to  mention  an  excellent  medicine, 
"recommended  by  Dr.  Trideau  (of  Andouille),  a  distinguished  practitioner 
of  Mayenne.J  This  physician,  comparing  diphtheritic  with  catarrhal  affec- 
tions, and  trusting  in  the  latter  to  the  good  effects  of  balsamic  medicine.-, 
had  in  the  first  instance  the  idea  of  employing  copaiba,  and  afterwards 
eubebs,  in  a  dreadful  epidemic  of  diphtheria,  raging  in  the  department  of 
Mayenne  :  by  using  these  medicines,  he  obtained  numerous  recoveries. 
Copaiba  has  the  disadvantage  of  disturbing  the  stomach,  but  eubebs  rather 
increases  the  appetite,  and  ought,  for  that  reason,  to  be  preferred.  I  have 
had  occasion  to  recommend  the  eubebs  treatment,  and  to  it  I  owe  rather 
remarkable  success — particularly  in  a  case  I  attended  with  Dr.  Peter  of  a 
lady  whose  granddaughter  was  treated  by  homoeopathy,  and  died  of  croup. 
The  lady,  who  had,  in  addition  to  pharyngeal  diphtheria,  a  commencement 
of  pseudo-membranous  coryza,  recovered  from  all  the  diphtheritic  symptoms 
in  live  days.  The  following  is  the  treatment  which  1  recommend.  I  order 
a  packet  of  lour  grammes  |<i2  grains]  of  the  powder  of  eubebs  to  be  taken 
in  unleavened  bread  every  lour  hours;  and  at  the  same  time  I  direct  that 
every  half  hour  lemon-juice  lie  applied  to  the  throat  by  means  of  a  camel's- 
hair  pencil.  I  associate  with  the  sorl  of  substitutive  action  of  the  eubebs, 
the  topical  action  of  a  vegetable  acid,  which  is  certainly  not  very  ener- 
getic; but  its  feebleness  is  compensated  for  by  frequency  of  application. 
As  a  good  substitute  for  the  powdered  eubebs  may  be  used  the  capsules  of 
the  extract  of  eubebs.  Bach  capsule  contains  equal  to  seven  and  a  half 
grammes  [about  108  grains]  of  the  pepper.    In  children  Dr.  Trideau  recom- 

Ozanam:   Memoire  sur  1' Action  Curative  el  Prophylactiquo  du  Brfimeeontre 
le8  affections  Paeudo-membraneuses.     8vo    Paris,  18  + 

f   Rilliet  kt  Babthbz:  Trait6  des  Maladies  des  Enfants.  • 

JTbidkau:  Nouveau  Traitemonl  de  I'Angine  Oouennouae,  du  Croup,  et  dea 
Autre,-,  Localisations  de  la  Dipb.tb.erie.     Paris,  I 


TREATMENT    OF    DIPHTHERIA    AND    CROUP.  407 

mends  the  use  <>f  a  syrup  of  cubebs  composed  of  12  grammes  [1<S<>  grains] 
of  powdered  cubebs,  and  240  grammes  [between  5  and  (i  ounces]  of  simple 
syrup.  A  teaspoonful  of  this  syrup  is  given  every  two  hours.  On  the 
third  or  fourth  day  of  the  treatment,  there  generally  appears  a  scarlatinous 
exanthem,  which  usually  coincides  with  the  disappearance  of  the  false 
membrane. 

I  now  come  to  speak  of  the  treatment  in  cases  of  pseudo-membranous 
sore  throat  and  of  croup,  which  I  call  treatment  by  indirect  agents — by 
emetics  and  revulsives. 

Emetics  have  been  and  are  still  regarded  by  a  large  number  of  physi- 
cians as  among  the  most  powerful  remedies  in  croup.  If  laryngismus 
stridulus,  or  false  croup,  be  included  under  that  name,  emetics  are  of  un- 
questionable utility ;  and  for  reasons  regarding  which  I  wish  to  say  a  few 
words. 

Whatever  may  be  the  special  properties  of  the  emetic  you  administer, 
whether  it  be  veratrum  album,  violet  root,  asarum  root,  or  the  polygala 
which  I  have  just  mentioned— whether  it  be  sulphate  of  zinc,  sulphate  of 
copper,  or  tartar  emetic — -in  addition  to  the  vomitive  action — you  will  get 
an  antiphlogistic  effect.  If  vomiting  be  excited  by  other  than  pharmaceu- 
tical means,  this  same  result  will  be  obtained.  There  will  be  induced 
nausea,  that  peculiar  state  of  discomfort  which  precedes  the  rejection  of 
the  contents  of  the  stomach.  The  pulse  becomes  small  and  frequent,  and 
the  heart  beats  very  feebly :  the  countenance  becomes  exceedingly  pale : 
the  body  is  bathed  in  sweat.  In  a  word,  the  patient  is  thrown  into  a  state 
analogous  to  lipothymia,  the  duration  of  which  may  be  considerable  :  there 
occurs,  though  in  a  less  degree,  something  similar  to  that  which  follows 
bloodletting  in  some  persons.  You  will  thus  perceive  how  it  is  that  by  a 
disturbance  of  the  system  affecting  chiefly  the  nervous  system,  there  is  pro- 
duced a  contra-stimulant  impression  sufficient  to  extinguish  slight  inflam- 
mation. 

Now,  in  false  croup,  the  inflammatory  element,  under  the  influence  of 
which  is  developed  the  spasmodic  element  leading  to  the  fits  of  suffocative 
cough,  which  it  is  our  object  to  subdue,  this  inflammatory  element,  I  say, 
not  in  general  going  beyond  what  may  be  called  a  slight  inflammation,  we 
can  conceive  the  utility  of  emetics  ;  but  the  aspect  of  affairs  is  very  differ- 
ent when  we  have  to  do  with  a  pseudo-membranous  laryngitis — we  cannot 
then  count  on  the  contra-stimulant  effect  of  the  emetic  treatment,  but  only 
on  the  mechanical  action.     Let  me  explain. 

Every  one  Avho  has  had  to  treat  children  in  croup  must  have  seen  cases 
in  which  there  was  a  great  amelioration  of  the  symptoms  consequent  upon 
the  administration  of  an  emetic:  this  change  for  the  better,  as  is  easily 
perceived,  depends  on  the  efforts  of  vomiting  having  caused  expulsion  of 
the  false  membranes  which  lined  the  larynx  and  trachea,  rendering  respira- 
tion easier,  by  removing  the  obstacle  which  they  presented  to  the  passage 
of  air  through  the  lungs.  As  to  the  dynamic  action  of  emetics,  to  which 
some  practitioners  attribute  the  benefit  which  they  produce,  it  can  only 
exert  an  influence  upon  the  inflammation  in  which  the  false  membranes 
originate,  and  it  is  impossible  to  grant  that  it  can  produce  any  influence 
whatever  on  the  exudations  which  have  been  already  formed.  Those  who 
wish  to  see  in  the  emetic  treatment,  and  particularly  in  the  employment  of 
tartarized  antimony,  of  which  they  speak  in  the  highest  terms  of  praise,  a 
dynamic  action,  in  which  I  do  not  believe,  tacitly  admit  that  that  action  is 
much  less*  real  than  they  say  it  is,  and  that  its  mechanical  action  is  much 
more  efficacious.     In  point  of  fact,  they  insist  on  the  necessity  of  exciting 


408  TREATMENT    OF    DIPHTHERIA    AND    CROUP. 

vomiting;  and  their  statistic?  show  that  the  patients  have  no  chance  of 
recovery,  unless  they  have  thrown  off  false  membranes. 

I  advise  you  to  read  the  remarks  of  Yalleix  on  this  subject  :*  you  will 
then  see  that  he  and  I  have  come  to  the  same  conclusions  in  respect  of  this 
question.  The  action  of  emetics  then,  is  mechanical :  it  is  by  clearing  the 
air-passages  of  the  plastic  deposits,  that  they  prove  of  service.  The  ad- 
vantages derived  from  this  treatment  must  not,  however,  be  exaggerated. 
When  I  resort  to  it  in  the  hope  of  obtaining  the  good  effects  which  one  is 
entitled  to  expect,  I  am  aware  that  these  effects  are  transient.  I  know  that 
diphtheria  is  a  disease  in  which  the  inflammation  giving  rise  to  the  false 
membranes  will  last  for  a  limited  time,  that  it  will  continue  after  the  first 
secreted  false  membranes  have  been  expelled,  and  give  rise  to  the  forma- 
tion of  others  in  their  place.  Xow,  if  by  a  repetition  of  the  same  treatment, 
if  by  causing  the  false  membranes  to  be  expelled  as  soon  as  formed,  I  pre- 
vent death  from  asphyxia,  although  I  do  not  by  direct  means  accomplish 
a  cure  of  the  malady,  I  carry  out  a  useful  treatment,  inasmuch  as  by  pro- 
longing the  life  of  the  patient  whilst  the  diphtheria  is  running  through  its 
stages,  the  time  may  come  when,  that  inflammation  having  reached  its 
natural  termination,  the  recovery  of  the  patient  will  take  place. 

The  selection  of  the  particular  emetics  to  be  employed  is  not  a  matter  of 
indifference.  Tartar  emetic,  so  lauded  by  some,  seems  to  me  to  be  the  most 
dangerous  of  all  emetics.  Dr.  Millard,  in  his  excellent  thesis,  has  very 
properly  insisted  upon  the  drawbacks  to  its  employment."?"'  In  point  of  fact, 
it  often  causes  formidable  symptoms,  such  as  obstinate  vomiting  and  cho- 
leriform  diarrhoea.  It  causes  extreme  prostration,  and  often  accelerates 
death.  The  dangers  which  I  enumerate,  experience  has  now  sufficiently 
pointed  out.  Sulphate  of  copper,  however,  does  not  deserve  the  reproaches 
directed  against  it;  and  I  often  have  recourse  to  it.  Administered  accord- 
ing to  the  method  which  I  employ,  that  is  to  say,  in  minutely  divided  doses, 
it  is  easier  to  avoid  producing  effects  in  excess  of  those  desired. 

But  whatever  utility  may,  under  certain  circumstances,  attach  to  the 
emetic  treatment,  too  much  reliance  must  not  be  placed  in  it.  After  a  long 
career  of  practice,  after  having  seen  a  great  number  of  persons,  children 
and  adults,  suffering  from  diphtheritic  sore  throat,  I  can  testify,  that  the 
failures  have  been  much  more  numerous  than  the  successes  obtained  by 
this  treatment.  Recollect  that  after  you  have  administered  an  emetic,  and 
obtained  a  decided  beneficial  result  from  it,  the  symptoms  which  have  been 
suspended  will  again  show  themselves;  often,  within  a  very  brief  space  of 
time,  the  oppressed  breathing,  and  the  suffocative  fits  from  which  you  have 
relieved  the  patient,  will  return,  in  consequence  of  new  false  membrane 
having  been  secreted,  If  you  should  a  second  time  be  fortunate  enough  to 
cause  their  expulsion,  the  third  time  you  employ  the  same  measures  they 
will  prove  a  failure ;  you  must,  therefore,  take  care  not  to  induce  nausea 
too  frequently,  lest  you  induce  such  a  degree  of  weakness  as  will  have  the 
patient  withoul  sufficienl  strength  to  contend  against  the  disease,  when  il 
has  become  necessary  to  have  recourse  to  tracheotomy. 

ives,  in  his  "Clinical    Lectures,"  speaks  strongly  in  favor  of  the  re- 
vulsive treatment  of  croup,  but  hi-  statements  evidently  appl)  to  cases  of 
laryngismus  stridulus:  the  method  extolled  by  the  eminent  clinical  pro- 
of Dublin  is  no  doubt  very  useful   in   false  croup:  I   have  already 

Vu.i.kix  :  Guide  du  Bfldicin  Practicien,  6me Edition,  revue  par  Lorain,  t   ii, 
p,  ill.     Paris,  I 

:  Millabd:  l»"  la  Tracheotomie  dans  le  cas  de  Croup,  Observations  Receuillies 
;i  1'Hdpita]  da  Enfants  Bialades.     Paris,  1858. 


TREATMENT    OF    DIPHTHERIA    AND    CROUP.  409 

explained  it  to  you,  when  lecturing  on  the  complication  of  measles.  I  shall 
return  to  the  subject  when  I  come  to  speak  of  false  croup;  and  I  shall  then 
toll  you  thai  there  are  circumstances  in  which  blisters  arc  useful,  although 
they  may  be  .-lower  in  acting  than  hot  water,  which  Graves  employed. 

'But  when  the  disease  we  have  to  treat  is  real  croup — when  we  have  to 
do  with  laryngeal  diphtheria — blisters  are  not  only  useless,  but  their  appli- 
cation is  too  often  productive  of  the  most  serious  consequences.  Reflect, 
and  without  difficulty  you  will  easily  understand  how  absurd  it  is. — the 
expression  is  not  too  harsh — to  expect  any  advantage  in  diphtheria  from 
blisters.  Supposing  that  the  larynx  is  coated  with  false  membrane,  the 
condition  in  which  it  is  generally  found,  for  no  one  entertains  the  idea  of 
applying  a  cantharides  plaster  till  extinction  of  voice,  dyspnoea,  and  par- 
oxysmal respiration  have  supervened — supposing  then,  I  say,  that  the  false 
membrane  is  present  in  the  larynx,  it  is  not  against  the  inflammatory  con- 
dition iti  which  plastic  formations  originate  that  we  have  to  contend,  but 
with  a  foreign  body — for  false  membrane  is  really  a  foreign  body — obstruct- 
ing the  passage  of  the  air  through  the  ramifications  of  the  respiratory  pas- 
sages. What  possible  advantage  can  result  from  the  use  of  revulsives  and 
blisters,  the  action  of  which  is  essentially  dynamic,  against  a  lesion  which 
is  purely  mechanical?  It  would  be  as  useful  to  blister  the  neck  of  a  child 
suffocated  by  the  passage  of  a  haricot  bean  into  the  windpipe.  You  would 
certainly  call  it  madness  in  a  surgeon  so  to  act  under  such  circumstances ; 
and  yet  the  surgeon  so  acting  would  not  be  doing  anything  different  from 
the  physician  who  hopes  to  cure  croup  by  cantharadine  revulsives :  there 
is,  however,  this  immense  difference  between  the  two,  that  whereas  in  the 
case  of  the  haricot  bean  the  treatment  would  be  useless,  it  can  at  least  do 
no  harm,  while  in  a  case  of  croup  the  results  may  be  most  disastrous.  This 
is  a  point  on  which  it  is  necessary  to  insist. 

I  have  told  you,  gentlemen,  wdien  giving  you  the  history  of  diphtheria, 
that  any  wound,  the  very  smallest  solution  of  continuity  in  the  skin,  may 
become  the  seat  of  new  manifestations  of  the  disease  in  a  patient  attacked 
with  plastic  sore  throat.  I  stated  that  it  was  enough  that  a  child  should 
have  croup  or  pseudo-membranous  sore  throat  for  diphtheria  to  be  commu- 
nicated to  other  members  of  the  family,  who,  up  to  the  time  of  their  seizure, 
were  in  perfect  health,  but  had  on  some  part  of  the  body  a  solution  of  con- 
tinuity to  afford  a  door  of  entrance  to  the  disease.  You  will  see  in  children 
who  have  been  blistered  on  the  arms  for  catarrhal  affections,  a  very  common 
practice,  and  which  may  even  have  been  resorted  to  by  medical  practitioners 
— you  will  see  the  blistered  surfaces  become  covered  with  false  membrane, 
if  the  children  are  living  in  the  midst  of  diphtheritic  contagion.  Then,  as 
I  have  already  pointed  out  to  you,  the  plastic  affection  extends  beyond  the 
denuded  surfaces.  I  cited  several  cases,  such,  for  example,  as  that  reported 
by  Dr.  Samuel  Bard,  in  which  the  diphtheritic  disease,  commencing  in  a 
surface  to  which  a  blister  had  been  applied,  gradually  spread  till  it  covered 
a  large  space,  and  induced  symptoms  which  terminated  in  death.  If  such 
symptoms  arise,  in  consequence  of  solutions  of  continuity,  in  persons  not 
under  the  influence  of  the  diphtheritic  diathesis,  they  are  all  the  more  to 
be  dreaded  in  those  in  whom  manifestations  of  that  diathesis  have  already 
shown  themselves.  I  gave  you  the  details  of  the  case  of  a  young  man,  who, 
just  as  his  recovery  from  croup  was  completed,  was  attacked  by  cutaneous 
diphtheria,  and  was  carried  off  by  it  in  ten  days.  In  that  case  the  cutane- 
ous affection  began  in  a  blistered  surface  on  the  front  of  the  neck,  gradually 
extended,  and  at  last  covered  the  chest  with  false  membrane,  as  if  with  an 
immense  breastplate.  The  situation  of  the  solution  of  continuity  matters 
little :  wdiether  you  apply  a  blister  to  the  nape  of  the  neck,  or  to  the  front 


410  TREATMENT    OF    DIPHTHERIA    AND    CROUP. 

of  the  neck  or  chest — wherever  you  have  a  surface  denuded  of  epithelium — 
the  pellicular  affection  may  show  itself,  and  become  the  cause  of  a  compli- 
cation difficult  to  contend  against.  During  ten,  twelve,  fifteen  days,  or  even 
longer,  you  will  have  to  combat  the  disease  by  the  most  energetic  cauteriza- 
tions, and  you  may  believe  that  you  have  mastered  it,  when  symptoms  of 
general  poisoning  of  the  system  will  appear,  symptoms  in  short  of  that  ma- 
lignant form  of  diphtheria  under  which,  do  what  you  will,  your  patient  will 
sink.  Death,  however,  in  these  cases,  does  not  always  take  place  in  this 
way:  sometimes,  in  consequence  of  the  extension  of  the  diphtheritic  inflam- 
mation, the  surfaces  invaded  by  diphtheria,  after  recovery  from  the  princi- 
pal disease  has  taken  place,  become  the  seat  of  very  extensive  suppuration, 
which  may  destroy  the  patients  by  an  exhausting  hectic  fever.  Gentlemen, 
I  beseech  you  to  adopt  the  rule  of  all  true  practitioners,  and  never,  under 
any  pretext  whatever,  apply  a  blister  to  a  patient  who  has  plastic  sore  throat 
or  croup.  When  called  in  to  cases  in  which  they  have  been  applied,  lose 
no  time  in  employing  energetic  topical  means  to  modify  the  character  of 
the  blistered  surfaces. 

Notwithstanding  the  opposition  to  topical  treatment,  at  present  existing, 
it  is  the  pre-eminently  best  treatment  of  diphtheria :  it  is  quite  as  much  in- 
dicated in  this  disease  as  in  malignant  pustule :  I  have  already  insisted 
upon  this  capital  point  in  practice.  Besides  red  precipitate  which  I  have 
sometimes  employed,  and  the  protochloride  of  mercury  which  I  have  already 
mentioned  as  a  medicine  possessing  a  certain  power  iu  modifying  the  action 
of  surfaces  invaded  by  pellicular  disease,  besides  and  superior  to  these  mer- 
curial preparations,  astringents  and  caustic  are  the  agents  by  which  the 
topical  treatment  is  best  carried  out.  From  time  immemorial,  local  treat- 
ment has  been  employed.  As  Bretonneau  has  well  remarked,  at  the  period 
when  the  disease  bore  the  name  of  the  Egyptian  disease,  there  was  also  an 
ointment  called  Egyptian,  which  was  pre-eminently  anti-diphtheritic,  viz. : 
a  mel  eupratum,  a  mixture  of  verdigris  and  honey.  Read  the  chapter  of 
Aretams  entitled  " De  Ouratione  PesUlentium  in  Fdueibus  Morborum,"  and 
you  will  therein  see  that  he  not  only  recommends  the  application  of  acrid 
lotions — "illitiones  acriorum  medicamentorum faeiendce  sunt" — but  also  rec- 
ommends that  the  disease  should  be  attacked,  not  by  the  actual  cautery 
(the  application  of  which  he  considered  difficult)  but  with  medicinal  sub- 
stances possessed  of  properties  similar  to  fire:  "porro  igne  vitium  adurere, 
(■Km  in  superiori  parte  sit :  imprudentis  esse  proper  isthmumjudieo.  Sed  med- 
icamentis  igni  similibus  quo,  et  ftepastio  coerceatur,  et  crustce  decidant,  utendum 
prcecipio."  He  prescribed  a  mixture  of  alum,  powdered  gall-nuts,  and 
honey;  likewise  dried  pomegranate  flowers  mixed  with  hydrorael  :  and  also 
calamine.  He  likewise  insufflated  powdered  alum  and  gall-nuts  into  the 
throat  by  means  of  a  tube. 

You  perceive,  gentlemen,  that  the  means  employed  in  the  presenl  day 
are  far  from  constituting  a  new  mode  of  treating  diphtheritic  sore  throat. 

It  is  very  remarkable  that  the  efficacious  treatment  of  Aivt:eus  should  BO 
long  have  been  forgotten.  In  the  17th  and  18th  centuries,  when  this  form 
of  sore  throat  reappeared  in  epidemic  forms,  when  the  suffocative  malady, 
or  Egyptian  disease,  made  so  many  victims,  nothing  was  heard  of  it.  Bre- 
tonneau himself,  who,  when  he  published  his  treatise  on  diphtheria,  knew 
better  than  any  other  person  what  A.retseus  had  written  about  alum,  had 
only  a  partial  belief  in  its  utility,  and  neglected  to  employ  it.  It  was  Do! 
till  a  later  period  that  he  had  any  confidence  in  it.      The  following  are  the 

circumstances  under  which  he  began  to  place  some  reliance  in  it. 

I  told  him  thai  during  the  epidemic  in  the  departments  constituting  the 
old  province  of  Bologne,  I  had  had  occasion  to  observe  the  efficacy  01  this 


TREATMENT    OF    DIPHTHERIA    AND    CROUP.  411 

medicament.  In  point  of  fact,  1  knew  that  in  the  commune  of  Marcilly- 
en-Vilette  where  at  first  66  persona  died  in  a  population  of  600,  this  fright- 
ful mortality  suddenly  diminished,  and  during  the  two  or  three  following 
months  there  were  very  few  victims.  To  get  at  the  reason  of  this  happy 
change,  I  visited  the  district.  I  there  interrogated  the  parish  priest,  who 
was  well  acquainted  with  all  that  had  taken  place,  and  Learned  from  him 
that  the  white  sore  throat  had  proved  a  less  formidable  scourge  from  the 
time  that  the  patients  had  been  attended  by  a  woman  who  kept  an  inn  in 
the  locality,  and  who  possessed  a  great  reputation  for  curing  diseases  of  the 
eye.  The  priest  was  ignorant  of  this  woman's  therapeutic  secret.  I  then 
applied  to  the  woman  herself,  hut  she  refused  to  tell  me,  and  contented  her- 
self by  sending  me  to  two  patients  upon  whom  at  the  time  she  was  in  at- 
tendance. One  of  them  was  a  young  lad,  a  journeyman  miller,  13$  years 
old.  I  verified  in  him  the  presence  of  false  membrane  covering  the  uvula 
and  tonsils.  >Some  time  previously,  there  had  been  three  deaths  in  the 
family  of  this  individual,  who  had  been  under  treatment  for  five  days:  he 
showed  me  his  gargle,  which  besides  using  as  a  gargle,  he  injected  into  the 
throat  by  means  of  a  syringe.  It  was  a  solution  of  alum  in  vinegar  and 
water.  When  I  left  the  district,  this  young  man  had  completely  recovered. 
I  collected  several  similar  cases ;  and  having  discovered  the  secret  of  the 
landlady  of  the  inn,  I  told  her  what  it  was.  She  then  admitted  that  she 
employed  alum,  and  stated  that  she  had  been  led  to  use  it  as  a  remedy  for 
the  "  white  sore  throat "  because  she  had  seen  it  cure  aphthse  of  the  mouth 
[chancre  de  la  bouche]  in  swine,  a  disease  characterized  by  white  pellicles  on 
the  gums  and  throat,  and  consequently  presenting,  as  this  good  woman  did 
not  fail  to  observe,  a  certain  resemblance  to  diphtheria.  I  communicated 
to  the  prefect  of  the  department  my  documents,  and  an  account  of  the  cases 
which  I  had  observed :  the  mode  of  treatment  was  forthwith  printed,  pub- 
lished, and  sent  to  the  different  communes.  I  at  the  same  time  mentioned 
what  I  had  seen  to  Bretonneau,  who  in  consequence  of  my  statements  em- 
ployed alum :  and  at  present  it  is  used  by  all  physicians  in  the  treatment 
of  diphtheria. 

Tannin  is  another  medicament  mentioned  by  Aretseus  in  the  passage  I 
quoted  ;  and  it  is  one  which  you  have  seen  me  employ  in  all  our  cases  of 
pseudo-membranous  sore  throat.  Aretseus,  it  is  true,  does  not  mention  tan- 
nin by  name,  because  in  his  day  the  substance  was  not  so  known  ;  but  he 
speaks  of  powdered  gall-nuts,  wdiich  he  prescribed  to  be  used  by  insuffla- 
tion",  and  in  mouth-washes.  Tannin  and  the  gall-nut  are  the  same  thing, 
inasmuch  as  the  former  is  the  active  principle  of  the  latter.  Alum  and 
tannin  in  insufflations,  mouth-washes,  and  gargles  are  powerful  topical 
agents,  and  are  of  great  service  in  the  treatment  of  diphtheritic  sore  throat. 
Let  me  recall  to  your  recollection  the  manner  in  which  I  employ  them. 

I  follow  exactly  the  plan  of  Aretseus.  The  alum  is  brought  into  contact 
with  the  lower  part  of  the  pharynx  by  insufflation  through  a  straw,  a  piece 
of  elder  from  wdiich  the  pith  has  been  extracted,  or,  if  nothing  else  is  at 
hand,  a  tube  made  of  stiff  paper.  It  is  not  necessary  to  be  very  exact  as 
to  the  quantity  of  powder  you  employ,  provided  you  employ  enough  :  one 
gramme,  two  grammes,  or  more  may  be  used.  The  only  condition  indis- 
pensably necessary  for  the  proper  application  of  the  powder  is  that  the 
tongue  be  very  effectually  held  down  during  the  insufflation.  This  detail, 
though  apparently  trivial,  solicits  our  attention  for  a  few  minutes.  It  may 
appear  an  easy  matter  to  depress  a  child's  tongue  whilst  you  examine  the 
throat,  yet  I  do  not  hesitate  to  say  that  few  know  how  to  perform  that 
operation  and  proceed  to  an  examination  wdiich  is  so  much  resisted  by  the 
little  patients.     However,  by  taking  the  precautions  which  I  am  now  going 


412  TREATMENT    OP    DIPHTHERIA    AND    CROUP. 

to  point  out,  it  is  easier  to  examine  in  opposition  to  the  will  of  the  indi- 
vidual the  throat  of  a  child  than  the  throat  of  an  adult,  for  in  the  one  case 
it  is  impossible  effectually  to  struggle  with  the  patient,  whereas,  by  man- 
agement, in  the  case  of  the  child,  the  end  in  view  can  be  attained.  First  of 
all,  you  must  let  the  child  see  that  you  are  his  master;  and  when  he  has 
seen  that  resistance  is  useless,  he  will  cease  to  offer  any.  To  accomplish 
this  object,  place  him  on  the  knees  of  an  assistant,  by  whom  he  is  to  be 
firmly  held :  another  person  is  directed  to  keep  the  head  fixed  in  position. 
When  the  child  struggles  and  cries,  seize  the  opportunity  of  his  opening 
his  mouth  to  introduce  the  handle  of  a  spoon,  pushing  it  back  quite  to  the 
base  of  the  tongue.  As  a  consequence  of  this  proceeding,  the  child,  being 
seized  with  a  desire  to  vomit,  opens  the  mouth  still  more  widely,  and  you 
are  thus  enabled  to  see  to  the  very  bottom  of  the  throat.  If,  however,  you 
only  introduce  half  way  the  handle  of  the  spoon,  he  will  close  his  teeth  upon 
it,  and  you  will  experience  the  greatest  difficulty  in  pushing  it  farther  on. 
One  such  examination  successfully  conducted  will  often  be  sufficient  to 
enable  other  examinations  to  be  made  whenever  they  are  required,  as  it 
will  have  shown  the  child  that  he  has  to  do  with  a  party  stronger  than  him- 
self. By  proceeding  in  the  manner  now  described,  it  will  be  easy  to  in- 
sufflate the  alum,  or  to  introduce  a  camel's-hair  pencil  charged  with  a 
lotion  or  with  honey  in  which  the  alum  is  mixed.  It  does  not  matter,  I 
repeat,  that  the  quantity  is  in  excess,  because  no  inconvenience  results  from 
the  patient  swallowing  a  little  alum.  The  insufflations  ought  to  be  repeated 
from  four  to  ten  times  in  the  twenty-four  hours :  it  is  necessary  that  they 
should  be  frequent  in  the  early  period  of  the  disease. 

To  render  the  medication  more  powerful,  the  insufflations  of  alum  ought 
to  be  alternated  with  insufflations  of  tannin.  From  forty  to  fifty  centi- 
grammes [4f- — 5§  grains]  of  the  latter  may  be  used.  This  is  precisely  the 
treatment  of  Aretams,  restored  to  favor  by  Dr.  Loiseau  of  Montmartre. 

I  have  recently,  in  adults,  sometimes  substituted  for  insufflations  of  tan- 
nin, the  inhalation  of  the  vapor  of  a  strong  watery  solution  of  that  sub- 
stance, as  adults  inhale  easily ;  and  I  employ  in  this  operation  the  "  <t/>- 
pareil  pulverisateur"  constructed  in  accordance  with  the  suggestions  of  I  >r. 
Sales-Girons.  You  are  aware,  gentlemen,  that  that  physician,  struck  by 
the  fact  that  the  vapor  of  a  mineral  water  contained  little  or  none  of  the 
saline  mineral  ingredients,  conceived  the  idea  of  substituting  for  the  inspi- 
ration of  vapor,  inhalations  of  the  mineral  water  reduced  to  very  tine  pow- 
der. This  is  not  the  place  to  describe  to  you  the  means  he  adopted  to  ac- 
complish this:  I  will  only  say  that  the  surgical  instrument  makers  have 
constructed,  in  accordance  with  this  principle,  a  portable  apparatus  easily 
employed  at  the  bed  of  the  patient,  and  which  you  have  seen  in  daily  use 
in  our  wards.  Drs.  Roger  and  Peter  have  recommended  in-i<i<tli<>n,  per- 
formed by  the  irrigator  in  common  use.  They  say  that  "irrigation  per- 
formed several  times  a  day  is  physically  and  therapeutically  beneficial  by 
cooling  the  inflamed  pails,  anil  by  likewise  possessing  the  mechanical  ad- 
vantage of  removing  the  false  membranes,  or  a1  Leasl  assisting  to  detach 
fchem,  and  of  thus  cleaning  the  throat."  It  is  even  possible  to  dissolve  a 
portion  of   the   diphtheritic    products   by  this    process.      At    the   Children's 

Hospital    Dr.  Roger  has  frequently  caused  the  disintegration  and  almost 
complete  disappearance  of  false  membranes  by  placing  them  for  live  or  ten 

minutes  in  a  glass  filled  with  a  saturated  solution  of  lime. 

Iii  my  opinion,  and  in  the  opinion  of  very  many  others,  the  treatment 


*  Rogeb  (Henri)  et  Peteb  (Michel):   Article,  "Anoink  Diphth£uiqi  b:  Dic- 
tionnaire  Encyclop6dique  dea  Sciences  Medicales,"  i    v.  p.  42. 


TREATMENT    OF    DIPHTHERIA    AND    CROUP.  413 

of  pseudo-membranous  sore  throat  by  astringents   is  so  useful,  that  if  we 

could  always  be  sure  of  our  instructions  being  properly  carried  out,  the 
catheretics  and  caustics  to  which  you  .sec  me  have  recourse  would  be  much 
less  frequently  employed. 

The  use  of  catheretics  and  caustics  in  diphtheria  is  nothing  new,  and  they 
are  mistaken  who  have  supposed  that  it  dates  no  farther  back  than  Bre- 
tonneau  :  he  never  dreamed  of  appropriating  to  himself  the  credit  of  having 
originated  this  treatment.  During  last  century,  physicians  were  strongly 
in  favor  of  cauterization  with  the  spirit  of  salt,  that  is  to  say  with  hydro- 
chloric acid,  in  the  treatment  of  those  affections  winch  they  designated 
gangrenous  sore  throats.  Marteau  de  Granvilliers  was  said  to  have 
obtained  great  success  from  using  it  during  epidemics  of  1759  and  1768,  of 
which  he  published  accounts.  Van  Swieten,  also,  in  several  passages  of 
his  Commentaries  on  the  Aphorisms  of  Boerhaave  speaks  of  mouth-washes 
containing  spirits  of  salt. 

Hydrochloric  acid  is  one  of  the  most  energetic  topical  agents  at  our  dis- 
posal for  the  treatment  of  pseudo-membranous  sore  throat.  Pure  fuming 
acid  may  be  employed  without  hesitation,  and  cauterization  with  it  may  be 
repeated  three  or  four  times  in  the  twenty-four  hours.  Hydrochloric  pos- 
sesses the  advantage  over  sulphuric  and  nitric  acids  of  modifying  the  mor- 
bid surfaces  without  going  any  deeper  into  the  tissue  than  nitrate  of  silver. 
It  has,  however,  one  drawback  which  I  must  point  out  to  you,  as  it  might 
sometimes  mislead  the  practitioner.  When  a  mucous  membrane  not  cov- 
ered with  false  membrane  is  touched  with  hydrochloric  acid,  a  white  spot 
is  immediately  formed,  presenting  the  exact  appearance  of  a  diphtheritic 
exudation.  This  plastic  exudation  is  similar  to  that  produced  by  can- 
tharidine  and  by  ammonia  ;  and  it  is  not  always  easy  to  distinguish  the 
morbid  product  of  diphtheria  from  that  caused  by  the  acid,  so  that  from 
not  knowing  whether  the  disease  is  cured,  the  treatment  may  be  continued 
after  it  has  ceased  to  be  required.  To  avoid  this  inconvenience,  it  is  better, 
after  making  three  or  four  cauterizations  during  the  first  days  of  the  mal- 
ady, to  suspend  the  use  of  the  caustic,  substituting  for  it  insufflations  of 
alum  and  tannin.  At  the  end  of  a  period  of  twenty-four  or  thirty-six 
hours,  the  white  spots  produced  by  the  hydrochloric  acid  will  have  disap- 
peared, and  it  will  be  easy  to  see  the  exact  condition  of  the  parts. 

Nitrate  of  silver,  introduced  into  general  use  by  Bretonneau  thirty  years 
ago,  is  more  commonly  employed  than  hydrochloric  acid.  The  reason  of 
this  is  obvious  :  every  practitioner  has  lunar  caustic  in  his  pocket-case  of 
instruments,  while  he  has  not  hydrochloric  acid  always  at  hand.  But  the 
nitrate  of  silver  has  inconveniences  similar  to  those  possessed  by  the  spirit  of 
salt,  and  it  has  them  in  a  higher  degree,  particularly  if  it  is  used  in  the  solid 
form.  A  small  slough  is  formed  on  the  part  touched  by  the  solid  nitrate, 
a  sort  of  white  pellicle,  which  remains  for  one  or  two  days :  if  the  cauteri- 
zation be  often  repeated,  it  is  very  difficult  to  avoid  the  mistake  which  I 
have  just  brought  under  your  notice.  Although  I  have  long  been  aware 
of  the  risk  of  committing  this  error,  I  very  recently  fell  into  it,  in  the  case 
of  a  man  with  sore  throat,  who  came  from  Chantilly  to  consult  me.  I 
found  one  of  the  sides  of  the  uvula  and  oue  of  the  tonsils  covered  with 
white  false  membrane  :  on  the  other  tonsil  there  was  also  a  spot  presenting 
a  similar  appearance.  The  patient  did  not  mention  that  anything  had 
been  done  for  him  by  his  medical  attendant,  and  even  asserted  that  he  had 
not  been  the  subject  of  any  treatment.  He  returned  home,  carrying  with 
him  a  letter  addressed  by  me  to  my  honorable  colleague  at  Chantilly, 
whose  attention  I  directed  to  the  thick  false  membranes  which  I  had  seen. 
I  certainly  added  that  these  false  membranes  were  not  of  a  more  than 


414  TREATMENT    OF    DIPHTHERIA    AND    CROUP. 

usually  shining  whiteness,  but  that  as  they  were  thick  and  occupied  a  large 
surface,  I  feared  they  were  diphtheritic.  I  concluded  by  recommending 
the  treatment  which  I  thought  ought  to  be  adopted.  Dr.  D.  in  reply 
informed  me,  that  the  pseudo-membranous  deposits  were  the  results  of  cau- 
terizations with  nitrate  of  silver,  performed  for  the  purpose  of  causing 
abortion  of  an  inflammatory  sore  throat  for  which  the  patient  had  con- 
sulted him. 

When  used  in  solution,  nitrate  of  silver  is  without  the  drawback,  which 
I  have  pointed  out  as  belonging  to  the  salt  in  its  solid  form.  Although 
the  solution  produces  a  whitish  exudation  it  forms  a  superficial  patch  easily 
distinguishable  from  diphtheritic  exudation.  This  remark  is  applicable  to 
the  strong  solution  I  am  in  the  habit  of  employing,  which  is  in  the  proportion 
of  three  parts  by  weight  of  water  to  one  of  the  salt.  The  solution  has  another 
advantage  over,  the  solid  nitrate,  besides  that  which  I  have  now  pointed  out. 
Even  when  the  cauterization  is  made  with  an  instrument  bent  at  the  extrem- 
ity in  such  a  manner  as  to  enable  the  operator  to  carry  the  caustic  pencil 
behind  the  veil  and  behind  the  pillars  of  the  veil  of  the  palate,  and  to 
reach  the  vicinity  of  the  epiglottis,  cauterization  with  the  caustic  pencil  as 
arranged  for  the  pocket-case  can  never  be  brought  into  contact  with  all  the 
affected  surface,  as  can  be  accomplished  when  the  solution  is  used.  By 
fixing  a  sponge  saturated  with  the  caustic  solution  at  the  extremity  of  a 
piece  of  bent  whalebone,  the  operator  is  enabled  to  touch  the  upper  part 
of  the  larynx,  and  the  posterior  cavity  of  the  pharynx — to  reach  even  to 
the  Eustachian  tube  and  posterior  aperture  of  the  nasal  fossae,  as  is  fre- 
quently necessary.  When  the  disease  is  confined  to  the  tonsils  or  other 
parts  within  view,  the  solid  caustic  or  a  badger's-hair  pencil  will  be  found 
quite  sufficient ;  but  as  it  is  often  otherwise,  or  at  least  as  there  is  often  reason 
to  fear  that  the  diphtheria  has  invaded  remoter  parts,  cauterization  with 
the  sponge  is  preferable.  It  is  important  to  use  a  piece  of  whalebone  hav- 
ing a  certain  curve.  It  ought  to  be  round,  and  to  possess  rigidity  sufficient 
to  enable  it  to  overcome  the  obstacles  presented  by  the  resistance  of  the 
patient  and  the  contractions  of  the  pharynx.  A  gun  or  pistol  cleaning- 
rod,  failing  that,  an  umbrella  whalebone,  will  answer  the  purpose.  1  laving 
rounded  the  whalebone,  it  is  plunged  in  boiling  water  or  exposed  for  some 
minutes  to  the  flame  of  a  candle,  after  which  it  is  bent :  it  is  then  placed 
in  cold  water  to  restore  its  rigidity  and  cause  it  to  preserve  the  curve 
imparted  to  it  when  in  a  warm  and  pliable  state.  Its  extremity  is  then 
armed  with  a  very  small  sponge  secured  by  thread,  or,  better,  still,  by 
sealing-wax.  To  enable  the  cauterization  to  be  conveniently  performed, 
it  is  necessary  to  depress  the  tongue  well,  and  firmly  to  retain  it  in  that 
position  by  means  of  the  tongue-depressor  or  the  handle  of  a  tin  spoon  bent 
almost  at  a  right  angle.  The  instrument  by  which  the  tongue  is  depi 
must  be  introduced  as  far  hack  as  the  insertion  of  the  base  of  the  tongue, 
elevating  at  the  same  time,  as  much  as  possible,  the  handle.  These  details 
have  their  value:  by  neglecting  them,  there  is  not  only  a  chance  of  not 
cauterizing  the  affected   part-,  hut  likewise  of  needlessly  cauterizing  parts 

which  arc  no!  implicated  in  the  malady.  But  by  adopting  all  the  precau- 
tions upon  which  I  have  now  been  insisting,  nothing  is  simpler  than  to 
operate  on  lie  pharynx  and  reach  the  superior  orifice  of  the  larynx,  which 
latter  it  is  always  necessary  to  accomplish,  when  the  patient  begins  to 
cough,  and  to  -how  symptom-  of  diphtheritic  inflammation  of  the  glottis  ; 
and  it  is  equally  easy  to  carry  the  cauterization  hack  as  far  as  the  posterior 
orifice  of  the  nasal  fossae,  The  sponge  ought  nol  to  be  too  wet,  lesl  there- 
by the  tongue  be  injured  and  the  teeth  blackened.  These  consequences  may 
not  be  very  serious ;  hut  -till,  an  unnecessarily  extensive  cauterization  is 


TREATMENT    OF    DIPHTHERIA    AND    CROUP.  415 

painful,  and  ought,  therefore,  to  be  avoided  :  moreover,  they  are  objection- 
able as  liable  to  place  new  obstacles  in  the  way  of  future  necessary  opera- 
tions, by  rendering  the  patients,  if  children,  still  more  determined  against 
submission.  Another  inconvenience  attending  the  use  of  nitrate  of  silver 
is  its  property  of  indelibly  staining  linen,  when  the  patients  spit,  as  they 
always  do  after  the  cauterization,  or  when  they  vomit,  which  is  not  an 
unusual  occurrence.  The  avoidance  of  this  staining  is  apparently  an 
extra-scientific  consideration,  but  still  it  is  not  without  importance  in 
practice. 

Sulphate  of  copper,  the  action  of  which  is  quite  as  energetic  as  that  of 
the  nitrate  of  silver,  has  not  the  same  drawbacks.  It  causes  no  membi'an- 
ous  patches  to  appear  on  the  surfaces  which  it  touches  :  you,  therefore,  see 
me  employ  it  by  preference  to  the  nitrate,  the  preparation  I  use  being  a 
saturated  solution. 

The  actual  cautery  has  likewise  been  employed  by  some  physicians. 
Long  ago,  I  saw  it  used ;  that  is  to  say  in  1828,  during  the  Sologne  epi- 
demic, of  which  I  have  spoken  to  you.  Dr.  Bonsergent,  an  old  practitioner 
at  Romarantin,  a  town  in  Sologne,  cauterized  with  the  actual  cautery  the 
'diphtheritic  throats  of  children.  The  iron  which  he  employed  was  the 
tool  used  by  makers  of  wooden  shoes  in  scooping  out  the  sabots;  he  made 
one  of  its  extremities  red  hot,  and  wrapped  up  the  other  in  wet  tow,  or 
placed  it  between  two  pieces  of  wood  to  serve  as  a  handle;  and  thus  it  was 
that  he  applied  the  actual  cautery  to  diphtheritic  tonsils.  I  had  an  oppor- 
tunity of  remarking  to  Dr.  Bonsergent  that  this  application  of  the  red-hot 
iron  was  not  free  from  danger — that  there  was  a  risk,  from  the  want  of 
docility  in  those  operated  on,  of  touching  parts  which  ought  not  to  be 
touched,  and  of  so  producing  deep  and  extensive  sloughs  of  mouth,  cheeks, 
or  lips.  To  this  objection  my  colleague  replied,  that  my  fears  were  ground- 
less, and  the  dread  of  being  burnt,  which  the  patients  themselves  experi- 
enced, made  them  open  the  mouth  wide  enough  to  enable  the  operation  to 
be  performed  with  the  greatest  ease.  I  witnessed  some  successful  results  ; 
but  still  there  was  nothing  in  these  cases  to  make  me  a  convert  to  the 
treatment  by  the  actual  cautery,  which  seemed  to  have  too  brutal  an  ap- 
pearance, and  to  be  a  very  dangerous  proceeding,  notwithstanding  the 
opinion  to  the  contrary  held  by  my  honorable  colleague.  The  recent  writ- 
ings of  Dr.  Valentin  have  failed  to  reconcile  me  to  the  use  of  the  actual 
cautery  in  diphtheritic  sore  throat.  It  is  quite  a  different  thing  when  the 
diphtheria  is  cutaneous,  anal,  or  vulvar,  or  when  the  affection  we  have  to 
treat  is  stomatitis  of  the  gums  or  mouth.  In  such  cases  the  actual  cautery 
has  seemed  to  me  to  be  of  real  utility ;  and  in  such  cases,  you  have  pretty 
frequently  seen  me  employ  it. 

In  the  treatment  likewise  of  laryngeal  diphtheria,  cathartics  and  caus- 
tics, insufflation  of  powdered  alum  and  tannin,  cauterization  with  solution 
of  nitrate  of  silver  or  sulphate  of  copper,  and  cauterization  with  hydro- 
chloric acid  may  be  employed. 

A  child,  for  example,  begins  to  have  a  croupy  cough,  but  as  yet  has  not 
croup :  false  membranes  have  not  yet  been  formed  in  the  larynx  :  there  is 
only  an  incipient  diphtheritic  inflammation,  but  before  twenty-four  or  forty- 
eight  hours  have  passed,  the  formation  of  false  membrane  will  have  taken 
place.  Under  such  circumstances,  therefore,  the  indication  is  to  prevent 
their  formation,  by  modifying  the  inflammation  in  which  they  originate ; 
and  this  is  to  be  done  by  applying  catheretics  to  the  superior  orifice  of  the 
larynx,  and  to  the  larynx  itself. 

The  following  method  has  been  practiced  by  Bretonneau  and  me.  We 
charge  a  tube  with  powdered  alum,  and  introduce  it  far  down  into  the  pa- 


416  TREATMENT    OF    DIPHTHERIA    AND    CROUP. 

tient's  throat :  after  making  him  depress  the  tongue  in  a  suitable  manner, 
the  insufflation  is  performed  and  repeated  several  times  in  rapid  succession. 
By  acting  thus,  a  time  comes  when  the  patient  is  forced  to  draw  in  a  full 
breath,  and  with  it  some  of  the  alum  necessarily  passes  into  the  respiratory 
passages.  To  accomplish  cauterization  with  hydrochloric  acid,  nitrate  of 
silver,  or  sulphate  of  copper,  it  is  sufficient  to  introduce  behind  the  epi- 
glottis a  sponge  soaked  in  the  fluid  caustic ;  once  the  sponge  has  been 
brought  into  contact  with  the  aryteno-epiglottidean  ligaments,  it  ought  to 
be  pressed  against  them  in  such  a  way  as  to  squeeze  out  a  little  of  the  fluid 
caustic  :  thepresence  of  the  sponge  excites  convulsive  inspiration,  by  which 
means  the  medicinal  agent  is  made  to  enter  the  larynx.  It  must  be  ad- 
mitted that  these  therapeutic  measures  are  very  imperfect,  and  lead  to  very 
uncertain  results. 

Inhalations  of  the  vapor  of  hydrochloric  acid,  for  a  short  time  practiced  by 
Bretonneau,  are  not  easily  accomplished  :  they  also  labor  under  the  heavy 
drawback  of  having  sometimes  induced  violent  bronchial  inflammation, 
and  even  peripneumonia.  Their  employment  has  now  been  generally 
abandoned. 

Catheterism  of  the  larynx,  by  enabling  the  application  of  medicinal  agents 
to  be  made  directly  to  the  larynx,  is  an  efficacious  practice.  I  do  not  refer 
to  catheterism  as  practiced  by  Dr.  Green,  of  New  York,  with  a  long  piece 
of  whalebone,  armed  with  a  sponge  at  its  extremity.  The  plan  devised  a 
few  years  ago  by  Loiseau,  of  Montmartre,  for  the  treatment  of  croup,  is 
much  more  reliable.  Although  Professor  Dieffenbach,  in  1839,  made  use 
of  the  same  method  at  the  Charity  Hospital  of  Berlin,  Loiseau  is  not  the 
less  entitled  to  the  honor  of  being  its  inventor,  for  when  the  idea  suggested 
itself  to  him,  he  was  entirely  ignorant  of  what  had  been  done  by  the  Ger- 
man surgeon.  Loiseau's  method  is  this:  he  arms  the  first  two  phalanges  of 
the  index  finger  of  the  left  hand  with  a  bent  metallic  finger-stall,  which 
leaves  free  the  last  joint  and  the  distal  phalanx.  The  finger  thus  protected 
is  carried  down  into  the  throat  as  deep  as  possible,  and  with  the  extremity 
of  the  finger  the  epiglottis  is  raised.  This  being  accomplished,  nothing  is 
easier  than  to  introduce  an  instrument  into  the  larynx.  The  instrument 
which  Loiseau  at  first  employed  was  a  bent  stem,  armed  with  a  receptacle 
for  the  solid  nitrate  of  silver:  he  afterwards  used  a  hollow  sound  resem- 
bling the  laryngeal  insufflator  of  Chaussier,  an  instrument  which  is  bint, 
pierced  with  two  eyes,  cylindrical,  broad  at  its  upper  extremity,  and  winch 
gradual] v  narrows  towards  a  bent  and  abruptly  flattened  extremity.  The 
affected  parts  can  then  be  operated  on  by  caustics,  either  by  introducing 
through  the  catheter  a  whalebone  rod  to  the  end  of  which  is  attached  a 
small  sponge  soaked  in  the  caustic  fluid,  which  is  pressed  out  through  the 
eyes  of  the  catheter,  or  by  injecting  a  caustic  solution  through  the  instru- 
ment.   This  latter  proceeding  some  of  you  may  recollect  seeing  me  employ 

in  the  case  of  a  little  Lrirl  of  four  years  of  age,  whose  case  was  published  in 

the  Gazette  des  B6pitaux,  of  31st  October,  L857. 

When  we  consider  how  easily  a  fit  of  BuffbcatioD  is  caused  by  a  foreign 
body  touching  the  upper  orifice  of  the  larynx,  we  are  apt  to  he   frightened 

at  the  idea  of  introducing -an  instrument  into  the  interior  of  that  organ  : 
there  is  much  more  reason  to  dread  a  suffocative  attack,  when  liquid-  are 

injected  into  the  air-passages.  The  only  part  of  the  operation  which  is 
painful  to  the  patient  is  the   seizure  and  elevation  of  the  epiglottis.      With 

reference  to  catheterism  it  may  be  Btated,  that  the  injection  of  even  a  con- 
siderable quantity  of  caustic  fluid  is  well  borne.  These  facts  may  undoubt- 
edly be  thus  explained.  Catheterism  is  not  the  introduction  of  a  foreign 
body  which  by  its  presence  tickles  and  excites  the  orifice  of  the  Larynx, 


TREATMENT    OF    DIPHTHERIA    AND    CROUP.  417 

but  of  a  foreign  body  which  rapidly  traverses  and  in  fact  forces  the  pas- 
sage.  Now,  if  we  suppose  that  the  sentinels — if  I  may  for  a  momenl  use 
that  figurative  expression — if  we  suppose  that  the  sentinels,  placed  at  the 
entrance  of  the  air-tube,  whose  constant  duty  it  is  to  prevent  the  admission 
of  foreign  bodies  which  might  otherwise  accidentally  get  in,  are  prevented 
from  being  of  any  service  in  consequence  of  the  passage  being  forced,  we 
see  how  it  is  that,  unless  the  calibre  of  the  tube  be  obstructed,  suffocation 
will  not  be  induced.  In  respect  of  the  injection  of  liquids,  it  may  be  stated, 
that  we  know  from  experiments  on  animals  that  the  trachea  is  very  toler- 
ant ;  and  that  caustic  injections  frequently  provoke  neither  suffocative  fits 
nor  even  coughing. 

We  may  also,  following  the  practice  of  Green,  but  carrying  it  out  by  a 
surer  plan,  by  directing  the  instrument  along  the  finger  which  holds  open 
the  laryngeal  orifice,  by  following  the  method  of  Loiseau,  we  may  intro- 
duce in  a  direct  manner  a  stiffish  whalebone  rod  armed  with  a  small  sponge 
soaked  in  a  caustic  solution.  With  this  apparatus  the  larynx  may  be 
swabbed  out  in  such  a  way  as  to  free  it  from  false  membranes.  When  the 
false  membranes  resisted  this  treatment,  Loiseau  was  iu  the  habit  of  de- 
taching them  by  the  aid  of  flat  curved  forceps. 

The  method  of  Loiseau  is  certainly  very  ingenious,  and  in  submitting  it 
to  the  judgment  of  the  Academy,  he  cited  numerous  cases  in  which  he 
had  obtained  remarkable  results.*  Upon  several  occasions  I  have  had  an 
opportunity  of  witnessing  its  successful  application ;  and  among  others  in 
a  child,  a  patient  of  my  friend  Dr.  Gros,  who  communicated  an  account  of 
the  case  to  the  Medical  Society  of  the  Hospitals  on  the  28th  July,  1858.f 
I  myself  have  only  once  had  recourse  to  catheterism :  the  patient  was  a 
little  girl  of  whom  I  am  by  and  by  going  to  speak  to  you.  In  her  case 
you  had  an  opportunity  of  judging  of  the  harmless  character  of  the  opera- 
tion, and  the  facility  with  which  it  is  performed. 

Loiseau's  cases  deserve  attention,  although  perhaps  the  narrator  has 
exaggerated  the  importance  of  the  bearing  of  some  of  them.  Cauteriza- 
tions of  the  larynx  may,  in  my  opinion,  under  certain  circumstances,  be 
productive  of  great  benefit. 

Perchloride  of  iron  has  been  recently  brought  forward  as  a  specific  remedy 
in  diphtheria.  Although  J  have  not  as  yet  had  sufficient  experience  to 
entitle  me  to  give  an  opinion  as  to  the  exact  value  of  this  medicine,  I  have 
employed  it  in  a  sufficient  number  of  cases  to  justify  me  in  refusing  to 
admit  that  it  possesses  the  specific  properties  which  some  practitioners  have 
ascribed  to  it.  It  cannot  be  denied,  however,  that  it  has  rendered  real 
service  both  in  my  hands,  and  in  those  of  the  honorable  physicians  who 
first  sounded  its  praises.  You  have  seen  me  use  it  in  the  form  of  concen- 
trated solution  as  a  caustic  agent,  with  a  view  to  modify  the  character  of 
the  surfaces  covered  with  diphtheritic  exudation.  You  have  also  seen  me 
administer  it  internally  in  a  potion  containing  from  4  to  10  grammes  [62 — 
155  grains]  which  the  patient  takes  during  twenty-four  hours.  But  its 
action  is  perhaps  not  more  special  than  that  of  other  ferruginous  medicines, 
which,  like  it,  are  indicated  in  the  general  treatment  of  diphtheria.  Its 
extreme  solubility,  however,  gives  it  a  certain  advantage  over  other  prepa- 
rations of  iron. 

I  have  insisted,  gentlemen,  upon  the  uselessness,  the  danger  of  antiphlo- 
gistics,  which  I  absolutely  interdict  in  the  treatment  of  diphtheria.     In 

*  Loiseau  :  Bulletin  de  l'Acad6mie  Imperiale  de  Medecino,  1857,  t.  xxii,  p. 
1139. 

f  See  the  "  Union  Medicate"  for  14th  September,  1858. 
yol.  I. — 27 


418  TREATMENT    OF    DIPHTHERIA    AND    CROUP. 

passing  before  you  in  review  the  other  different  medicinal  agents  recom- 
mended in  diphtheria,  I  have  endeavored  to  show  that  mercurials  and 
alkalies,  in  so  far  as  they  are  alterative  remedies,  present  more  disadvan- 
tages than  advantages.  I  also  told  you,  that  certain  medicines,  such  as 
sulphate  of  potash  and  polygala  senega,  to  which  for  a  time  anti-diphtheritic 
properties  were  attributed,  have  justly  fallen  into  oblivion.  I  have  laid 
great  stress  upon  the  question  of  blisters,  and  have  implored  you  never  to 
employ  them,  their  action  in  diphtheria  being  deplorable  and  perilous  in 
the  highest  degree.  Finally,  I  stated  that  I  had  come  to  the  conclusion, 
after  the  teaching  of  a  long  experience,  that  topical  treatment  by  astrin- 
gents, catheretics,  and  caustics,  is  pre-eminently  the  best  treatment  of  diph- 
theritic affections ;  but  I  did  not  say  that  it  could  by  itself  cure  the  disease. 

General  treatment  constitutes  an  important  part  of  the  treatment  of  diph- 
theria. It  ought  to  be  essentially  tonic  and  restorative,  as  in  all  diseases 
in  which  from  the  first  the  vital  forces  seem  to  be  disturbed  and  depressed. 
Alimentation  occupies  the  first  place  in  the  general  treatment ;  and  I  have 
observed  that  the  severer  the  attack,  the  more  imperative  is  the  necessity 
to  sustain  the  patients  with  nourishing  food.  Loss  of  appetite,  that  is, 
disgust  for  every  kind  of  food,  is  one  of  the  most  alarming  prognostic 
signs.  We  must  try  to  overcome  this  loathing  of  food  by  every  possible 
means :  and  to  get  nourishment  taken,  I  sometimes  do  not  hesitate,  in  the 
case  of  children,  to  threaten  punishment.  When  the  patient  retains  his 
appetite  for  food,  there  is  good  hope  of  recovery. 

There  are  no  rigid  rules  in  respect  of  the  choice  of  food.  We  are  often 
obliged,  in  some  individuals,  to  satisfy  the  strangest  possible  caprices  of 
taste.  In  pseudo-membranous  sore  throat,  when  there  are  pain  and  diffi- 
culty in  swallowing,  I  give  nourishment  in  a  semi-solid  state — thick  soups, 
farinaceous  food,  chocolate  made  with  water,  creams,  boiled  eggs,  and  such 
like  alimentary  articles.  As  soon  as  possible,  I  begin  a  more  reparative 
animal  diet. 

The  pharmaceutical  agents  which  I  employ  in  the  general  treatment  are 
the  preparations  of  cinchona  and  iron.  I  generally  give  the  powder  of 
yellow  cinchona  in  doses  of  from  one  to  two  grammes  [lo]  to  :>1  grains]  in 
a  cup  of  cafe  noir,  the  object  of  the  coffee  being  to  mask  the  bitterness  of 
the  drug,  and  facilitate  its  digestion.  For  those  who  have  a  repugnance  to 
this  preparation  of  bark,  and  also  when  I  wish  to  obtain  a  more  speedy 
effect,  I  substitute  sulphate  of  quinine  for  the  powder  of  cinchona,  admin- 
istering it  also  in  a  similar  manner  in  coffee.  I  am  likewise  in  the  habit 
of  prescribing  the  wine  and  syrup  of  cinchona.  The  preparations  of  iron 
which  I  prefer  are  those  which  are  the  most  soluble,  such  as  the  per- 
chloride,  the  citrate,  and  the  tartrate. 


TRACIIEOTOMY    IN    DIPHTHERIA.  419 


Tracheotomy. 

In  the  present  day  no  one  ran  deny  its  I  'lilily  and  Necessity. — Mode  of  Op- 
erating.—  The  Dilator. —  Operation  ought  to  be  very  Slowly  Performed: 

J )n ngers  of  Rapid  Performance. — 1) resting. —  Cauterization  of  the 
Wound. —  The  Neckcloth. —  General  Treatment. —  The  Changes  of  Success 

are  the  Greater,  the  Lex*  Energetic  the  Anterior  Treatment  has  been. — 

Alimentation  of  the  Patients. — Removal  of  the  Canida — Infected  Canulce. 

— A  Condition  favorable  to  Success  is  to  Operate  as  Soon  as  Possible. — 
Unfarora/ile  Condi/ions. — Death  is  Certain  in  Malignant  Diphtheria. — 

Death  is  Almost  Certain  in  Children  under  Two  Years. 

Gentlemen:  Let  us  assume  that  all  treatment  has  failed  to  prevent 
the  propagation  of  diphtheria  to  the  air-passages,  and  that  croup  exists — 
that  we  have  in  vain  attempted  to  combat  the  disease  by  the  measures 
which  I  have  described  to  you,  and  which  I  must  say  are  more  frequently 
unsuccessful  than  successful ;  or  let  us  suppose  that  we  are  called  to  a 
patient  in  whom  there  already  exists  confirmed  croup,  in  whom  asphyxia 
threatens,  and  in  whom  death  is  inevitable :  under  such  circumstances, 
there  still  remains  one  important  resource, — tracheotomy.  It  was  recom- 
mended by  Stoll,*  who,  however,  seems  never  to  have  performed  it.  John 
Andree  a  London  surgeon  performed  it  for  the  first  time,  and  with  success, 
in  1782.  The  subject  operated  on  was  a  child,  an  account  of  whose  case 
Jacob  Locatelli  sent  to  Borsieri,  by  whom  it  was  published  in  his  Insti- 
tutes.f  At  the  beginning  of  the  present  century,  Caron,  a  French  physi- 
cian, renewed  the  praises  of  tracheotomy,  although  he  had  only  performed 
it  once,  and  that  unsuccessfully.  It  is  in  reality  to  Bretonneau  that  the 
merit  of  a  first  success  is  due ;  for  John  Andree's  case  has  been  the  subject 
of  much  controversy.  After  two  unfortunate  attempts  in  1818  and  1820, 
the  illustrious  physician  of  Tours,  undismayed  by  these  disappointments, 
made  a  third  attempt  in  1825.  The  patient  was  the  daughter  of  one  of 
his  most  intimate  friends,  the  Count  de  Puysegur,  who  had  had  three  chil- 
dren carried  off  by  croup :  this  time,  Bretonneau  had  the  good  fortune  to 
save  his  patient.  I  believe  I  was  the  second  person  who,  following  the 
example  of  my  master,  performed  tracheotomy  in  laryngeal  diphtheria, 
and  the  second  also  to  record  a  successful  result  of  the  operation.  This 
case  is  now  of  old  date.  The  child  upon  whom  I  operated  was  the  son  of 
a  man  whose  name  has  in  recent  times  made  a  certain  noise — Marcillet, 
the  magnetizer  of  Alexis,  the  somnambulist.  I  published  the  history  of 
this  case  in  18334  I  have  now  performed  the  operation  in  more  than  two 
hundred  cases  of  diphtheria  ;  and  I  have  the  satisfaction  of  knowing  that 
one-fourth  of  these  operations  were  successful.  Others  after  me  have  pur- 
sued the  same  practice,  and  have  met  with  success.  It  was  at  the  Children's 
Hospital  that  I  gave  the  first  impulse  to  this  practice.  Now,  there  is  hot 
an  interne  who  fulfils  a  year  of  duty  at  that  establishment  without  having 
opportunities  of  snatching  from  the  grave  several  children  irrevocably  lost 
but  for  his  judicious  operative  intervention.  The  proportion  of  successful 
cases  has  greatly  increased  since,  profiting  by  past  experience,  we  have 
attached  great  importance  to  the  management  of  the  case  after  the  opera- 

*  Stoll  :  Aphorismes  sur  l'Anginc  Inflammatoire. 
f  Borsieri  :  Tome  iv.      Angina  Trachealis,  \  ccccxxxvi. 

%  See  Journal  des  Connaissances  M6dico-Chirurgicales  for  the  month  of  Sep- 
tember, 1833,  Number  First. 


420  TRACHEOTOMY    IX    DIPHTHERIA. 

tion.  The  details  of  the  mode  of  management  I  shall  have  forthwith  to 
enlarge  upon.  At  the  Children's  Hospital,  in  the  Rue  de  Sevres,  the  pro- 
portion of  successful  cases  in  recent  years  has  been  more  than  a  fifth,  a 
large  proportion,  when  we  bear  in  mind  the  social  position  of  the  children 
who  are  brought  to  the  hospital,  and  the  deplorable  treatment  to  which 
they  have  been  subjected  by  midwives,  quacks,  and  old  women,  whose  ad- 
vice is  preferred  by  the  lower  classes  to  that  of  medical  practitioners  ;  and 
then  again,  still  more,  when  we  recollect  the  dangers  of  the  hospital  itself, 
where  the  unfortunate  children  operated  on  are  in  a  hotbed  of  formidable 
and  varied  contagion,  as  is  shown  by  the  great  frequency  with  which  an 
attack  of  scarlatina,  measles,  small-pox  or  hooping-cough  supervenes  as  a 
terrible  complication,  when  all  seems  to  be  progressing  favorably  after 
tracheotomy.  My  impression  is  that  one-half  of  the  cases  operated  on  in 
private  practice  ought  to  prove  successful,  provided,  of  course,  the  opera- 
tion is  performed  under  conditions  in  which  recovery  is  possible.  I  shall 
tell  you  what  these  conditions  are.  The  successful  results  which  are  pro- 
claimed on  all  sides  speak  so  loudly  in  favor  of  operating,  as  to  bear  down 
all  opposition  ;  and  I  do  not  stand  alone  in  preaching  that  there  is  an  im- 
perative duty  imposed  on  the  practitioner  of  performing  tracheotomy,  a  duty 
as  obligatory  as  tying  the  carotid  artery  when  that  vessel  has  been  wounded, 
although  death  quite  as  often  as  recovery  follows  the  operation.  In  the 
early  days  of  tracheotomy  in  croup,  there  was  a  great  deal  of  opposition  to 
it ;  but  at  present,  it  has  no  opponents  except  among  the  wayward,  ill-dis- 
posed, or  ignorant.  There  is  now  no  longer  anything  serious  in  the  opposi- 
tion :  and  henceforth  the  proceeding  must  be  looked  on  as  one  conquest 
more  of  the  healing  art  added  to  the  ordinary  practice  of  therapeutics. 

Tracheotomy  is  opening  the  windpipe  so  as  to  allow  air  to  enter  when 
the  natural  orifice  of  the  glottis  is  almost  obliterated.  The  professor  of 
operative  medicine  will  pardon  my  encroaching  for  a  moment  upon  his 
territory,  that  I  may  describe  to  you,  if  not  in  accordance  with  the  rules 
of  surgery,  at  least  after  my  own  fashion,  an  operation  which  physicians  are 
more  frequently  called  upon  to  perform  than  surgeons. 

The  instruments  required  are  a  sharp-pointed  somewhat  convex  bistoury, 
and  a  probe-pointed  bistoury;  two  blunt  hooks  with  good  handles,  or  fail- 
ing them  two  hair-crimping  pins;  a  dilator,  like  a  sort  of  dressing-forceps, 
curved  at  the  extremity,  with  the  two  limbs  forming  at  the  end  of  the  in- 
strument a  sort  of  spur  projecting  outwards,  SO  as  to  enable  it  to  fasten  the 
lips  of  the  tracheal  wound,  and  prevent  their  displacement  by  the  respi- 
ratory movements.  The  use  of  this  instrument  is  to  dilate  the  opening  made 
in  the  trachea, so  a-  to  allow  the  tube  to  be  introduced.  The  tube  ought  to 
be  double — an  external  and  an  internal  canula.  In  tin'  expanded  extrem- 
ity of  the  external  tube  are  two  apertures  to  receive  tapes,  which  are  tied 
at  the  back  of  the  neck,  so  as  to  keep  the  apparatus  in  its  place.  Besides 
these  two  apertures,  there  is  in  the  upper  part  of  the  expanded  extremity 
of- the  external  canula  a  soil  of  key  which  fits  into  a  slit  in  the  correspond- 
ing part  of  the  internal  canula.      The  internal,  which  necessarily  has  a  less 

diameter  than  the  external  canula,  has  two  ears  projecting  from  its  ex- 
panded extremity,  by  which  it  can  lie  held  when  it  is  wished  to  lake  it  out 
or  replace  it  :   it  is  fixed  to  the   external    canula   by  the   little   key  which    I 

have  mentioned,  and  which  can  l»e  easily  opened  and  -hut.  The  diameter 
of  the  tube  oughl  to  be  considerable ;  it  can  never  be  too  large,  provided 
the  instrument  can  easily  enter  the  trachea.  Its  curve  ought  to  form  a 
quarter  circle:  this  is  the  principle  upon  which  all  these  instruments  are 
now  made  by  M.  Mathieu,  who  adopted  the  fixed  Btandard  to  avoid  incon- 
veniences which  i  pointed  out  to  him,  the  curve  of  the  differenl  tubes  pre- 


TRACHEOTOMY    IN    DIPHTHERIA.  421 

viously  shown  to  me  being  either  too  great  or  too  small,  in  consequence  of 
the  workmen  having  always  departed  from  the  exact  form  of  the  model 
placed  in  their  hands.  That  the  tube  be  double,  is  an  absolute  necessity; 
aud  when  we  see  the  manner  in  which  Van  Swieten  insists  on  the  necessity 
of  using  a  double  tube,  and  that  he  does  so  on  the  authority  of  the  English 
author,  George  Martin,  it  is  remarkable  that  the  precept  was  forgotten  ;  it 
is  strange,  too,  that  although  the  double  canula  was  recommended  by 
Bretonneau,  who  from  his  earliest  operations  employed  an  uncurved  double 
tube,  I  myself  for  years  employed  the  single  tube.* 

The  dilator  is  indispensable.  I  have  only  once  lost  a  child  during  the 
operation ;  the  patient  was  under  the  care  of  my  honorable  colleague,  Dr. 
Barth.  I  went  to  the  consultation  ignorant  of  the  state  of  matters,  and 
found  the  child  dying.  Dr.  Barth  was  prepared  with  tube  and  bistoury. 
From  not  having  a  dilator,  I  was  unable  to  keep  aside  the  vessels  as  I 
should  have  wished :  I  felt  about  with  my  finger  for  a  long  time  before  I 
was  able  to  make  an  entrance  into  the  trachea,  and  during  that  time  a 
great  quantity  of  blood  entered  the  bronchi  and  suffocated  the  patient : 
this  could  certainly  not  have  happened,  if  I  had  had  a  dilator  which  I 
could  at  once,  on  making  the  incision,  have  introduced  into  the  windpipe. 
When  a  dilator  cannot  be  obtained,  recourse  may  be  had  to  a  plan  devised 
by  Dr.  Paul  Guersant :  it  consists  in  arming  the  tube  with  an  ordinary  gum- 
elastic  catheter,  projecting  some  centimetres  from  the  inferior  opening  of 
the  tube.  You  can  understand  how  much  the  manual  proceedings  will  be 
simplified  by  this  contrivance.  The  gum  elastic  catheter  is  easily  intro- 
duced into  the  tracheal  wTound,  the  finger  being  used  as  a  conductor ;  and 
then  all  that  is  required  to  get  the  canula  into  position  is  to  cause  it  to  slide 
upon  the  catheter. 

I  shall  now  describe  the  operation.  The  patient  is  laid  on  a  table,  on 
which  there  are  a  mattress  and  several  folds  of  a  blanket:  a  doubled  up 
pillow,  or  better  still  a  rouleau  made  with  sheets,  is  placed  under  the 
shoulders  and  back  of  the  neck,  so  as  to  put  on  the  stretch  the  anterior 
region,  and  bring  the  trachea  as  much  as  possible  into  relief.  This  is  un- 
doubtedly a  very  distressing  position  for  an  individual  in  a  state  of  asphyxia, 
but  it  has  not  to  be  long  endured.  An  assistant  placed  behind  the  patient 
is  appointed  to  hold  the  head  firmly ;  another  assistant,  placed  opposite  the 
operator,  is  charged  with  keeping  aside  the  different  layers  of  tissue  and  the 
bloodvessels,  by  means  of  a  blunt  hook  held  in  the  left  hand,  while  he  is 
on  the  alert  to  use,  when  required,  the  right  hand  in  sponging  the  wound 
with  small  sponges  placed  beside  him  ready  for  use.  The  assistance  of  other 
persons  is  also  needed  to  prevent  the  patient  moving.  Finally,  that  I  may 
omit  nothing,  let  me  add,  that  if  you  operate  at  night,  there  must  be  some 
one  to  hold  for  you  a  candle  giving  a  strong  light.  If  the  operation  is  per- 
formed in  full  daylight,  the  patient  ought  to  be  placed  directly  in  front  of 
a  window7  of  the  room,  the  feet  being  next  the  window,  so  that  the  light  may 
fall  full  on  the  neck. 

*  Van  Swietex  :  "  Majus  incommodum  inveniabatur,  dum  mucosi  humoris 
copia  per  tubi  orificium  effluens,  ej usque  lateribus  adherens,  sensim  inspissata 
angustabat  tubi  cavum,  liber  am  que  aeri  ingressuro  viam  impediebat;  unde  coge- 
batur  Georgius  Marti nius  tubum  educere  et  mundare.  Multum  quidem  hue  caveri 
potest,  dum  alterum  tubi  extremum  multo  latius  liberum  humoribue  exitum  per- 
mittit :  interim  tamen  non  incongruum  videtur,  uti  monuit  Celebris  auctor,  si  duplex 
foret  tubulus  in  asperam  arteriam  dimissus,  quorum  major  alterum  exciperet." 
.  .  .  "  Hoc  enim  commodi  a  duplici  tali  tubo  baberetur,  quod  interior  eximi 
posset  et  mundari,  dum  exterior  et  major  interim  in  vulnere  maneret." — [Commen- 
taries a  l'Aphorisme  813  de  Boerhaave.     Paris:  1757,  t.  ii,  p.  628.] 


^ 


422  TRACHEOTOMY    IN    DIPHTHERIA. 

These  precautions  taken,  the  operator  standing  on  the  patient's  right — 
observe,  I  say  the  right  and  not  the  left,  because  otherwise,  unless  he  be 
ambidexter,  be  will  be  embarrassed  by  the  projection  of  the  chin :  the 
operator,  then,  standing  on  the  right  of  the  patient,  grasps  the  tracheal 
region  with  the  left  hand,  when  with  the  right  hand  he  makes  an  incision 
in  the  median  line,  from  the  cricoid  cartilage  to  within  a  little  of  the 
sternum.  The  importance  of  making  the  incision  in  the  median  line  is  so 
great,  that  if  this  rule  be  neglected,  the  operator  is  liable  to  be  very  much 
embarrassed  during  the  whole  of  his  proceedings.  I  recommend  those  who 
have  no  pretensions  to  surgery  to  draw  on  the  skin  the  proper  course  of  the 
bistoury  with  ink  or  a  cord  blackened  in  the  flame  of  a  candle.  Having 
incised  in  succession  the  skin  and  the  cervical  aponeurosis,  there  is  reached 
a  small  white  mark  indicating  an  interstice  between  the  muscular  masses. 
The  blood  now  flowing  is  soaked  up  by  the  sponges ;  the  operator  then  cuts 
in  the  line  of  the  small  white  mark,  separating  the  sterno-hyoid  and  sterno- 
thyroid muscles,  which,  by  means  of  the  blunt  hook  in  his  left  hand,  are 
held  aside,  while,  at  the  same  time,  the  assistant  who  is  in  front  of  the  ope- 
rator separates  them  from  each  other.  This  is  the  point  at  which  difficulties 
begin. 

The  isthmus  of  the  thyroid  gland  has  now  been  reached ;  its  size  and 
position  vary  so  much,  that  it  is  sometimes  found  covering  the  first  rings  of 
the  trachea,  and  at  other  times  is  much  higher  up.  Lower  down  we  find 
the  thyroid  plexus  of  veins,  and  Neubauer's  artery  when  it  exists.  Now  is 
the  time  when  the  operator  must  bear  in  mind  the  cardinal  precept,  to  avoid 
wounding  the  bloodvessels.  If  he  see  a  large  vein  he  must  dissect  it  out, 
and  draw  it  to  one  side  with  the  blunt  hook.  If  the  left  subclavian  vein, 
gorged  with  blood,  shows  itself  in  the  jugular  fossa,  it  may  be  depressed  and 
protected  by  a  finger,  and  the  terrible  accident  be  thereby  avoided  which 
would  result  from  its  being  wounded.  For  still  stronger  reasons  attention 
ought  to  be  paid  to  the  trunk  of  the  brachio-cephalic  vein,  which  in  chil- 
dren often  projects  considerably  beyond  the  substernal  fourchette. 

As  soon  as  the  trachea  is  brought  into  view  it  ought  to  be  denuded,  and 
a  small  incision  made  in  it,  as  near  as  possible  to  the  cricoid  cartilage,  the 
bistoury  being  directed  upon  the  nail  of  the  index  finger  which  is  placed  at 
the  bottom  of  the  wound.  A  hissing  noise  indicates  that  the  trachea  has 
been  opened:  the  sponge  is  now  used,  and  then,  by  means  of  the  probe- 
pointed  bistoury,  the  incision  is  forthwith  enlarged.  If  the  original  opening 
has  been  made  far  from  the  cricoid  cartilage,  it  must  be  enlarged  by  cutting 
from  below  upwards,  so  as  to  avoid  the  trunk  of  the  brachio-cephalic  vein. 
Many  practitioners  prefer  opening  the  crico-thyroid  space,  cutting  the  cri- 
coid cartilage  or  the  two  first  tracheal  rings,  in  accordance  with  Heister's 
plan.  It  is  evident  that,  by  proceeding  in  this  way,  we  penetrate  the  larynx 
itself;  and  thai — as  often  happens — if  the  tube  remain  some  weeks  in  the 
wound,  tin'  resull  will  be  partial  necrosis  of  the  cricoid  cartilage,  and  even 
of  the  thyroid  cartilage,  the  probable  source  of  serious  ulterior  consequences, 

among  which  may  he  mentioned  an  irremediable  alteration  of  the  voice. 
Let  it  be  understood  that  I  am  now  speaking  of  what  OUghl  to  he  done  in 
cases  of  croup  occurring  both  in  adults  and  in  children;  for,  afterwards, 
when  1  shall  have  to  speak  to  you  of  tracheotomy  in  other  laryngeal  affec- 
tions, I  shall  have  to  point  out  that  in  the  more  aged  a  different  method  of 
proceeding  is  sometimes  required.     In  cases  of  croup  it  is  only  necessary  to 

Open  the  trachea. 

I  cannot,  gentlemen,  too  strongly  insist  upon  the  necessity  of  dividing  the 
tissues  layer  by  layer,  holding  aside  the  vessels  and  muscles  by  the  blunt 

hook-,  anil  entirely  denuding,  before  opening,  the  trachea  :  I  lay  greal  stress 


TRACHEOTOMY    IN    DIPHTHERIA.  423 

upon  the  absolute  necessity  of  proceeding  very  slowly.  If,  even  during  the 
operation,  the  child  has  a  suffocative  attack,  stop  to  allow  him  to  struggle, 
and  permit  him  tosit  up  that  he  may  get  his  breath:  you  may  thus  perhaps 

Lose  a  minute,  but  of  that  you  need  not  be  afraid.  I  have  never  seen  an 
accident  arise  from  too  much  slowness;  but  I  have  often  witnessed  the 
difficulties  and  dangers  of  a  too  nimble  tracheotomy,  even  when  performed 
by  an  able  operator. 

Hence  it  is,  therefore,  that  I  denounce  with  all  my  strength  the  expedi- 
tions mode  of  operating  lately  recommended  by  Chassaignac,  which  consists 

in  fixing  the  larynx  by  means  of  a  tenaculum,  and  then  penetrating  the 
trachea  by  a  direct  puncture  through  the  skin  and  subjacent  parts.  This 
is  not  a  new  method  of  performing  tracheotomy.  In  1586  Sanctorius,  who 
seems  to  have  been  the  first  to  practice  bronchotomy,  proposed  puncture  of 
the  trachea  with  the  trocar  which  he  had  invented  for  performing  abdom- 
inal paracentesis.  In  1748  Garengeot  recommended  laryngocentesis  as  being 
very  superior  to  the  operation  by  which  we  reach  the  trachea  step  by  step : 
he,  however,  advised  that  the  skin,  without  disturbing  the  muscles,  should 
be  incised  in  the  first  instance,  at  least  in  thin  subjects.*  Direct  puncture, 
without  previous  incision,  is  also  recommended  by  Heisteiyj"  because  it  is 
more  expeditious,  and  because  it  saves  suffering  to  the  patient,  as  one  stroke 
makes  the  puncture  with  the  trocar  and  introduces  the  canula  into  the 
windpipe.  Decker,  Bauchot,  Barbeau-Dubourd,  and  Richter  had  thought 
of  bronchotomy,  with  a  view  of  rendering  the  operation  safer  and  quicker. 
Van  Swieten,  in  the  813th  Commentary,  which  I  have  just  referred  to, 
speaks  at  some  length  of  bronchotomy,  which  he  denounces  as  dangerous, 
after  having  performed  it  experimentally  on  the  dead  body,  and  on  living 
animals.^  A.  Berard,  who  also  had  invented  a  proceeding  similar  to  that 
of  Heister,  ultimately  discovered  that  the  quickest  was  not  always  the  best 
method :  towards  the  close  of  his  career,  he  renounced  his  expeditious  pro- 
ceeding for  the  more  common  and  safer  operation.  Dr.  Paul  Guersant 
likewise  adopted,  for  a  short  time,  the  expeditious  method  ;  and  although 
he  operates  better  and  more  quickly  than  those  of  us  who  are  not  surgeons, 
he  proceeds  sufficiently  slowly  to  avoid  the  serious  mishaps  to  which  I  have 
directed  your  attention.  On  the  one  hand,  there  is  the  danger  of  fixing 
the  larynx,  for,  as  Dr.  A.  Millard  has  sensibly  remarked  in  his  excellent 
thesis,§  and  as  Lenoir||  had  previously  said  in  1841,  by  impeding  move- 
ments connected  with  the  exercise  of  a  function  already  threatened,  you  run 
the  risk  of  accelerating  asphyxia  and  death ;  and  on  the  other  hand,  there 
is  the  risk  of  exciting  fatal  hemorrhage,  if  by  accident  the  instrument  wounds 
a  vessel  from  encountering  an  anomalous  distribution  of  arteries,  as  hap- 
pened in  a  case  communicated  to  me  by  Dr.  Richet.  In  a  little  girl,  in 
whom  he  had  operated  for  croup,  he  was  obliged,  just  at  the  moment  he 
was  going  to  open  the  trachea,  to  divide  an  artery  almost  as  large  as  the 
radial :  it  was  an  anastomosis  of  the  two  inferior  thyroids.  The  bleeding 
was  stopped  by  the  application  of  a  ligature  to  each  of  the  extremities  of 
the  divided  vessel ;  and  the  able  operator  had  to  congratulate  himself  upon 

*  Garengeot:  Operations  de  Chirurgie,  t.  ii,  p.  447  et  448. 

f  Heister:  Institutions  de  Chirurgie,  t.  iii,  p.  153,  annee  1770. 

j  Van  Swieten":  "  Tentavi  aliquoties  in  cadavere  et  in  vivis  animalibus  banc 
rnethodurn,  sed  videbatur  mihi  admodiim  diffieilis,  et  non  carere  periculo,  ne  quan- 
doque  valida  vi  adactum  instrumentum  deviaret,  unde  crederem  priorem  methodum, 
licet  magis  operosam,  prseferendam  esse."  \_Cammentaria  in  Buerhaavii  Aphorism, 
de  coognosc.  et  curand.  rnorbis:  Apb.  813,  t.  ii,  p.  627.] 

\  A.  Millard:  De  la  Tracheotomie  dans  le  cas  de  Croup.     Paris,  1858. 

||  Lenoir:  De  la  Bronchotomie.     These,  1841. 


424  TRACHEOTOMY    IN    DIPHTHERIA. 

the  slowness  with  which  he  was  in  the  habit  of  performing  tracheotomy. 
In  another  case  I  found  the  left  carotid  artery  arising  from  the  trunk  of 
the  innominata,  and  crossing  the  trachea.  Again,  it  is  not  easier  to  punc- 
ture the  trachea  through  the  skin  than  from  the  bottom  of  a  wound  ;  still, 
the  instrument  may  deviate,  and,  in  place  of  entering  the  windpipe,  may 
penetrate  the  oesophagus,  an  accident  which  occurred  to  my  colleague  Dr. 
A.  Berard.  Finally — what  ought  to  be  clone,  if,  at  the  moment  of  intro- 
ducing the  tube,  an  obstacle  is  presented  by  the  false  membrane  lining  the 
trachea?  How  are  you  to  see  what  to  do  at  the  bottom  of  a  deep  narrow 
wound  inundated  with  blood?  Under  such  circumstances  death  will  be 
inevitable. 

Some  of  you,  who  have  followed  my  clinic  for  several  years  past,  will 
recollect  that  the  very  case  I  have  now  supposed  actually  occurred  in  our 
wards.  On  the  27th  May,  a  little  girl  of  four  years  of  age  was  brought  to 
me  suffering  from  croup:  as  she  was  at  the  last  extremity,  I  lost  no  time  in 
resorting  to  tracheotomy.  Just  as  I  had  laid  bare  the  trachea,  I  cut  a 
somewhat  large  thyroid  vein :  with  the  view  of  arresting  the  hemorrhage, 
which  was  rather  abundant,  I  hastened  to  introduce  the  canula.  This, 
however,  did  not  re-establish  respiration :  there  was  a  great  degree  of  suffo- 
cation, and  the  face  of  the  little  patient  was  frightfully  livid.  I  withdrew 
the  canula,  and  introduced  the  dilator.  The  child  was  in  a  state  of  appar- 
ent death,  respiration  was  suspended;  and  the  pupils  were  dilated,  indi- 
cating that  asphyxia  had  proceeded  very  far.  We  then  caused  the  thorax 
to  perform  blowing  movements :  after  a  minute  and  a  half  or  two  minutes, 
an  interval  which  seemed  dreadfully  long,  we  saw  the  patient  make  some 
grimaces ;  then,  a  deep  inspiration  drew  air  into  the  chest,  and  brought 
back  life.  An  occurrence  had  taken  place  similar  to  others  I  had  observed 
during  my  long  practice.  False  membrane  coated  the  larynx,  trachea, 
and  bronchi;  and  whilst  I  was  inserting  the  canula,  this  false  membrane, 
being  torn,  was  compacted  by  my  instrument  in  such  a  way  as  to  com- 
pletely obstruct  the  passage  of  air.  After  I  had  withdrawn  the  canula  and 
introduced  the  dilator,  respiration  was  re-established  :  the  false  membrane 
was  then  seen  at  the  opening  of  the  trachea:  I  removed  by  the  forceps  a 
large  piece  of  it,  which  was  branched  at  its  inferior  extremity.  When  the 
canula  was  readjusted  in  its  place,  other  portions  of  false  membrane,  coming 
from  the  bronchial  tubes,  passed  out  through  it,  their  expulsion  being  pro- 
moted by  coughing  excited  by  tickling  the  trachea  with  a  feather.  These 
portions  of  false  membrane  were  tubular,  and  their  calibre  showed  that  the 
■diphtheritic  affection  had  reached  far  down  into  the  lungs,  so  that  although 
respiration  was  re-established,  there  was  no  permanent  advantage  to  be 
hoped  for  from  the  operation.     The  child  died  during  the  night. 

The  expeditious  method  exposes  the  patient  to  another  accident,  which, 
it  is  true,  may  also  sometimes  arise  when  the  safer  operative  proceeding  is 
followed.  I  refer  to  entj/hyxeiiiu  of  the  cellular  tissue,  resulting  either  from 
Avant  of  parallelism  in  the  incisions  through  the  soft  parts  and  the  trachea, 
Or  from  the  opening  into  the  tracheal  wound  being  so  narrow  as  to  make 
the  introduction  of  the  canula  n  difficulty.  There  is  nothing  in  thifl  em- 
physema to  occasion  anxiety.  When  Limited  to  the  Deck  and  the  neighbor- 
hood of  the  wound,  it  quickly  disappears,  and  may  he  looked  on  as  an  acci- 
dent of  no  consequence.  Hut  when  it  is  so  extensive  as  to  invade  the  chest, 
it  tends  to  embarrass  the  breathing:  if  it  reach  the  \\\rr.  it  has  the  addi- 
tional drawbacks  of  disfiguring  the  patient  ami  frightening  the  family,  li 
sometimes  attains  extraordinary  proportions,  becoming  almost  general,  as 
occurred  in  ;i  case  observed  by  Dr.  Mtillard  :  i(  is  then  a  very  serious  com: 
plication.     In  addition  to  the  dyspnoea  which  ii  occasions,  it  give-  rise  to 


TRACHEOTOMY    IN    DIPHTHERIA.  425 

so  much  swelling  of  all  the  tissues  of  the  neck,  and  consequently  makes  the 
wound  so  deep,  that  the  common  tracheal  tubes  are  too  short  to  reach  the 
trachea,  and  it  becomes  necessary  to  have  recourse  to  very  troublesome 
expedients. 

Operate  slowly,  therefore, — very  slowly.  When  the  trachea  is  opened, 
the  operation  is  not  completed  :  what  remains  to  be  done,  though  not  the 
most  difficult  part  of  the  proceeding,  is  that  which  demands  the  greatest 
amount  of  coolness  and  presence  of  mind.  This  is  the  moment  when  the 
blood  deluges  the  bronchi,  when  the  venous  hemorrhage,  so  far  from  stop- 
ping, becomes  more  abundant,  in  consequence  of  the  respiration  being  more 
difficult.  It  is  now  necessary  at  once  to  take  the  dilator,  which  ought  to 
be  lying  ready  to  hand,  and  introduce  it  shut  between  the  lips  of  the  wound 
in  the  trachea,  and  then  open  it  moderately  by  separating  its  rings.  This 
mauipulation,  however  easy  it  may  seem  from  description,  does  not  the  less 
require  some  practice.  I  have  very  often  placed  the  extremity  of  the  in- 
strument between  the  muscles,  and  have  only  introduced  one  of  its  branches 
into  the  trachea.  Here  again,  it  is  essential  to  proceed  slowly  :  it  is  neces- 
sary to  go  as  deep  as  possible.  When  the  dilator  is  properly  placed,  the 
air  enters  easily :  the  blood,  mucus,  and  false  membrane  are  discharged  ; 
and  respiration,  in  general,  becomes  easy.  At  this  stage  of  the  operation, 
the  assistant  who  holds  the  patient's  head  ought  to  elevate  it  a  little  in 
front,  so  as  to  facilitate  the  introduction  of  the  dilator,  by  relaxing  the 
edges  of  the  wound,  and  so  favoring  the  discharge  of  the  blood  and  mucus. 
If  there  is  taking  place  a  somewhat  abundant  venous  hemorrhage,  as  in 
the  case  I  have  just  related  to  you,  at  once  introduce  the  canula,  and  when 
you  have  done  so,  the  bleeding  will  immediately  cease. 

The  dilator  serves  as  a  director  in  introducing  the  canula,  which  ought 
to  be  previously  provided  with  a  caoutchouc  shield,  or  covered  with  oiled 
silk,  so  as  to  prevent  its  expanded  part  from  causing  excoriation  of  the 
skin  of  the  neck.  This  stage  of  the  operation  is  often  very  difficult :  some- 
times the  operator  misses  the  opening  in  the  trachea,  and  buries  the  instru- 
ment in  front  of  it,  in  the  cellular  tissue.  The  entrance  of  the  tube  into 
the  windpipe  is  known  to  have  taken  place  by  the  escape  of  air  and  mucus 
from  its  external  orifice,  and  by  the  facility  with  which  respiration  is  per- 
formed. It  is  indispensable  that  the  canula  be  of  sufficient  length  to  ex- 
tend into  the  trachea  one  or  two  centimetres  beyond  the  inferior  angle  of 
the  opening  which  has  been  made  into  that  passage.  If  too  short,  it  is 
displaced  by  coughing,  and  gets  out  of  the  trachea  into  a  sort  of  pouch 
which  always  exists  in  front  of  it :  in  a  few  minutes,  the  patient  dies  as- 
phyxiated. Thrice  have  I  had  to  deplore  this  frightful  accident,  though 
I  had  left  my  patients  after  the  operation,  under  the  charge  of  pupils  who 
were  not  without  experience.  To  avoid  similar  catastrophes,  it  is  essential 
to  secure  the  canula  firmly  in  its  place  by  tapes  carried  round  the  neck. 

Provided  the  canula  be  introduced  into  the  trachea,  it  really  matters 
little  how  that  has  been  accomplished.  Whether  the  operation  has  been 
performed  with  more  or  less  dexterity,  or  with  more  or  less  rapidity,  the 
result  is  the  same,  provided  there  has  not  been  hemorrhage.  Loss  of  blood 
has  a  very  unfavorable  influence  upon  the  results  of  the  operation. 

Treatment  in  relation  to  tracheotomy  is  a  subject  which  has  still  to  be 
considered.  This,  which  is  entirely  a  medical  question,  is  now  looked  upon 
as  of  paramount  importance  :  nor  is  this  surprising  when  we  consider  that 
some  lose  nearly  all  their  patients,  while  others  save  a  third  or  even  a  half. 
1  should  be  doing  wrong,  were  I  only  to  speak  of  that  which  has  to  be 
done  :  great  importance  must  be  conceded  to  the  treatment  of  the  cases 
prior  to  the  operation.     The  majority  of  physicians  are  fortunately  agreed 


426  TRACHEOTOMY    IN    DIPHTHERIA. 

that  remedies  intended  to  act  on  the  entire  economy  are  often  useless, 
and  that  the  chances  of  success  are  all  the  greater,  the  less  energetic  the 
therapeutic  measures  which  are  employed  ;  that,  in  particular,  blisters  are 
very  objectionable,  as  I  have  often  pointed  out :  consequently,  they  do  not 
exhaust  their  little  patients  by  the  abstraction  of  blood,  and  they  abstain 
from  usiug  blisters.  I  am  convinced  that  the  greater  success  which  has 
attended  tracheotomy  in  recent  years  is  due  to  the  sounder  principles  of 
treatment  which  during  that  period  have  been  pursued  by  my  professional 
brethren. 

Before  entering  upon  the  subject  of  consecutive  treatment,  I  ought  to 
mention  some  details  regarding  the  manner  of  dressing  the  wound,  to  which 
it  may  appear  perhaps  that  I  attach  undue  importance ;  but  the  older  I 
grow,  the  more  do  I  become  convinced  that  attention  to  minutiae  is  of  much 
more  importance  in  therapeutics  than  is  generally  believed.  I  have  already 
mentioned  the  importance  of  interposing  a  piece  of  caoutchouc  or  oiled  silk 
between  the  expanded  part  of  the  tube  and  the  wound  in  the  trachea,  so 
as  to  prevent  the  occurrence  of  irritation ;  and  I  have  referred  to  the  neces- 
sity of  keeping  the  tube  in  its  place  by  tapes  or  bands.  Other  minutiae  are 
deserving  of  notice. 

The  neck  ought  to  be  surrounded  by  a  knitted  comforter  or  with  a  large 
muslin  neckcloth,  so  that  the  patient  may  expire  into  this  thick  material, 
and  inspire  air  impregnated  with  the  steam  supplied  by  his  expiration. 
This  is  a  rule  of  fundamental  importance;  by  attending  to  it  the  interior  of 
the  canula  as  well  as  of  the  trachea  is  jn*evented  from  becoming  dry :  irri- 
tation of  the  mucous  membrane  is  guarded  against,  and  there  is  also  pro- 
vision made  against  the  formation  of  coriaceous  crusts  similar  to  those  which 
form  in  the  nose  in  coryza — crusts  which  become  detached  as  tubes  or  frag- 
ments of  tubes,  leading  to  terrible  fits  of  suffocation,  and  sometimes  causing 
death  from  occlusion  of  the  canal.  Before  Dr.  Paul  Guersant  and  I  had 
adopted  this  plan,  we  lost  a  great  many  of  the  patients  we  operated  on  from 
catarrhal  pneumonia:  this  is  now  a  much  loss  usual  cause  of  death.  Prob- 
ably, the  introduction  of  warm  moist  air  into  the  bronchi  is  a  condition 
exceedingly  favorable  to  the  prevention  of  pneumonic  attacks. 

The  plan  of  covering  the  neck  with  a  cravat  was  adopted  in  old  times. 
The  object,  however,  for  which  it  was  recommended  was  to  prevent  the 
entrance  by  the  canula  of  dust  and  small  bodies  which  might  be  floating 
about  in  the  air.  As  G.  Martin  remarked,  this  fear  was  chimerical.  But 
in  addition  to  the  precaution  of  wearing  a  cravat,  from  their  point  of  view, 
an  unnecessary  precaution,  the  old  physicians  advised  the  patients  to  be 
kept  in  warm  rooms:  for,  said  they,  the  cold  air  may  prove  injurious,  inas- 
much as  the  air  which  reaches  the  lungs  by  ordinary  respiration  is  warmed 
in  passing  through  the  mouth  and  nasal  cavities.  This  was  the  opinion 
enunciated  by  Van  Swieten.*  Garengeot,  however,  grasped  the  true  indi- 
cation when  he  recommended  the  placing  of  cotton  over  the  orifice  of  the 

*  Van  Swiktkn:  "Solliciti  pariter  fuerunt  plerique  hujus  operntionis  descrip- 
nt  caverent  ae  una  cum  aere  pulvisculi  in  i lie  volitantea  patulum  tubi  orificium 

intrarent  libere ;  bine  gosaypio,  lint larpto,  spongia,  &c.,  tegi  volueruntextrorsum 

patena  tubuli  orificium.  MLartiniua  tamen  usu  didicit  nulbtm  notabilem  inde  noxam 
aegro  accidere,  licet  non  tegeretur  tubuli  orificium,  quamvis  etiam  in  demo  non  adeo 
nitida  decumberel  eager.  Si  tamen  inde  quid  metueretur,  posset  hoc  facile  evitari, 
si  collo  circumduceretur  laze  rarum  linteum,  Bpleniia  ita  in  vicina  tubuli  dispoaitis, 
ut  illud  quidem  tegeret  tubi  orificium,  non  tangeret.  Expediet  tamen  ut  aer  parum 
calidior  sit  in  loco  quo  decumbil  Beg<  p,  emu  frigore  buo  nocere  plus  possel  quam  dum 
communi  respirationis  via  in  pulmonem  i  rabibur,  Bemper  in  transitu  vel  os  vel  uares 
caleecena  utcumque."     \_Loc.  cit.,  p.  628.] 


TRACHEOTOMY    IN    DIPHTHERIA.  427 

canula,  to  modify  the  air  entering  the  trachea,  or  better  still,  placing  over  the 
orifice  of  the  canula  a  pledget  of  fine  lint  or  a  piece  of  linen  of  rather  loose 
texture.  In  our  day  it  has  been  proposed  to  evolve  steam  in  the  patient's 
room,  hut  this  is  certainly  neither  a  .simpler  nor  more  convenient  method 
than  the  cravat. 

There  is  still  another  practice,  without  having  recourse  to  which  recovery 
seldom  occurs.  I  refer  to  cauterization  of  the  ivound.  Immediately  after 
the  operation,  and  during  the  four  following  days,  all  the  cut  surfacesought 
to  be  vigorously  rubbed  with  solid  nitrate  of  silver.  By  this  means  an  ac- 
tion very  much  to  be  dreaded  is  prevented — viz.:  the  wound  being  affected 
with  diphtheria,  and  becoming  covered  with  thick  and  fetid  false  mem- 
brane. Moreover,  the  specific  diphtheritic  inflammation,  spreading  to  the 
surrounding  cellular  tissue,  often  originates  in  that  situation  phlegmonous 
erysipelas  of  a  bad  character,  leading  to  local  gangrene,  or  at  least  to  vio- 
lent symptomatic  fever,  and  general  poisoning  of  the  system,  a  condition 
from  which  recoveries  are  rare.  Dr.  Millard  states  in  his  thesis  that  he 
never  performs  this  cauterization  at  the  time  of  the  operation ;  and  accord- 
ing to  information  which  I  have  obtained  from  one  of  the  ministering 
sisters  of  the  Hospital  of  the  Rue  de  Sevres,  possessed  of  great  practice  and 
experience  in  the  treatment  there  followed  by  my  colleagues,  it  is  never 
performed  till,  at  the  soonest,  twenty-four  hours  after  the  operation ;  if  the 
child  have  fever,  it  is  allowed  to  subside  before  cauterization  is  performed, 
and  it  is  also  considered  necessary  that  the  child  be  not  intractable.  I  am 
opposed  to  these  rules  of  practice,  because  I  have  witnessed  the  bad  conse- 
Cjuences  which  result  from  observing  them.  After  the  fifth  day,  the  surface 
of  the  wound  is  so  modified  that  the  complications  which  have  been  referred 
to  are  no  longer  to  be  dreaded. 

When  once  the  operation  has  been  performed,  the  first  care  of  the  phy- 
sician ought  to  be  the  nourishment  of  the  patient.  Alimentation,  gentle- 
men, as  I  have  reiterated  on  several  occasions,  is  the  chief  remedy  in  the 
majority  of  acute  diseases,  and  particularly  in  those  of  childhood.  There 
can  be  no  doubt  that  abstinence,  as  prescribed  by  Broussais,  and  as  still 
inculcated  by  a  great  many  physicians,  who,  unable  to  put  off  the  old  man, 
retain  too  strongly  the  prejudices  of  their  earty  medical  education,  is  one 
of  the  deadliest  complications  of  disease,  that  which  is  most  calculated  to 
keep  up  the  contamination  of  the  system,  the  most  calculated  to  promote 
the  absorption  from  without  of  miasmata  an.d  of  morbid  elements  formed 
from  the  diseased  body — the  most  opposed  to  that  power  of  resistance  which 
is  the  great  well-spring  of  convalescence  and  of  ultimate  recovery.  I  do  not 
mean  to  say  that  it  is  necessary  to  cram  the  little  patients  with  food :  I 
only  wish  to  say  that  their  appetite  for  food,  if  it  exist,  ought  to  be  grati- 
fied, and  that  if  they  have  a  repugnance  to  it,  it  is  then  essential  to  force 
them  to  take  a  little.  I  revert  to  this  point,  upon  which  I  have  already 
spoken  when  discussing  the  general  treatment  of  diphtheria :  do  not  be 
afraid  of  employing  intimidation.  Many  is  the  time,  that,  arming  myself 
with  an  assumed  expression  of  great  severity,  I  have  obliged  children  to 
take  food,  and  have  thus  paved  the  way  for  recovery,  which  otherwise  could 
Dot  have  taken  place.  The  alimentary  articles  which  I  most  insist  on  are 
milk,  eggs,  cream,  chocolate,  and  soup.  If  necessary,  the  oesophageal  tube 
must  be  used  to  introduce  into  the  stomach  the  sustaining  food  which  the 
child  refuses  to  swallow. 

What  I  have  now  said  sufficiently  indicates  that  I  absolutely  interdict 
the  continuance  after  the  operation,  of  certain  means,  which  before  it,  might 
be  judged  more  or  less  useful,  such  as  calomel,  alum,  emetics,  and  purga- 


428  TRACHEOTOMY    IN    DIPHTHERIA. 

fives.  Such  remedies  are  quite  incompatible  with  the  nature  of  the  alimen- 
tation which  I  recommend. 

It  is  a  remarkable  fact,  that  when  once  tracheotomy  has  been  performed, 
there  need  no  longer  be  entertained  any  anxiety  regarding  the  diphtheritic 
manifestations  of  the  pharynx  or  larynx  which  formerly  it  was  imperative 
to  attack  by  very  active  measures :  they  disappear  spotaneously.  It  ap- 
pears that  by  the  time  the  disease  has  reached  the  air-passages,  it  has  ex- 
hausted itself;  and  that  if  by  admitting  air  to  the  lungs,  by  tracheotomy, 
the  patient  be  prevented  from  dying,  recovery  will  take  place.  I  speak  of 
the  pharyngeal  and  laryngeal,  and  not  of  the  cutaneous  manifestations;  for 
the  latter  ought  always  to  be  most  determinedly  followed  up  and  eradicated 
by  the  topical  means  which  I  have  indicated,  lest  otherwise,  they  become, 
through  absorption,  the  source  of  a  deadly  general  poisoning  of  the  system. 

When  first  I  practiced  tracheotomy,  following  Bretonneau's  example,  I 
was  in  the  habit  of  prescribing  the  mopping  out  of  the  windpipe,  as  far 
down  as  it  was  possible  to  reach,  with  a  small  sponge  fixed  to  the  end  of  a 
piece  of  whalebone.  I  have  long  since  discontinued  this  proceeding:  I 
have  likewise  relinquished  cauterization  of  the  trachea,  which  I  used  to  per- 
form by  applying  to  it  a  sponge  soaked  in  a  caustic  solution,  or  by  drop- 
ping into  it  some  of  that  solution.  These  proceedings  have  seemed  to  be 
productive  of  inconveniences  which  were  not  counterbalanced  by  any  real 
advantages.  I  may  here  add  that  the  dropping  in  of  the  solution  of  chlor- 
ate of  soda,  as  recommended  by  Dr.  Barthez,  was  abandoned  by  that  phy- 
sician himself,  after  he  had  made  it  the  subject  of  a  communication  to  the 
Medical  Society  of  the  Hospitals. 

The  frequent  cleansing  of  the  internal  canula  is  an  essentially  necessary 
precaution,  so  that  the  ingress  of  air  may  be  as  free  as  possible.  I  recom- 
mend that  this  cleansing  should  be  performed  every  two  hours. 

There  still  remains  a  word  to  be  said  on  the  last  part  of  the  treatment, 
which  is  one  of  some  delicacy.  I  refer  to  the  removal  of  the  tube,  and  the 
final  closure  of  the  wound. 

I  do  not  speak  of  Dr.  Millard's  method  of  temporarily  removing  the 
canula  from  the  very  first  dressing,  twenty-four  hours  after  the  operation. 
The  idea  of  my  intelligent  young  colleague  is  that  by  so  acting,  he  assists 
the  expulsion  of  bulky  false  membranes,  which  by  being  allowed  to  remain 
in  the  canula,  may,  by  choking  it  up,  induce  fits  of  suffocation.  Unques- 
tionably, in  cases  in  which  there  is  risk  of  suffocation,  the  removal  of  the 
tube  is  proper;  but,  under  ordinary  circumstances,  1  see  no  advantage  in, 
far  less  any  necessity  for,  this  proceeding.  In  saying  this,  I  am  not  the  less 
decidedly  of  opinion  that  the  sooner  the  better  the  canula  can  be  finally 
removed  ;  but  this  can  seldom  be  done  before  the  sixth  day  :  the  eases  are 
lew  in  which  the  tube  ought  to  remain  after  the  tenth.  There  are  cases, 
however,  in  which  recovery  takes  place  after  the  larynx  has  remained  com- 
pletely closed  for  fifteen,  twenty,  or  even  for  twenty-four  days,  as  I  saw  in 
the  case  of  a  young  girl.  I  have  mentioned  the  case  of  a  child  who  retained 
the  canula  for  live  years.  That  patient  is  still  alive,  hut  has  a  tracheal 
fistula. 

The  tube  ought  to  he  removed  at  the  end  of  the  first  week,  care  being 
taken  not  to  make  the  child  cry  or  lie  frightened.  The  poor  little  creatures 
who  have  lieen  operated  on  are  so  much  accustomed  to  breathe  by  the  arti- 
ficial passage,  that  when  ii  is  closed,  to  facilitate  the  entrance  of  air  through 
the  larynx,  they  are  apt  to  he  seized  with  a  paroxysm  of  tear,  which  finds 
expression  in  excitement  and  cries,  leading  to  acceleration  of  the  respira- 
tory movements.  The  larynx  is,  at  this  period,  somewhat  obstructed  by 
slightly  adherent  false  membrane,  by  the  presence  of  mucus,  or  by  the  ex- 


TRACHEOTOMY    IN    DIPHTHERIA.  429 

istence  of  slight  swelling  of  the  mucous  membrane ;  and  possibly,  also,  the 
laryngeal  muscles  may  have  lost  the  habit  of  giving  harmonious  response 
to  the  demands  of  the  respiratory  function  :  from  these  causes,  there  is  often 
greatly  embarrassed  breathing.  In  the  majority  of  cases,  this  embarrass- 
ment J  'asses  away  pretty  readily,  provided  the  little  patient  can  be  tran- 
quillized: the  accomplishment  of  this  is  more  within  the  province  of  the 
mother  than  of  the  physician.  The  wound  has  now  to  be  closed  with  strips 
of  adhesive  plaster.  If  the  sound  of  the  cough  or  the  respiration,  if  the  nature 
of  the  voice  or  the  cry  show  that  the  laryngeal  passage  has  become  fairly  pat- 
ent, the  dressing  is  completed  in  such  a  way  as  to  promote  immediate  union 
of  the  edges  of  the  wound;  but  if  the  air  does  not  enter  in  sufficient  quan- 
tity, the  adhesive  plaster  is  not  put  on:  the  wound  is,  under  such  circum- 
stances, simply  dressed  with  a  piece  of  loose  linen  smeared  with  cerate,  and 
the  closing  of  the  wound  is  delayed  till  next  clay.  Should  there  be  no  pas- 
sage of  air  through  the  larynx,  the  canula  must  be  replaced,  another  trial 
bemg  made  two  or  three  days  later.  As  soon  as  respiration  is  well  per- 
formed with  the  artificial  opening  closed,  the  wound  ought  to  be  dressed 
two  or  three  times  a  day :  generally,  the  opening  into  the  trachea  ceases  to 
exist  at  the  end  of  four  or  five  days:  all  that  remains  to  be  attended  to  is 
dressing  the  external  wound  till  its  closure,  which  soon  takes  place. 

The  presence  of  the  canula  may  occasion — and  that  sometimes  with  con- 
siderable rapidity — a  serious  occurrence,  to  which  Dr.  Henri  Roger  in  par- 
ticular has  called  attention :  I  refer  to  ulceration  of  the  trachea*  _  From  the 
researches  of  this  intelligent  observer,  it  appears  that  ulceration  of  the 
windpipe  is  a  frequent  consequence  of  the  contact  of  the  canula,  and  that 
the  lesion  varies  from  a  mere  superficial  erosion  to  a  complete  perforation. 
Dr.  Eoger  has  observed  that  ulceration  of  the  anterior  is  much  more  fre- 
quent than  of  the  posterior  wall  of  the  trachea:  it  arises  in  the  former  case 
from  the  friction  of  the  lower  edge,  and  in  the  latter  from  contact  with  the 
curve  of  the  canula.  Complete  perforation  of  the  trachea  by  ulceration  is 
obviously  a  very  formidable  accident:  in  two  cases  communicated  by  Dr. 
Barthez,  nothing  intervened  between  the  canula  and  the  brachio-cephalic 
artery  except  the  muscular  coat  of  the  trachea:  at  other  times,  the  tracheal 
lesion  has  caused  the  formation  of  abscesses  and  purulent  sinuses:  in  any 
case,  this  ulceration  becomes  a  new  cause  of  loss  of  power  from  the  suppu- 
ration which  it  induces. 

As  these  ulcerations  are  evidently  caused  by  excessive  friction,  and  as 
friction  cannot  be  altogether  avoided,  the  problem  is,  how  to  render  it  as 
moderate  as  possible.  Dr.  Roger  first  of  all  proposed  to  adopt  the  curve 
of  which  I  speak,  and  then  proposed  to  make  the  body  of  the  canula  move 
on  its  expanded  extremity,  so  that  in  all  the  movements  of  the  trachea,  the 
body  of  the  canula  should  move  with  the  trachea,  without  rubbing  against 
the  side  of  the  passage  with  which  it  is  in  contact,  the  friction  being  upon 
the  expanded  extremity  of  the  canula,  with  which  it  is  loosely  articulated. 
In  this  way,  the  expanded  extremity  of  the  canula  is  solidly  fixed  to  the 
neck;  and  the  body  of  the  instrument,  which  is  in  contact  with  the  wound 
and  with  the  internal  surface  of  the  trachea,  moves  upon  the  expanded  ex- 
tremity. Since  the  publication  of  Dr.  Roger's  work,  only  jointed  tubes 
have  been  used  at  the  Children's  Hospital,  and  since  that  time,  also,  ulcer- 
ations have  been  less  frequent,  as  well  as  less  serious  when  they  have  oc- 
curred. Although  I  believe  that  the  predominating  bad  character,  and 
the  special  constitution  of  an  epidemic,  have  much  to  do  with  the  frequency 

*  Roger  (Henri)  :  Dos  Ulcerations  de  la  Traehee-artere  Procluitcs  par  le  sejour 
de  la  Canute  apres  la  Tracheotomie.     [Archives  Generates  de  Medecine,  1859.] 


430  TRACHEOTOMY    IN    DIPHTHERIA. 

of  the  lesions  pointed  out  by  Dr.  Eoger,  I  do  not  hesitate  to  recognize  in 
his  suggestions  a  real  step  in  advance;  and  consequently  I  recommend  you 
to  prefer  articulated  to  non-articulated  tubes. 

Difficulty  in  swallowing  is  a  formidable  symptom,  to  which  I  long  ago  di- 
rected attention,  and  to  which  Dr.  Archambault  attaches  special  impor- 
tance. This  difficulty  arises  from  fluids  passing  through  the  glottis:  the 
result  is  violent  convulsive  cough  every  time  the  child  tries  to  drink;  and 
the  fluids,  entering  the  trachea  and  bronchi,  spurt  out  in  quantity  by  the 
canula.  Besides  the  serious  consequences  arising  from  the  contact  of  fluid 
aliment  (which  is  sometimes  insoluble,  and  consequently  irritating)  with 
the  bronchial  mucous  membrane,  children  sometimes  feel  an  insurmount- 
able disgust  at  food,  and  prefer  to  allow  themselves  to  die  from  huuger 
than  to  eat  or  drink.  This  complication  has  too  often  been  the  cause  of 
death  after  tracheotomy  not  to  stimulate  me  to  use  all  my  efforts  to  find  a 
means  of  contending  against  it.  The  best  plan  is  to  interdict  liquid  food: 
I  give  children  very  thick  food,  milk  or  beef  tea  thickened  with  vermicelli 
to  such  a  consistence  as  to  render  it  fitter  to  be  eaten  with  the  fork  than 
with  the  spoon ;  or  I  give  them  hard  eggs,  well  boiled  eggs  beat  up  with 
milk,  and  underdone  butcher-meat:  I  interdict  every  kind  of  fluid.  Should 
excessive  thirst,  however,  exist,  I  allow  pure  cold  water,  taking  care  that 
it  is  given  a  long  time  after,  or  immediately  before  eating,  so  as  to  avoid 
the  excitation  of  vomiting.  It  ought,  however,  to  be  remarked,  that  the 
symptom  of  which  I  am  speaking  rarely  begins  to  show  itself  till  three  or 
four  days  after  the  operation,  and  that  it  seldom  continues  later  than  the 
tenth  day,  although  in  some  children  I  have  seen  it  last  much  longer. 

One  might  suppose  that  the  laryngeal  passage,  which  is  thus  so  very  open 
for  the  reception  of  drinks  and  liquid  food,  must  also  be  sufficiently  open 
to  admit  air  enough  for  the  purposes  of  respiration ;  but  such  is  not  the  case. 
It  is  found,  on  removing  the  canula,  that  the  laryngeal  aperture  is  still  in- 
adequate; and  even  some  days  later,  upon  closing  the  wound  with  strips  of 
adhesive  plaster,  the  symptoms  just  described  continue  with  equal  violence. 

It  is  not  very  easy  to  explain  these  symptoms — this  difficulty  of  swal- 
lowing. Dr.  Archambault  believes  that  the  child  who  has  breathed  through 
a  canula  for  some  days  loses  the  habit  of  harmoniously  moving  the  muscles 
which  shut  the  larynx,  and  of  managing  those  which  propel  the  alimentary 
bolus  into  the  oesophagus.  He  says  that  he  has  discovered  a  remedy  for 
this  dysphagia:  it  is  sufficiently  ingenious,  and  consists  in  closing  the  canula 
for  an  instant  with  the  finger,  at  the  moment  when  something  has  to  be 
swallowed:  in  this  way,  the  child  is  obliged  to  open  his  larynx,  and  thus, 
normal  harmony  of  muscular  action  is  re-established.  In  some  cases,  tins 
little  stratagem  is  successful,  but  generally  it  is  a  complete  failure.  This 
frequency  of  failure  is  explained  by  what  I  have  already  said;  for  even 
when  the  canula  is  removed  and  the  wound  is  quite  closed,  difficulty  of  deg- 
lutition continues,  although  the  laryngeal  respiration  is  \'wr  and  regular: 
this  probably  depends  upon  the  muscles  of  these  parts  being  affected  with 
that  paralysis  of  which  1  have  spoken  to  yon  at  some  length. 

I  have  now,  gentlemen,  laid  before  you  my  views  on  tin1  operation  <>\' 
tracheotomy,  and  have  staled  the  little  precautions  which  ought  to  he  at- 
tended to,  80  that  success  may  he  secured.  I  have  once  more  repeated  pre- 
cepts which  I  have  a  hundred  times  proclaimed  during  past  years.  1  should, 
however,  leave  the  subject  unfinished,  were  I  to  omil  speaking  to  yon  of  the 

Conditions  under  which  the  operation  OUghl  to  he  performed. 

Firsl  of  all,  what  is  Hi,  period  of  croup  moat  t>i>i><>rfit/i>  for  interfering  by 
operationf     In  1834  I  wrote,  and  in   1851  1  repeated  the  statement:  "So 

long  as  tracheotomy  did    not  prove  a  reliable  resource   in    my  hands  I  -aid 


THACIIEOTOMY    IN    DIPIITIIEHI A.  431 

that  the  operation  ought  to  be  delayed  as  long  as  possible;  but  now,  when 
my  successful  cases,  are  numerous,  I  say  that  it  ought  to  be  performed  as 

si as  possible."*     Modifying  that  proposition,  so  as  to  deprive  it  of  its 

absolute  form,  I  still  maintain  that  the  earlier  the  operation  is  performed,  the 
greater,  are  the  chances  <>)'  success.  The  ingenious  experiments  of  Dr.  Faure 
have  indeed  demonstrated  that  when  an  animal  is  slowly  and  methodically 
asphyxiated,  clots  form  in  the  heart  and  large  vessels  during  the  latter 
period  of  life.f  The  operation  ought,  therefore,  to  be  performed  before 
death  is  imminent;  but  still,  let  me  add,  that  to  whatever  degree  asphyxia 
may  have  proceeded — though  the  child  should  only  have  minutes  to  live — 
tracheotomy  ought  to  be  tried:  there  is  a  chance  of  success,  provided  the  local 
lesion,  the  croup,  constitutes  the  chief  danger  of  the  disease. 

This  limitation  is  important:  for  if  the  diphtheritic  poisoniug  has  seri- 
ously tainted  the  economy ;  if  the  skin  and  nasal  fossse  are  the  seat  of  the 
specific  inflammation ;  if  a  rapid  pulse,  delirium,  and  prostration  indicate 
extreme  poisoning;  if,  in  a  word,  we  have  to  do  with  malignant  diphtheria, 
the  chief  danger  is  in  the  general  state  of  the  patient,  and  not  in  the  local 
lesion  of  the  larynx  or  trachea.  The  operation  must  not  be  attempted  in 
such  cases,  as  in  them  it  is  invariabty  followed  by  death. 

The  condition  which  exceeds  all  the  rest  in  value  as  a  prognostic  of  suc- 
cess, as  has  been  admirably  expressed  by  Dr.  Millard  in  his  excellent 
thesis,];  is  the  predominance  of  the  symptoms  of  asphyxia  over  all  the 
patient's  other  symptoms.  "Unfortunately,"  says  he,  "it  is  not  always  easy 
to  be  quite  sure  amid  an  aggregate  of  symptoms,  often  very  complex,  what 
symptoms  are  dependent  upon  the  physical  affection,  and  what  are  due  to 
diphtheritic  poisoning  of  the  system  or  to  some  special  complication."  We 
are  often  obliged  to  follow  the  indication  which  is  most  urgent,  constrained 
to  make  the  dying  child  breathe,  and  do  not  perceive  till  after  doing  so, 
that  there  is  no  chance  of  recovery:  even  when  we  suspect  the  presence  of 
incipient  death,  we  feel  compelled  to  operate,  notwithstanding  the  almost 
hopelessness  of  the  case,  simply  because  there  is  no  absolute  certainty  as  to 
its  hopeless  nature.  "Operations  for  tracheotomy,"  continues  the  same 
author,  whom  I  take  a  pleasure  in  quoting,  "  performed  under  such  circum- 
stances are  not  otherwise  objectionable,  except  in  this,  that  they  figure  in 
statistics  along  with  other  cases,  and  so  have  a  tendency  to  mislead  opinion 
and  to  discredit  one  of  the  greatest  triumphs  of  curative  art.  The  fear  of 
reducing  the  proportion  of  successful  cases  must  not,  however',  too  easily 
induce  the  physician  to  desist  from  operating:  he  must  not  assume  so  grave 
a  responsibility  till  he  has  made  a  minute  methodical  analysis  of  all  the 
symptoms,  and  has  detected  the  existence  of  an  inevitable  cause  of  death. 
I  have  on  several  occasions  exercised  this  right,  in  cases  which  would  not 
have  borne  discussion,  and  at  the  autopsy  I  have  never  regretted  having 
followed  this  course:  but  in  every  case  in  which  I  have  had  the  slightest 
doubt,  however  unfavorable  the  conditions  for  operating  may  have  been,  I 
have  used  the  bistoury,  deeply  impressed  with  the  soundness  of  the  maxim 
— Melius  anceps  quam  nullum.'"  These,  gentlemen,  are  the  words  of  wis- 
dom, and  I  most  heartily  adopt  them. 

Age  is  still  a  question  which  remains  to  be  considered.  It  is  one  of  chief 
importance,  and  requires  to  be  well  weighed.  I  have  stated,  that  in  the 
croup  of  adults,  tracheotomy  is  less  successful  than  in  children.     I  gave 

*  Journal  des  Connaissances  Medico-Chirurgicales  for  September,  1834:  and  Nou- 
velles  Recberches  sur  la  Periode  Extreme  du  Croup,  in  the  Union  Medicale  for  1851. 

f  Faure:  Archives  Generates  de  M6decine:  5me  serie. 

%  Millard  (Herman) :  De  la  Traeheotomie  clans  le  eas  du  Croup:  Observations 
recueilles  a  L'Hopital  des  Enfants  Malad.es.     [Thlse]  Paris,  1858. 


432  TRACHEOTOMY    IN    DIPHTHERIA. 

you  as  a  reason — possibly  an  incorrect  reason — that  in  adults,  from  the 
anatomical  disposition  of  the  parts,  the  passage  of  the  air  into  the  lungs 
has  been  left  free  for  a  longer  period,  so  that  the  diphtheria  has  had  time 
to  gain  the  bronchial  tubes  and  their  minute  ramifications,  before  the  abso- 
lute necessity  has  arisen  for  having  recourse  to  tracheotomy:  but  in  chil- 
dren, success  is  all  the  more  certain,  that  the  child  is  not  very  young. 
This  is  a  fact  which  has  been  clearly  established  by  the  statistical  tables 
given  to  elucidate  the  cmestion  of  age  in  the  works  of  Dr.  Millard  and  Dr. 
Peter. 

Dr.  Peter  says :  "  Both  in  boys  and  in  girls,  tracheotomy  was  always 
unsuccessful  when  performed  on  very  young  subjects :  thus  in  56  girls  and 
51  boys,  on  whom  tracheotomy  was  performed  during  the  year  1858  at  the 
Children's  Hospital,  it  was  performed  15  times  on  girls  between  two  and 
three  years  of  age,  and  11  times  upon  boys  between  the  same  ages:  in  these 
26  cases  it  failed.  It  was  only  in  children  above  three  years  that  suo  --- 
ful  cases  occurred.  Taking  as  the  basis  of  comparison  a  very  large  num- 
ber of  cases  of  tracheotomy,  it  was  found  that  the  age  which  gave  the 
largest  proportion  of  recoveries  was  five  years  in  boys ;  viz.,  7  recoveries  in 
8  operations;  and  six  years  in  girls,  viz.,  three  recoveries  in  4  operations."* 
Again,  to  quote  Dr.  Peter,  who,  in  the  work  from  which  I  have  just  quoted 
thus  expresses  an  opinion  in  conformity  with  my  own :  "  Children  below 
two  and  up  to  two  and  a  half  years  of  age  seem  to  sink  under  the  influence 
of  traumatic  fever,  and  it  is  generally  during  the  twenty-four  or  thirty-six 
hours  which  immediately  follow  the  operation  that  death  occurs.  Scarcely 
have  two  hours  elapsed  after  the  operation,  when  the  number  of  pulsations 
and  respirations  increase  in  a  remarkable  manner,  and  the  temperature  of 
the  skin  rises  in  the  same  degree :  then,  little  by  little,  the  face  becomes 
red,  and  there  is  burning  thirst,  while  the  heat  of  the  body  is  dry  and  in- 
tolerable :  the  child  sinks  into  a  slumber,  which  is  occasionally  disturbed 
by  some  convulsive  movements :  and  then  he  dies." 

You  are  aware  that  before  two  years  of  age  croup  seldom  occurs ;  but 
still,  as  you  may  meet  with  cases  in  children  of  an  earlier  age,  even  in  chil- 
dren at  the  breast  (as  has  occurred  in  my  own  practice),  it  is  essential  to 
bear  in  mind  that  at  that  period  of  life,  there  is  a  very  .-mall  chance  of 
tracheotomy  proving  successful.  I  must  tell  you,  however,  that  in  1834, 
I  operated  on  and  cured  a  child  thirteen  months  old;  and  with  your  per- 
mission I  shall  now  relate  the  history  of  this  case,  which  I  published  in  the 
Journal  des  Connaissances  Medico-Chirurgicales  for  June,  1834. 

On  the  morning  of  Sunday,  11th  May,.  1834,  Dr.  Corsin  sent  for  me  to 
see  the  child  of  a  carter  of  Petite-Vilettc,  by  name  Pierre  Drodlinger.  The 
child  was  an  unweaned  boy,  thirteen  months  old.  He  had  had  cough  for 
four  days:  and  during  the  night  of  Saturday,  greal  oppression  of  the 
breathing  supervened:  the  cough  in  the  first  instance,  completely  ceased, 
and  the  voice  was  lost.  Under  these  circumstances,  Dr.  Corsin  was  called 
in,  and  finding  that  the  patient  was  already  in  a  desperate  stale,  he  re- 
stricted his  treatment  to  the  administration  of  a  draught  of  tartar  emetic 
and  musk:  ami  immediately  sent  for  me.  The  symptoms  of  croup  were 
well  marked :  the  suffocative  fit-  were  so  severe,  and  followed  each  other  in 
such  close  succession,  that  I  made  the  necessary  arrangements  for  perform- 
ing tracheotomy. 

The  operation  was  difficult  :  at  hist,  after  being  occupied  with  it  for  ten 
minutes,  I  opined  the  trachea  :  and  just  as  I  did  so,  a  large  -trip  of  false 

I'    rsa  (Michel):  Relation  d'une  Epidemic  de  Diphtheria,  observe©  4  l'B6pital 
des  Bnfants  en  1868.     [Mfimoire  Couronnee  par  la  Faculty  eo  1859.] 


TRACHEOTOMY    IN    DIPHTHERIA.  433 

membrane  was  spurted  out  to  some  distance.  I  cleared  out  the  trachea 
and  bronchial  tubes,  injected  eight  or  ten  drops  of  a  solution  of  nitrate  of 
silver,  and  inserted  a  canula.  The  poor  child  breathed  at  his  ease:  with 
fear  he  regarded  us,  and  looked  about  for  his  mother,  who  had  fled  from 
the  house.  1  sent  for  her:  when  she  arrived,  the  little  fellow  stretched  out 
his  arms  to  her,  immediately  unfastening  her  dress  and  the  neckerchief 
which  covered  her  bosom,  set  himself  to  suck  with  avidity.  For  three 
davs,  the  canula  was  changed  evening  and  morning,  and  every  six  hours 
I  introduced  some  of  the  solution  of  nitrate  of  silver  :  on  the  fourth  day, 
this  injection  was  performed  for  the  last  time.  Every  hour,  some  drops  of 
water  were  thrown  into  the  trachea,  and  the  canula  was  inopped  out.  The 
introduction  of  water  was  continued  for  ten  days.  During  the  first  four 
days  after  the  operation,  the  child  threw  off  pellicular  masses  ;  and  one  of 
the  pellicles  expectorated  on  the  second  day  was  of  considerable  thickness. 

Fever  set  in  some  hours  after  the  operation,  and  subsided  on  the  third 
day.  On  the  seventh  day,  the  introduction  of  a  new  canula  irritated  the 
wound,  caused  swelling  of  the  edges  of  the  opening,  and  rekindled  high 
fever.  By  the  ninth  day,  these  symptoms  were  calmed  down  :  on  the  tenth 
day,  a  great  part  of  the  air  which  entered  the  lungs,  passed  through  the 
larynx  :  on  the  eleventh  day,  the  canula  was  removed,  and  the  wound 
closed.     Next  day,  all  the  air  passed  through  the  larynx. 

I  have  had  very  recently  another  successful  case  which  I  may  place  in 
the  same  category  with  that  now  detailed,  although  the  child,  being  two 
years  old  all  but  six  days,  was  on  the  very  confines  of  that  age  within 
which  I  said  the  operation  was  attended  with  very  little  hope  of  success. 
This  patient  was  a  female  child  born  on  the  30th  April,  1856  :  she  was 
brought  to  our  wards  on  the  24th  April,  1858,  having  then  all  the  symp- 
toms of  the  last  stage  of  croup.  There  was  no  trace  remaining  of  pharyn- 
geal diphtheria  :  I  operated  on  her,  and  after  the  operation,  she  evacuated 
strips  of  false  membrane  through  the  artificial  opening  in  the  neck.  Con- 
valescence was  long  and  difficult.  It  was  impossible  to  remove  the  canula 
finally  till  the  seventeenth  day,  although  before  that  date  several  attempts 
to  do  so  were  made.  Diphtheria  invaded  the  wound,  and  was  only  got  rid 
of  by  repeated  cauterizations.  An  attack  of  distinct  small-pox  afterwards 
supervened,  but  did  not  impede  the  progress  of  the  cure  ;  which  was  com- 
plete on  the  13th  May,  when  the  child  was  taken  from  the  Hotel-Dieu. 

This  case,  that  of  the  child  Drodlinger,  and  the  memoir  of  Dr.  Maslieu- 
rat-Lagemard  presented  to  the  Academy  of  Medicine  in  1841,  inspired 
confidence  in  the  value  of  the  operation  of  tracheotomy  in  croup  irrespec- 
tive of  the  age  of  the  patient.  Dr.  Maslieurat's  memoir  contained  the 
report  of  a  third  successful  case  of  tracheotomy  in  a  very  young  child — in 
a  child  of  twenty-three  moDths  old.  To  these  cases  I  now  add  a  fourth, 
for  wdiich  we  are  indebted  to  Dr.  Bell  of  Edinburgh,  who,  in  1862,  per- 
formed tracheotomy  with  success  in  a  child  of  seven  months  :  also  a  fifth 
case,  published  by  Dr.  Barthez,*  my  honorable  colleague  in  the  hospitals, 
the  subject  of  which  was  a  little  girl  of  thirteen  months. 

Great  clinical  importance  belongs  to  these  cases  :  they  stand  alone  in 
the  records  of  science,  but  still  they  seem  to  me  to  justify  operative  inter- 
vention, irrespective  of  the  age  of  the  patient,  whenever  asphyxia  threatens 
life.  Possibly,  at  some  future  period,  we  may  be  able  to  calculate  from 
statistical  data  the  probability  of  success  from  tracheotomy  performed  on 
very  young  children  :  but  even  though  the  chance  of  success  should  be 
found  to  be  small,  I  should  not  hesitate  to  recommend  the  operation,  be- 

*  Barthez  :  "Gazette  Hebdomadaire,"  for  19th  December,  1862. 
vol.  i.— 28 


434  THRUSH. 

cause,  when  it  is  well  executed,  it  is  riot  in  itself  a  source  of  danger,  and 

may  often  offer  the  only  hope  of  saving  the  patient's  life. 

In  conclusion,  gentlemen,  I  sum  up  the  whole  argument  by  saying,  that 
whatever  be  the  age  of  your  patients  you  ought  always  to  give  them  the 
chance  of  being  saved  by  tracheotomy,  when  there  is  no  special  or  absolute 
contraindication.  Should  the  performance  of  the  operation  be  difficult,  in 
consequence  of  narrowness  of  the  trachea,  from  shortness  or  fatness  of  the 
neck,  be  assured  that  by  operating  slowly,  and  in  accordance  with  my  pre- 
cepts, you  will  be  enabled  to  surmount  all  the  little  obstacles  originating 
in  these  conditions. 


LECTURE  XXI. 

THRUSH. 

Synonyms. — Micrographists  regard  it  as  a  Mycelium. — Arises  from  Modifica- 
tion of  the  Secretion*  produced  by  Inflammation  of  the  Mouth. — In 
Adults,  i<  met  with  in  advanced  stage  of  nearly  all  Chronic  Diseases. — - 
Accompanies  Intestinal  Derangement. — In  Children,  supervenes  also  in 
Discuses,  which,  regard  being  had  to  the  Age  of  the  Subject,  may  be  con- 
sidered Chronic. — Indicates,  irrespective  of  the  cans,,  a  general  state  of 
Inanition. —  When  purely  Local,  is  Not  a  Serious  Affection. — Mixed 
Thrush. — The  Mouldy  Eruption  of  Thrush  may  become  developed  on 
any  Mucous  Membrane  covered  with  Epithelium  in  which  Secretion  is 
Altered. —  The  Different  Erythematous  Affections  which  Accompany  it 
depend  upon  a  General  State  of  the  System. —  Treatment:  TTu 
Lesion  is  Easily  Destroyed. — Necessary  to  Continue  ih<  Ust  of  Topical 
Agents  for  some  days  after  tht  Disappearance  of  Thrush  to  Modify  the 
Inflamed  State  of  the  Mucous  Membrane. — Same  Treatment  is  Applicable 
to  the  Cutaneous  Lesions. —  When  Thrush  depends  on  a  General  Condi- 
tion of  the  System,  the  Treatment  must  be  directed  to  the  removal  of  the 
Causes  of  that  Condition. 

Gentlemen:  A  woman,  who  had  been  confined  a  fortnight  previously 
in  the  Lariboisiere  Hospital,  was  admitted  to  bed  No.  1"  of  St.  A_ 
Ward.  She  had  left  that  hospital  perfectly  re-established  in  health,  and 
came  t"  the  H6tel-Dieu  with  her  infant,  whom  she  did  not  wish  to  nurse, 
being  in  this  respect  like  too  many  other  women.  The  pour  infant  was 
dying  from  hunger,  and  in  a  deplorable,  utterly  hopeless  state.  You  have 
seen  confluent  thrush  covering  the  mucous  membrane  of  the  mouth.  I 
avail  myself  of  the  opportunity  afforded  by  tin-  case  of  speaking  to  you  of 
this  disease,  which,  in  pathological  treatises,  is  confounded  with  plastic 
affections,  though  it  has  but  a  remote  analogy  to  them. 

Thrush  [muguet,  blanchet]  is  an  affection  characterized  by  the  presence 
of  small  granular  masses,  which  at  first  are  transparent,  but  soon  acquire 
a  dull  white  color :  they  aredeveloped  on  the  surface  of  mucous  membranes, 
particularly  <»n  that  of  the  mouth  :  they  generally  first  -how  themselves  on 
the  tiji  and  edges  of  the  tongue,  and  at  other  times  on  the  labial  commissure 
and  inside  of  the  lips,  as  well  as  on  the  inside  of  the  cheeks.  The  millet) 
seed  rash  [le  millet] — for  so  the  affection  is  still  designated  —also  appears  on 
the  veil  of  the  palate,  tonsils,  and  pharynx.     The  individual  miliary  con- 


THRUSH.  435 

cretions,  by  increasing  in  number,  form  irregular  patches  varying  in  extent 
and  thickness,  of  a  creamy-white  color  and  caseous  consistence,  suggesting 
the  idea  of  a  layer  of  coagulated  milk.     Sometimes  they  have  a  yellowish, 

and  at  other  times  a  gray  tint,  in  which  latter  case  there  is  a  possibility 
of  their  being  mistaken  for  diphtheritic  deposits. 

Whatever  may  he  the  seat  and  extent  of  the  affection,  it  is  only  developed 
on  mucous  membranes,  which,  when  in  a  normal  state,  are  paved  with  epi- 
thelium. It  is  never  found  in  the  nasal  fossae;  and  when  it  invades  the 
pharynx,  it  stops  short  at  the  posterior  orifice  of  these  cavities.  When  it 
covers  the  epiglottis,  and  the  aryteno-epiglottidean  folds,  it  never  penetrates 
into  the  larynx.  If  it  reach  the  oesophagus,  it  never  proceeds  to  the  intes- 
tine; for,  as  yon  know,  the  epithelial  pavement  of  the  upper  portion  of  the 
digestive  canal  stops  at  the  cardiac  orifice  of  the  oesophagus. 

Thrush  was  formerly  called  aphthes  con-fluents,  aphthae  confluences,  aphthae 
lactantiwn,  and  aphtha  infanMles.  No  names  could  be  more  objectionable, 
for  the  affection  has  not  the  least  resemblance  to  aphthae.  In  thrush  we 
meet  with  no  vesicles,  papules,  nor  ulcerations,  not  at  least  in  the  first  state 
of  the  affection  ;  and  the  difference  between  thrush  and  aphthae  is  as  wide 
as  that  between  scarlatina  and  small-pox.  The  terms  w/uguet  and  blanchet 
are  much  to  be  preferred  to  aphthes,  for  they  do  not  imply  any  opinion  as 
to  the  nature  of  the  affection :  they  refer  to  the  aspect  of  the  lesion  which 
they  characterize,  an  aspect  which  has  been  justly  compared  to  a  little  white 
flower  of  powerful  perfume,  the  lily  of  the  valley  [muguef]  convallaria  maialis, 
which,  iu  May,  blossoms  in  our  woods,  and  which  all  of  you  know. 

Thrush,  then,  is  chiefly  an  affection  of  the  buccal  mucous  membrane.  It 
is  sometimes  a  purely  local  affection,  but,  at  other  times,  it  is  the  sign  of  a 
particular  condition  of  the  general  system. 

When  infants  are  obliged  to  make  violent  efforts  in  sucking,  from  the 
nipple  being  too  small  or  not  well  formed ;  when  they  have  to  suck  those 
linen,  leather,  or  caoutchouc  contrivances  used  by  women  whose  nipples  are 
chapped  or  too  short ;  or  when,  being  artificially  nourished,  they  have  sucked 
the  hard  orifices  of  feeding-bottles,  their  mouths  very  soon  become  the  seat 
of  an  inflammation  which  leads  to  a  fibrinous  exudation,  upon  which  the 
sporules  of  thrush  are  developed. 

Till  the  microscope  came  to  our  assistance  in  the  study  of  pathological 
lesions,  it  was  believed  that  the  whitish  concretions  of  thrush  were  entirely 
composed  of  fibrin  deposited  in  very  fine  layers  upon  an  inflamed  mucous 
membrane,  and  that  the  affection  was  of  the  plastic  character.  The  micro- 
scope, however,  has  demonstrated  that  the  characteristic  element  of  thrush 
is  a  cryptogamicplant  similar  to  the  sporotritium,  according  to  M.  Gruby ; 
or  a  mycelium,  the  oidium  albicans,  according  to  M.  Charles  Robin,*  con- 
sequently a  mould  similar  to  that  which  forms  on  milk,  as  well  as  on  organic 
animal  and  vegetable  substances.  This  is  a  point  regarding  which,  at  the 
present  day,  no  doubt  can  exist.  It  is  equally  a  matter  of  certainty  that, 
for  the  development  of  this  mycelium,  special  conditions  are  requisite  :  there 
must  be  a  pre-existing  inflammation  of  the  mucous  membrane  on  which  it 
is  seated,  and  that  inflammation  must  have  a  somewhat  specific  character. 

When  there  is  inflammation  of  the  mucous  membrane  of  the  vagina, 
the  mucous  secretion  resulting  therefrom  contains  animalcules  of  a  particular 
kind,  which  are  more  or  less  numerous  according  to  the  greater  or  less  severity 
of  the  inflammation.  It  does  not  follow  that  the  inflammation  is  the  result 
of  the  presence  of  the  animalcules :  it  only  shows  that  the  muco-purulent 
secretion,  in  undergoing  alteration,  becomes  possessed  of  qualities  in  virtue 

*  Eobin  (Charles)  :  Histoire  Naturelle  des  Vegetaux  Parasites.     Paris,  1853. 


436  THRUSH. 

of  which  animalcules  are  developed.  Something  takes  place  analogous  to 
that  which  occurs  in  milk.  When  milk  is  pure  it  is  impossible  to  discover 
in  it  any  extraneous  animal  or  vegetable  product ;  but  if  it  be  allowed  to 
get  sour  its  constitution  becomes  modified,  and  then  there  is  developed  in  it 
an  infinite  number  of  microscopic  animalcules  which  have  their  place  in 
the  nosological  scale. 

The  first  condition,  then,  required  for  the  development  of  thrush  is  the 
presence  of  a  special  secretion,  and  that  secretion  is  necessarily  a  product  of 
inflammation.  Even  micrographers  do  not  dispute  this  fact ;  for  they  admit 
that  a  fibrinous  substance  constitutes  the  greater  portion  of  the  granular 
bodies  of  thrush,  and  that  the  mycelium  is  a  secondary  element. 

Such  being  the  state  of  the  case,  it  is  of  very  little  importance,  looking 
at  the  question  from  a  clinical  point  of  view,  whether  thrush  be  a  vegetable 
parasite  originating  under  certain  special  conditions,  and  in  accordance 
with  the  laws  of  the  so-called  spontaneous  generation  of  an  inferior  order 
of  organized  beings;  or  whether  it  is  an  animal  substance  composed  of 
fibrin  and  muco-pus.  Is  it  not,  whether  we  adopt  the  one  theory  or  the 
other,  a  pathological  product,  originating  in  a  morbid  condition  of  the 
persons  in  whom  it  is  found?  Does  the  settlement  of  this  question  affect 
the  aspect  of  the  affection,  the  nature  of  the  malady,  or  its  symptomatic 
manifestations?  Assuredly  not.  Neither  does  it  affect  the  treatment;  for 
it  matters  very  little  to  the  physician  whether  he  has  to  do  with  a  mush- 
room or  a  false  membrane,  as  experience  has  put  him  in  possession  of  sure 
means  of  curing  the  patient :  and  his  highly  scientific  views  upon  the 
mooted  point  have  proved  useless  to  him.  Far  be  it  from  me,  however, 
gentlemen,  to  disparage  the  service  which  micrographers  have  rendered  to 
nosology;  but  on  the  other  hand,  it  would  be  wrong  to  exaggerate  the  bear- 
ing and  practical  utility  of  their  discoveries. 

Under  what  conditions  does  thrush  supervene?  In  the  first  place,  let  us 
see  in  what  circumstances  it  occurs  in  adults  f  It  supervenes  in  all  chronic 
maladies,  in  pulmonary  phthisis,  pleurisy,  chronic  peritonitis,  and  affec- 
tions which  are  generally  under  the  influence  of  the  tubercular  diathesis  : 
it  supervenes  in  chronic  diarrhoea,  which  is  often  related  to  this  same  dia- 
thesis:  it  supervenes  in  those  cancerous  diseases  of  the  stomach  and  intes- 
tines which  give  rise  to  exhausting  intestinal  fluxes:  it  likewise  supervenes 
in  persons  wasting  from  profuse  and  long-continued  suppuration.  Thrush 
also  develops  itself  at  the  close  of  hectic  maladies:  it  is  then  a  prog- 
nostic of  the  very  worst  character.  When  chronic  maladies  have  arrived 
at  their  last  stage,  nausea,  vomiting,  and  diarrhoea  testily  to  the  existing 
disturbance  of  the  digestive  function:  the  mucous  membrane  of  the  stomach 
and  intestines  has  then  been  attacked,  and  is  (he  seat  of  morbid  modifica- 
tions: the  mucous  membrane  of  the  mouth,  participating  in  these  anatomi- 
cal  and    functional    disturbances,    becomes   subject    to   an   alteration    in    its 

secretions,  and  thus  a  condition  is  produced  favorable  to  the  developmenl 

of  thrush.  The  local  affection,  then,  is  entirely  dependent  upon  a  serious 
lesion  of  the  digestive  apparatus,  a  lesion  too  which  is  itself  the  sign  of  a 
still  more  serious  lesion  of  the  general  system.  Finally,  I  repeal  the  prop- 
osition, that,  however  we  may  explain  it.il  is  a  fact  that  when  thrush 
supervenes  at  the,  close  of  chronic  diseases,  it  is  generally  a  prognostic  that 

dissolution  is  near. 

In  children,  thrush  is  observed   under  similar  circumstances.     In  them 

also,  it,  is  in  diseases  of  long  duration  that  it  appears:  here,  however,  dura- 
tion is  a  term  relative  to  the  age  of  the  subjects,  for,  a  disease  which  lasts 
eight,  or  ten  days  is  a  long  disease  in  one  whose  age  is  only  fifteen  days.  It 
is  in  infants  of  a  few  days  old  or  in  children  in  the  first  months  of  their  exist- 


THRUSH.  437 

ence,  who  have  been  affected  for  some  time  with  affections  of  the  digestive 
function  or  with  a  disease  of  the  skin  or  respiratory  apparatus,  that  we 
find  thrush  becoming  developed.  In  them,  as  in  the  adult,  it  is  the  local 
expression  of  a  very  had  state  of  the  whole  system.  Usually,  this  bad 
general  condition  is  the  result  of  improper  alimentation,  or  to  speak  more 
correctly,  of  inanition,  which  is  the  final  consequence  of  malnutrition. 

The  defect  in  diet  may  possibly  be  in  itself  absolute,  as  I  have  too  often 
seen ;  or  the  infants  may  be  fed  with  aliment  quite  unsuited  to  their  diges- 
tive organs  ;  as  for  example,  when  in  place  of  getting  the  milk  of  women, 
or  at  least  of  cows,  they  are  gorged  at  a  very  early  age  with  boiled  meat, 
meat  broths,  and  vegetables  passed  through  the  cullender,  a  practice  which 
we  see  perpetrated  by  nurses,  and  even  by  mothers  devoid  of  intelligence 
or  under  the  dominion  of  stupid  prejudices.  When  thus  undergoing  prem- 
ature weaning,  the  poor  infants  are  attacked  with  gastric  and  intestinal 
affections,  regarding  which,  on  a  future  occasion,  I  shall  have  to  speak  to 
you,  and  under  the  influence  of  which  thrush  is  developed. 

But  the  defect  in  alimentation — in  this  particular  case  we  must  say  the 
malassimilation — may  depend  upon  an  original  and  direct  lesion,  or  on  a 
sympathetic  disorder  arising  during  the  course  or  the  beginning  of  some 
other  disease,  such  as  erysipelas  or  pneumonia ;  or  also  in  the  course  of 
scleremia,  that  disease  peculiar  to  new-born  infants,  which  is  characterized 
by  great  debility,  and  in  particular  by  induration  of  the  skin  and  cellular 
tissue  of  the  extremities,  extending  sometimes  to  the  trunk,  and  in  which 
oedema  and  swelling,  one  or  both,  may  be  either  present  or  absent. 

Thrush,  therefore,  being  the  local  manifestation  of  a  serious  general  affec- 
tion of  the  system,  it  ceases  to  be  matter  of  surprise  that  so  excellent  an 
observer  as  the  late  Dr.  Valleix  asserted  that  it  was  so  formidable  that 
twenty  of  every  twenty-two  patients  who  had  it  died  from  it.*  Valleix 
collected  at  the  Children's  Hospital  the  dismal  statistics  on  which  he  based 
this  opinion:  the  subjects  observed  by  him  were  children  abandoned  by 
their  mothers,  and  almost  in  every  case  dying  from  hunger,  suffering  for 
the  most  part  from  inflammatory  affections,  generally  from  affections  of 
the  stomach  and  intestines.  Now,  in  such  cases,  thrush  is  the  herald  of 
the  near  approach  of  death ;  but  it  is  the  disease  during  the  course  of  which 
thrush  has  supervened,  and  not  the  supervening  thrush  which  carries  off 
the  patient. 

Gentlemen,  the  first  form  of  thrush  to  which  I  have  referred  has  no 
prognostic  significance  :  it  is  simply  a  local  affection.  It  has  no  import  in 
the  least  degree  serious,  and  remains  confined  to  the  parts  in  which  it  origi- 
nally appeared  :  this  is  the  only  form  of  the  affection  which  those  physi- 
cians have  had  in  view7,  who  have  maintained,  in  opposition  to  Valleix, 
that  thrush  is  one  of  the  mildest  of  maladies.  As  I  stated  at  the  begin- 
ning of  this  lecture,  when  an  infant  encounters  difficulty  in  sucking,  whe- 
ther that  difficulty  arise  from  the  nipple  of  the  breast  being  badly  formed, 
or  whether  it  proceed  from  sucking  a  hard  teat  attached  to  a  feeding-bottle, 
or  an  artificial  nipple,  it  is — under  an  epidemic  influence  of  which  Ave  know 
nothing — seized  with  inflammation  of  the  mucous  membrane  of  the  mouth, 
in  other  respects  the  general  health  remaining  good :  this  stomatitis  forth- 
with gives  rise  to  thrush,  which  will  generally  be  very  transient,  and  not 
troublesome.  But  should  this  form  of  thrush  become  confluent,  if  the 
patches  which  form  are  very  thick  in  their  substance,  and  very  large,  they 
cause  considerable  embarrassment  in  sucking,  an  embarrassment  of  which 


*  Valleix  :  Clinique  des  Maladies  des  Enfants  Nouveau-nes,  chap.  iii.     Paris, 
1838.     See  also  the  same  author's  "  Guide  du  Medecin." 


438  THRUSH. 

the  infant  gives  evidence  by  making  a  ceaseless  chewing  movement  with 
the  jaw,  and  almost  incessantly  protruding  the  tongue.  This  embarrass- 
ment will  be  increased  by  the  pain  which  the  infant  suffers  from  the  acute 
inflammation  of  the  tongue  and  mouth.  From  the  important  part  which 
the  tongue  plays  in  the  action  of  sucking,  you  can  understand  why  an  infant 
with  an  inflamed  tongue  will  refuse  to  suck :  you  can  also  understand  that 
although  idiopathic  thrush  is  in  itself  a  mild  affection,  it  may  become, 
under  certain  circumstances,  the  starting-point  of  a  formidable  disease  :  by 
rendering  alimentation  difficult  or  perhaps  impossible,  it  may  be  the  indi- 
rect cause  of  the  patient's  death.  Such  cases,  however,  are  altogether 
exceptional.  I  must,  therefore,  still  maintain  the  proposition  that  idio- 
pathic thrush  is.  strictly  speaking,  not  a  disease,  but  simply  a  slight  and 
transient  local  affection.  One  who  understands  the  right  treatment  can 
generally  master  the  affection  in  twenty-four,  thirty-six,  or  forty-eight 
hours,  or  at  least  in  three  or  four  days.  Infants  very  quickly  begin  to 
take  the  breast  as  before,  and  return  to  perfect  health,  when  the  transient 
disorder  of  the  mouth  has  passed  away. 

There  is  another  kind  of  thrush  which  requires  to  be  distinguished  from 
those  which  I  have  already  described,  and  to  which,  if  I  may,  I  propose 
to  give  the  name  of  mixed  thrush  [muguet  mixte].  The  affection  of  the 
mouth  in  which  it  originates,  and  which,  in  the  first  instance,  was  alone 
present,  is  simply  the  earliest  manifestation  of  a  general  condition  under 
the  influence  of  which  it  is  produced.  Symptoms  of  a  more  or  less  serious 
character  connected  with  the  stomach  and  bowels  supervene,  showing  that 
mischief  exists  of  so  formidable  a  character,  as  to  lead  to  a  general  derange- 
ment of  the  whole  system  in  very  young  children.  Indeed,  it  is  not  un- 
common to  see  new-born  infants,  who  at  first  seemed  only  to  have  stoma- 
titis along  with  thrush,  very  soon  afterwards  seized  with  vomiting  and  diar- 
rhoea, accompanied  by  erythema  of  the  buttocks,  which  I  pointed  out  to 
you  in  our  little  patient  who  lies  in  bed  2so.  16.  The  state  of  phlegmasia, 
or  if  you  prefer  the  term,  the  pathological  state  (for  perhaps  I  am  wrong 
in  making  use  of  the  term  phlegmasia,  since  inflammation  really  exists 
that  pathological  condition  occupies  the  entire  continuity  of  the  digestive 
canal  from  the  mouth  to  the  extreme  end  of  the  passage.  In  the  mouth, 
you  see  the  mucous  membrane  stripped  of  its  epithelium,  of  a  more  or  less 
vivid  red  color,  and  the  surface  of  the  denuded  dermis  covered  with  char- 
acteristic concretions,  distinct  on  the  upper  surface  of  the  tongue,  and  con- 
fluent 'forming  caseous  patches')  upon  its  under  surface  and  on  the  inside 
of  the  cheeks.  On  the  buttocks,  likewise,  the  skin  is  of  a  bright  red,  and 
in  -Mine  places  .-tripped  of  its  epidermis.  <  m  the  skin  and  on  the  mucous 
membrane,  the  lesion  is  the  same  in  kind ;  but  a<  there  is  no  secretion  from 
the  -kin,  to  cause  the  developmenl  of  mycelium,  you  will  then'  only  find 
a  trace  of  phlegmasia;  whereas  from  the  mucous  secretion  offering  condi- 
tions favorable  to  the  generation  of  oidium,  the  mucous  membrane  of  the 
mouth  simultaneously  prc.-ents  the  lesions  which  indicate  inflammation, 
and  the  production  of  the  peculiar  deposit  on  which  the  thrush  is  de- 
veloped. 

Tin-  child  on  who—  case  I  am  now  lecturing  is  affected  with  that  kind  of 
thrush.  It  is  in  him.  in  point  of  fact,  the  first  manifestation  of  a  very  serious 
general  condition  of  the  system,  under  the  influence  of  which  the  inflamma- 
tion of  the  month  has  originated.     This  child  does  not  .-nek,  and  although 

he  has  -till  all  the  appearance  of  g 1  health,  his  life  is  in  great  jeopardy. 

From  want  of  proper  alimentation  the  blood,  no  longer  receiving  its  repara- 
tive materials, becomes  impoverished, and  its  secretions  are  necessarily  altered 
in  character.     Th  •  organs,  whose  function  it  is  to  eliminate  from  the  bl 1 


THRUSH.  439 

the  elements  of  these  secretions,  must  in  consequence  undergo  a  special 
pathological  modification  possessing  all  the  characters  of  inflammation. 
Tin-  mucous  membrane  of  the  mouth  was  first  attacked,  and  that  of  the 

Stomach  and  intestines  will  be  affected  next  in  turn,  although  as  yet  the 
ease  seems  to  be  nothing  more  than  thrush,  that  is  to  say,  nothing  more 
than  an  unimportant  local  affection  if  looked  at  by  itself:  the  child  is  never- 
theless inevitably  doomed  to  die  within  a  very  brief  interval,  unless,  with 
all  possible  speed,  measures  be  taken  to  supply  it  with  the  nutriment  of 
which  it  is  in  need. 

Here,  then,  gentlemen,  are  the  three  kinds  of  thrush  which  ought,  in  my 
opinion,  to  be  recognized.  First :  there  is  thrush  occurring  in  infants  as  a 
purely  local  affection,  depending  upon  irritation  of  the  mouth,  more  or  less 
acute  in  character,  and  longer  or  shorter  in  its  duration.  It  is  not  accom- 
panied by  any  symptoms  affecting  the  general  system,  nor  is  it  more  than 
an  insignificant  malady,  although,  in  a  few  very  exceptional  cases,  it  may 
be  the  cause  of  serious  mechanical  obstacles  to  due  alimentation.  Second  : 
there  is  that  kind  of  thrush  which  supervenes  both  in  adult  and  child,  as 
the  sequel  of  a  severe  attack  of  disease,  appearing  as  the  final  manifestation 
of  some  serious  disorder  to  which  the  system  has  been  subjected.  Third : 
there  is  thrush  showing  itself  as  the  first  manifestation  of  a  severe  constitu- 
tional disorder,  the  other  symptoms  of  which  are  not  long  in  following. 
You  can  perfectly  appreciate  the  differences  which  exist  between  the  second 
species  of  thrush  and  that  which  I  call  the  mixed  [mixte]  form  of  the  affec- 
tion. 

Valleix  attached  great  importance  to  erythema  of  the  buttocks,  which  he 
regarded  as  present  in  almost  every  case,  and  as  one  of  the  earliest  observed 
svmptoms  of  thrush  in  children.  This  erythema  is  more  or  less  extended : 
sometimes  it  invades  the  thighs,  the  posterior  and  inner  aspects  of  the  legs, 
the  scrotum,  aud  the  labia  majora :  the  redness  varies  between  a  bright  red 
and  a  brownish-red.  The  skin  is  often  excoriated,  and,  in  some  rare  cases,  it 
becomes  scarred  with  pretty  deep  ulcerations.  The  erythematous  redness 
and  the  ulcerations  show  themselves  likewise  on  the  heels  and  malleoli. 
It  would,  however,  be  a  mistake  to  consider  them  as  symptoms  of  thrush. 
Cutaneous  inflammations  originate  in  the  same  causes  as  the  inflammation 
of  the  mouth  which  gives  rise  to  thrush.  The  two  affections  are  similar  in 
respect  of  their  cause,  but  neither  of  them  in  any  way  dominates  over  the 
other. 

In  the  majority  of  cases  the  erythema  is  the  result  of  the  irritation  pro- 
duced in  the  affected  parts  by  the  contact  of  urine  and  fecal  matter,  and 
the  friction  of  these  parts  with  the  swaddling-clothes  of  the  infant:  this 
explains  why  the  erythematous  inflammation  is  met  with  particularly  in 
the  shins  and  heels,  and  why  it  is  more  decided,  and  why  it  more  commonly 
proceeds  to  inflammation  in  these  parts.  They  are  the  parts  subjected  to 
the  most  energetic  and  constant  friction,  from  the  child  ceaselessly  moving 
the  legs  and  rubbing  his  heels  against  one  another,  and  against  the  swad- 
dling-bands in  which  the  malleoli  are  wrapped.  You  will  see  redness  of 
the  buttocks  and  inferior  extremities  in  the  healthiest  infants,  particularly 
in  those,  of  whom  we  receive  too  many  in  the  hospitals,  more  or  less  neglected 
in  respect  of  cleanliness,  and  swaddled  in  coarse  linen.  Erythematous  red- 
-  -howing  itself  independently  of  thrush  may  be  regarded  as  a  first 
degree  of  the  erythema  which  accompanies  that  affection :  it  enables  us  to 
understand  the  mechanical  causes  of  the  erythema  of  thrush,  though  there 
is  this  difference,  as  I  have  already  remarked,  that  in  the  erythema  of  thrush 
there  exists  a  general  cause,  as  well  as  one  which  is  local  and  mechanical. 

Here  the  same  thing  takes  place  as  occurs  in  persons  suffering  from  putrid 


440  THRUSH. 

fever  or  any  other  septic  disease.  Seeing  that  an  individual  who  has  sus- 
tained an  injury,  a  fracture  of  the  thigh-bone  for  example,  but  who  in  other 
respects  is  in  good  health,  cannot  remain  on  his  back  for  fortv-five  days 
without  having  some  redness  of  the  buttocks,  it  is  obvious  that*  much  less 
time  will  be  necessary  for  a  patient  with  typhoid  fever  not  only  to  have 
erythematous  redness,  but  even  excoriations  and  gangrenous  ulcerations  of 
greater  or  less  depth  over  the  sacrum,  the  ischiatic  tuberosities,  the  heels, 
or  any  of  the  bony  projections  subject  to  pressure  or  friction.  This  arises 
from  the  fact  that  independent  of  pressure  or  friction,  independent  of  irri- 
tation produced  by  the  contact  of  urine  or  fseces,  there  exists  deficient 
vitality  of  the  skin,  and  a  remarkable  tendency  to  sphacelus,  which  is  one 
of  the  characters  of  that  condition  conventionally  called  putridity  in  severe 
fevers,  and  is  one  of  the  consequences  of  inanition. 

There  is,  I  repeat,  a  similar  state  of  matters  in  the  erythema  and  ulcer- 
ations of  children  affected  with  thrush.  There  exist,  both  in  the  erythema 
and  ulcerations,  and  in  the  thrush,  manifestations  of  the  bad  general  state 
of  the  individual's  system ;  but  the  two  have  not  that  mutual  relation  to 
each  other  which  Valleix  wished  to  establish.  : 

Without  dilating  more  on  these  questions,  I  now  come  to  the  subject  of 
treatment. 

When  thrush  is  a  purely  local  affection,  it  is  easily  cured  ;  all  that  is 
required  is  the  use  of  borax-honey.  This  preparation,  according  to  the 
formula  which  I  employ,  is  composed  of  equal  weights  of  borax  and  honey — 
of  each  10  grammes  [loo  grains].  The  whole  of  the  interior  of  the  infant's 
mouth  ought  to  be  smeared  with  this  mixture  seven  or  eight  times ;  and  if 
this  be  done,  it  will  generally  be  found,  at  the  end  of  twentv-four  or  forty- 
eight  hours,  that  the  malady  is  gone.  Possibly,  some  of  the  salve  may  be 
swallowed  by  the  patient;  but  from  that  no  great  inconvenience  ran  arise, 
as  borax  is  no  more  injurious  to  the  economy  than  bicarbonate  of  soda; 
there  may  even  be  an  advantage  in  the  occurrence,  should  the  thrush  have 
reached  the  lower  portions  of  the  pharynx  and  oesophagus,  by  the  salve 
there  producing  a  beneficial  effect.  The  topical  application  winch  I  have  now 
described  is  in  such  general  use  in  my  wards,  that  the  nurses  frequently  do 
not  wait  for  the  arrival  of  the  physician  to  commence  the  treatment  of 
children  brought  in  with  thrush.  Consequently,  it  often  happens  that  in 
the  morning  I  see  little  patients, .who  had  been  admitted  with  thrush  on 
the  preceding  afternoon,  who  were  quite  cured  of  it  in  a  tew  hours. 

It  is  necessary,  however,  gentlemen,  to  continue  the  treatment  even  after 
the  disappearance  of  the  thrush,  because  there  still  remains  a  necessity  to 
cure  tiie  inflammation  of  the  mucous  membrane  of  the  mouth,  under  the 
influence  of  which  the  affection  was  developed:  unless  that  inflammation  is 
modified,  the  thrush  which  went  away  so  quickly  will  be  certain  to  reap- 
pear. 

Chlorate  of  potash  may  he  substituted  lor  borax,  the  quantity  ami  the 
method  of  employing  it  being  the  same.  I  must  say.  however,  that  it  has 
never  seemed  to  me  to  ad  BO  rapidly  a-  borax. 

Should  thrush  n-i-i  the  action  of  these  modifying  agents,  there  remains 
another  to  be  employed  which  it  never  resists;  that  is  nitrate  of  silver.  A 
weak  solution,  a  solution  in  the  proportion  of  one  gramme  of  the  salt  | '1  •">.'. 
grains]  to  ten  grammes  of  distilled  water,  1  consider  preferable  to  the  solid 
caustic,  because  it  is  easier  to  touch  all  the  little  folds  of  the  buccal  mucous 
membrane  with  a  hair  pencil  than  with  a  stick  of  lunar  caustic.  Perhaps 
the  solution  of  the  nitrate  of  silver  is  to  this  extenl  objectionable,  thai  if 


Vai.lkix:  Olinique  des  Maladies  des  Enfanta  Nouveau-nes.     Paris,  L888. 


THRUSH.  441 

the  child  swallowed  some  of  it,  nausea  or  even  vomiting  might  be  the  con- 
sequence; but  these  inconveniences,  Which  after  all  are  not  very  serious, 
may  be  averted  by  injecting  water  into  the  mouth  after  the  use  of  the  solu- 
tion.    In  the  adult,  the  blackening  of  the  teeth  is  an  additional  drawback 

to  the  nitrate  of  silver.  When,  therefore,  in  adults,  thrush  does  not  yield 
to  salves,  or  washes  of  borax,  or  chlorate  of  potash,  recourse  must  be  had 
to  cauterizations  with  solutions  of  sulphate  of  zinc  or  sulphate  of  copper, 
in  the  proportion  of  ten  parts  (by  weight)  of  the  salt  to  one  of  water,  the 
patients  being  recommended  to  rinse  the  mouth  and  spit  immediately  after 
the  operation. 

The  local  affection  is  cured  !  If  it  had  alone  existed,  nothing  more 
would  remain  to  be  done;  and  the  infant  would  resume  taking  the  breast. 
But  when  the  local  affection  is  under  the  dominion  of  a  peculiar  state  of 
the  system,  it  will  not  be  long  in  reappearing,  whatever  you  may  do ;  or  at 
least  you  will  require  constantly  to  repeat  the  application  of  the  means  by 
which  you  seek  to  destroy  it.  I  need  hardly  say  that  this  end  is  unattain- 
able in  persons  who  have  phthisis  or  cancer,  or  who  have  arrived  at  the  last 
stage  of  an  attack  of  a  bad  fever,  or  are  the  subjects  of  hectic  fever. 

In  infants,  when  thrush  is  connected  with  a  bad  state  of  system  de- 
pendent on  malnutrition;  no  time  must  be  lost  in  providing  them  with  good 
wet-nurses.  In  families,  mothers  very  often  wish  to  have  the  pleasure  of 
suckling  their  children,  even  when  from  delicate  health  they  do  not  possess 
the  essential  conditions  of  a  good  nurse.  Their  infants,  from  sucking  empty 
breasts  or  only  getting  very  poor  milk,  soon  begin  to  pine  and  to  become 
affected  with  thrush.  However  much  displeasure  you  may  give  to  a  mother 
to  whom'  to  continue. the  suckling  of  her  infant  would  be  a  great  delight, 
do  not  hesitate  to  use  your  authority.  It  is  one  of  those  occasions  upon 
which  the  physician  must  speak  with  imperious  authority,  so  as  to  bear 
down  all  the  opposition  which  his  opinions  may  meet  with  from  the  family. 
Set  forth  the  danger  which  is  being  incurred  by  the  patient  confided  to  you, 
and  insist  with  all  your  power  on  the  absolute  necessity  of  action  being 
taken  in  accordance  with  your  demands. 

Reparative  aliment — and  woman's  milk  is  the  best  and  most  suitable 
food  for  infants — may  of  itself  prove  sufficient  by  restoring  the  infant  to 
health,  to  prevent  the  reappearance  of  the  thrush  which  the  topical  reme- 
dies have  cured  for  the  time  being.  If  there  exist  erythema  of  the  but- 
tocks, or  ulceration  of  the  shins  and  heels,  you  are  then  in  a  position  to 
contend  against  them  advantageously.  This  may  be  done  by  powdering 
the  affected  parts  with  white  bismuth.  If  that  fail,  employ  a  mixture  of 
powdered  starch  and  white  precipitate.  If  still  the  cure  progresses  slowly, 
prescribe  lotions  of  eau  phagedenique*  and  touch  the  ulcerated  points  with 
a  weak  solution  of  sulphate  of  copper. 

When  thrush  is  connected  with  disordered  digestion  in  an  infant  whose 
feeding  is  suitable,  the  treatment  must  be  directed  to  that  disordered  diges- 
tion and  the  associated  gastro-intestinal  phlegmasia.  On  a  future  occasion, 
gentlemen,  I  shall  return  to  this  important  question ;  but  to-day  I  may 
mention  that  in  the  treatment  of  such  cases  much  benefit  is  obtained  from 
the  use  of  alkaline  preparations.  Prepared  chalk  rubbed  up  with  syrup, 
and  given  to  the  infant  before  sucking  five  or  six  times  a  day,  in  doses  of 
from  25  to  30  centigrammes  [from  3f  to  4|  grains],  and  lime-water  in 
doses  of  from  40  to  60  grammes  [about  from  1^  to  2  fluid  oz.],  have  often,  in 

*  The  eau  phagedenique  is  a  solution  of  hydrochlorate  of  lime,  holding  suspended 
binoxide  of  mercury,  which  gives  it  its  yellow  color.  It  is  prepared  by  pouring  an 
aqueous  solution  of  eight  grains  of  corrosive  sublimate  into  four  ounces  of  lime- 
water. — Translator. 


442  SPECIFIC    ELEMENT    IN    DISEASE. 

my  practice,  rendered  real  service.  White  bismuth  is  also  indicated  in 
doses  of  from  2  to  4  grammes  [31  to  62  grains]  ;  when  the  powder  is  thor- 
oughly mixed  up  with  sugar,  children  take  it  easily.  It  is  of  paramount 
importance  to  regulate  the  diet,  so  that  the  infant  may  have  the  breast 
with  as  much  regularity  as  possible  every  two  hours. 

The  statistical  results  published  by  Valleix  are  appalling:  but  you  must 
bear  in  mind  that  you  will  be  more  fortunate  in  your  private  than  we  are 
in  our  hospital  practice  ;  for  you  will  rarely  meet  with  patients  so  unfavor- 
ably placed  as  the  wretched  children  who  from  the  very  nature  of  things 
come  to  die  in  our  establishments.  Exhausted  by  the  misery  and  pro- 
tracted starvation  to  which  they  have  been  subjected  by  the  persons  who 
abandon  them,  they  sink,  notwithstanding  all  the  attentions  by  which  they 
are  surrounded.  In  such  cases,  the  non-success  of  treatment  must  not  be 
imputed  to  the  want  of  skill  in  the  physicians,  but  to  the  deplorable  hygi- 
enical conditions  to  which  the  patients  have  been  subjected. 


LECTURE  XXII. 

SPECIFIC  ELEMENT  IN  DISEASE. 

The  Specific  Element  is  Dominant  through  out  the  whole  of  Medicine. — Dicho- 
tomic Doctrines  of  Brown  and  Broussais. — Diseases  havi  Certain  Charr 
acters  in  Common,  and  also  Individual  or  Specific  Characters. — Specific 
Causes. — Specific  Symptoms. — Knowledge  of  Specific  Character  applied 
to  Diagnosis,  Prognosis,  and  Treatment. 

Gentlemen:  The  eruptive  fevers  are  the  most  typical  examples  of 
specific  diseases.  Before  proceeding  any  farther  in  the  study  of  the  cases 
which  we  are  observing  together,  I  wish  to  pause  for  a  little  to  examine 
the  subject  of  specific  character  in  disease.  I  hope  to  be  able  to  show  you 
that  this  important  question  is  dominant  throughout  the  whole  of  pathology 
and  therapeutics — in  fact,  throughout  the  whole  of  medicine.  1  have  al- 
ready, in  former  lectures,  had  opportunities  of  bringing  this  subject  under 
your  notice.  In  practice,  you  will  find  it  confronting  you  at  every  step ; 
and  as  not  a  day  will  pass  without  your  hearing  me  refer  to  it  at  the  bed- 
sides of  the  patients,  I  must  endeavor  to  give  you  as  complete  an  idea  as 
possible  of  that  which  is  understood  by  the  term  specific,  when  applied  to 
diseases. 

Though  we  are  in  the  habit  of  saying  that  we  have  emancipated  our- 
selves from  the  yoke  imposed  by  the  doctrines  of  Brown  and  of  BroUSSais, 
we  really  are  still  under  their  influence  :  although  we  repudiate  them,  they 
are  re-echoed  in  our  medical  speculation-.,  and  in  the  very  language  we 
employ.  It.  therefore,  becomes  necessary  for  me  to  recall  to  your  recollec- 
tion the  errors  which  arc  embraced  in  these  doctrines.  However  much 
the  two  doctrines  may  he  opposed  to  each  other,  they  reel  on  a  common 
basis;  for  although  Broussais  was  the  great  antagonist  of  Brown,  he  never- 
theless derived  the  principles  of  his  physiology  from  the  pathological  sys- 
tem of  the  Scottish  reformer,  whose  incitability  differed  in  an  abstract  man- 
ner only  from  the  irritability  of  Broussais. 


SPECIFIC    ELEMENT    IN    DISEASE.  443 

Brown  said  that  life  was  maintained  by  incitanU:  Broussais  said  that  it 
was  maintained  by  stimulants. 

Their  physiological  theory  was  founded  on  this  assumption  ;  and  on  it 
likewise  was  based  their  pathological  hypothesis.  In  point  of  fact,  they 
both  held  that  there  was  only  one  morbid  cause,  the  excessive  or  unreason- 
able use  of  incitants  or  stimulants.  Difference  in  the  intensity  of  the  cause, 
and  difference  in  the  mode  of  the  reaction  of  the  economy  are,  they  said, 
the  sources  of  the  innumerable  diversities  of  form  presented  lty  diseases. 
This  is  their  common  starting-point;  for  here  "incitants"  and  "stimulants" 
are  two  absolutely  synonymous  words. 

Brown  said,*  and  Broussais  repeated  in  other  terms,  that  light  is  the 
natural  incitant,  or,  what  comes  to  the  same  thing,  the  natural  stimulant 
of  the  eve,  the  incitation  of  that  organ  being  vision  ;  that  food  is  the  natu- 
ral incitant  of  the  stomach,  the  result  of  the  incitation  of  which  is  diges- 
tion ;  that  the  assimilated  materials,  the  nutritive  juices,  are  the  natural 
incitants  of  different  organs,  whence  we  have  nutrition;  that  the  blood  is 
the  natural  incitant  of  the  organs  of  secretion,  whence,  for  example,  when 
the  kidneys  are  concerned,  we  have  the  urinary  secretion,  and  when  the 
seminal  glands  are  concerned,  the  spermatic  secretion.  While  Brown  and 
Broussais  held  that  the  cause  was  always  the  same,  varying  only  in  degree, 
they  could  not  avoid  admitting  the  existence  of  a  modifying  influence  in 
the  structure  of  individual  organs,  in  virtue  of  which  the  effects  of  stimu- 
lation are  different.  Their  assertion  that  everything  was  dependent  upon 
the  quantity  of  the  stimulus,  and  that  there  was  an  identity  in  the  condi- 
tion of  organs  in  all  persons,  was  a  denial  of  evident  facts.  Upon  their 
hypothesis,  how  can  diversity  of  effects,  that  is  diversity  of  functions,  be 
explained?  Does  not  their  hypothesis  involve  prodigious  absurdities,  ab- 
surdities quite  as  great  as  that  which  Recamier,  a  man  of  undoubted  talent, 
was  led  into — to  the  effect,  that  by  exalting  the  incitability  of  the  nerves 
of  the  finger  or  epigastric  region,  to  a  degree  of  incitability  equal  to  that 
of  the  retina,  wTe  could  see  with  the  finger  or  the  stomach,  on  adapting  to 
them  an  optical  apparatus  similar  to  the  eye  ? 

Brown  and  Broussais,  then,  were  obliged  to  admit  that  there  exists 
diversity  in  the  manifestations  of  vital  power  due  to  the  special  anatomical 
properties  of  tissues  and  organs,  of  solids  and  liquids,  as  well  as  diversity  in 
the  functions  therewith  connected  :  but  they  did  not  take  them  into  account. 
The  fundamental  idea  of  their  doctrines  is  identical :  this  Broussais  has  rec- 
ognized by  adopting  as  the  test  of  his  own  doctrine  the  synthetic  proposition 
of  Brown,  that  all  diseases  are  sthenic  or  asthenic,  that  is,  dependent  either 
upon  excess  or  deficiency  of  excitement ;  but  by  the  manner  in  which  he 
interprets  the  effects  of  reaction,  he  completely  diverges  from  the  path  of 
his  predecessor,  and  arrives  at  therapeutical  conclusions  entirely  opposed  to 
those  of  the  disciples  of  Cullen. 

Brown  maintained  that  all  parts  of  the  body  are  endowed  with  a  particu- 
lar special  aptitude,  which  he  called  incitability.  This  incitability  he  said 
was  manifested  by  incitation,  and  this  incitation  could  only  be  the  result  of 
an  inciting  force  :  but  this  aptitude  is  limited.  Since  whenever  it  is  brought 
into  play,  it  becomes  by  that  very  circumstance  exhausted,  so  it  requires  to 
be  constantly  renewed  by  augmentation  of  the  quantity  of  the  force  by 
nutrition;  or  by  an  accumulation  of  force  taking  place  through  non-expen- 
diture consequent  upon  repose  of  the  organism.  Thus,  by  movement,  the 
incitability  of  muscles  is  exhausted,  and  when  muscular  action  has  been 
excessive  in  degree  or  too  prolonged,  the  individual,  being  in  the  last  stage 

*  Brows  (John,  M.D.)  :  Elements  of  Medicine.     London,  1795. 


444  SPECIFIC    ELEMENT    IN    DISEASE. 

of  fatigue,  loses  the  power  of  moving.  Thus,  gentlemen,  you  perceive  how 
both  the  pathological  and  therapeutical  doctrine  of  Brown  wholly  originates 
iu  this  fundamental  fact. 

According  to  Brown  every  disease  depends  either  upon  diminished  inci- 
tability,  the  consequence  of  excessive  incitation,  or  an  increased  incitability 
the  effect  of  a  diminution  of  incitation.  In  both  cases  the  final  result  is 
debility;  and,  consequently,  the  part  of  the  physician  ought  always  to  be 
restricted,  first,  to  the  restoration  of  the  vital  powers  by  very  moderate 
stimulants,  and,  in  the  second  place,  to  the  use  of  means'  capable  of  aug- 
menting the  incitability. 

Broussais,  taking  an  isolated  view  of  the  irritability  which  exists  in  tis- 
sues, held  that  all  diseases  spring  from  the  untimely  or  excessive  action  of 
agents  having  the  power  of  exciting  that  irritability.  According  to  his 
view,  therefore,  the  only  morbific  causes  are  irritants,'and  the  effects  winch 
they  producers  irritation.  Holding  the  opposite  of  Brown's  opinion,  he 
thought  that  it  was  necessary  to  restore  the  functions  to  their  physiological 
condition,  and  to  endeavor  to  calm  and  remove  the  irritation. 

Whether  the  pathological  state  consists,  according  to  the  Edinburgh  doc- 
trine, in  a  greater  or  less  degree  of  incitability,  or  according  to  the  Yal-de- 
Grace  theory  in  an  excess  or  more  rarely  in  diminished  irritability,  in  these 
dichotomic  symptoms  (essentially  opposed  to  each  other,  though  having  one 
and  the  same  origin),  the  quantity  only,  and  in  no  way  the  quality,  of  the 
morbific  cause  is  taken  into  account.  Treatment  of  disease  based  on  such 
systems  must  necessarily  possess  extreme  simplicity.  Brown  confined  him- 
self to  the  use  of  the  class  of  remedies  known  as  excitants,  using  in  some 
very  rare  cases  antisthenics,  if  I  may  be  allowed  to  use  such  .a  term  ;  while 
Broussais  always  employed  antiphlogistic  medicines,  except  when,  under 
very  exceptional  circumstances,  he  prescribed  excitants. 

There  is  no  denying  that  a  certain  class  of  acute  inflammations  are  pretty 
exactly  comprehended  within  the  description  applicable  to  the  system  of 
Broussais;  for  that  which  renders  an  inflammatory  disease  more  or  less 
serious  is,  on  the  one  hand,  the  greater  or  less  intensity  of  the  cause  under 
the  influence  of  which  it  has  been  developed,  and,  on  the  other,  the  differ-' 
ence  of  the_ organizations  which  are  affected.     But  there  is  another  class  of 
diseases  which  has  not  this  dichotomy:  it  is  the  class  of  specific  diseases. 
It  mattered  very  little  to  Brown  whether  small-pox  was  a  specific  disease. 
All  he  required  was  to  ascertain  whether  the  malady  was  sthenic  or  asthenic 
to  enable  him  to  formulate  the  therapeutic  indication  of  stimulating  or  lower- 
ing.    It  mattered  very  little  to  Broussais  whether  cholera  differed   in  form 
from  dothinenteria  ;  in  both  diseases  be  saw  irritation  of  the  digestive  canal 
setting   up  different  symptoms,  but  the  irritation  was  to  him   the  dominant 
fact  which  constituted  the  necessity  for  antiphlogistic  treatment. 

Thus  it  was  that  the  whole  ofnosology  and  therapeutics  became  a  tabula 
rasa.  Matters  were  in  this  state  at  the  beginning  of  I  he  century.  The  doe- 
trine  of  Broussais,  on  first  acquaintance  seductive  from  its  simplicity,  had 
obtained  many  adherents  when  Laennccand  Ibvtonneau,  each  Prom  his  own 
point  of  attack,  dealt  a  blow  at  it,  the  formidable  character  of  which  BroUS- 
sais  tried  in  vain  to  conceal.  Laennec,  under  the  modest  title  of  a  seinio- 
logical  discovery,  and  seeming  to  confine  his  observations  to  the  stud]  of 
the   diseases   of  the    respiratory   organs,  wrote  a    very   striking   chapter  on 

Dosology.     While  Bretonneau  was  restoring  the  history  of  acute,  Laenne 

restored   the  history  of  chronic  diseases. 

I  he  illiMrioiis    phy-ieian  of  Tours   overthrew  to  it>  very  foundations  the 

greal  edifice  of  phydologism  and  pretended  rationalism  in  therapeutics,  and 

"ii  its  ruin-  raised  the  doctrine  of  the  existence  of  a  specific  element  in  dia- 


SPECIFIC    ELEMENT    IN    DISEASE.  445 

ease.  This  he  did,  by  falling  attention  to  the  elementary  fact,  thai  differ- 
ences in  the  nature  of  the  cause  impart  to  diseases  much  greater  differences 
than  those  which  they  derive  from  greater  or  less  intensity  of  the  cause,  or 
from  diversity  of  organization.* 

In  physiology,  Bretonneau  attributed  to  the  special  properties  of  differ- 
ent tissues  and  different  organs  a  much  greater  importance  than  that  which 
he  accords  to  the  agencies  which  modify  the  organism:  in  pathology,  he 
admitted  that  a  great  number  of  diseases  have  a  common  element  generally 
called  irritation  or  inflammation ;  but  he  did  not  accord  to  this  common 
element  the  importance  assigned  to  it  by  Broussais.  Undoubtedly  furun- 
culus,  malignant  pustule,  syphilitic  chancre,  herpes  preputialis,  gastric 
disturbance  and  dothinenteria  have,  as  an  element  in  common,  inflamma- 
tion characterized  by  fluxion,  by  redness  appreciable  when  the  inflamed 
parts  are  within  view,  by  pain,  and  by  increased  temperature  ;  but  along 
with  this  common  element,  there  are  other  elements  of  great  importance 
which  distinguish  the  different  affections  from  each  other,  and  have  a  sig- 
nificance altogether  peculiar. 

The  natural  history  of  disease  has  some  remarkable  analogies  with  the 
natural  history  of  plants  and  animals.  This  truth  was  long  ago  enunciated 
by  Sydenham,  when,  in  one  of  the  chapters  of  the  second  section  of  his 
Medical  Observations,  he  says,  in  speaking  of  pestilential  fever  and  the 
plague  of  armies  which  committed  ravages  in  1665 — 1666  :  "  Unaquaeque 
morborum  non  minus  quam  auimalium  aut  vegetabilium  species,  aflectiones 
sibi  proprias  perpetuas  ac  pariter  univocas  ab  essentia  sua  promanantes 
sortita  est."  Examples  in  illustration  taken  from  Botany  and  Zoology 
will  facilitate  the  understanding  of  the  subject  of  which  I  am  now  treating. 

Different  kinds  of  vegetables,  for  instance,  present  us  with  characters  in 
common,  in  virtue  of  which  we  place  them  in  the  same  natural  families  ; 
and  these  common  characters  are  also  found  in  some  proximate  families ; 
but  in  the  form  of  the  flower,  in  the  shape  of  the  fruit,  in  the  juices  secreted 
by  the  plant,  there  are  distinctions  which  not  only  prevent  families  being 
mistaken  for  one  another,  but  also  prevent  the  most  similar  species  from 
being  confounded.  Thus,  dulcamara,  datura  stramonium,  celandine,  poppy, 
the  wild  brier,  and  cherry-laurel  possess  characters  in  common,  but  they 
have  each  well-marked  special  characters  which  make  it  impossible  for  the 
botanist  to  mistake  any  one  of  them  for  the  other. 

When  you  study  two  individuals  of  the  class  rejrtilia  and  the  order 
ophidic,  the  ring-snake  and  the  viper,  you  notice  similitudes  in  their 
external  forms  and  anatomical  structure,  but  you  bestow  special  attention 
upon  their  specific  distinctions.  The  presence  or  absence  of  scales  or 
plates  on  the  head  of  the  animal,  the  presence  or  absence  of  poison-fangs, 
establish  for  you  fundamental  differences  between  two  individuals  similar 
in  their  general  appearance ;  and  you  could  not  commit  such  an  error  as 
to  regard  the  viper  as  a  variety  of  the  ring-snake. 

Well,  then,  gentlemen,  in  diseases  which  seem  to  bear  the  strongest 
resemblance  to  one  another,  there  are  specific  characters  quite  as  distinc- 
tive as  those  which  distinguish  the  different  species  of  the  same  family  of 
plants,  or  the  different  species  of  the  same  class  of  animals.  Now  this  is 
what  Broussais  was  not  inclined  to  admit.  The  inflammation-element,  the 
existence  of  which  we  cannot  deny,  was,  to  his  mind,  the  chief  and  indeed 
the  only  dominant  fact.  It  is  so  in  some  cases  :  in  a  purely  inflammatory 
disease,  the  quantity  of  the  morbific  cause  is  everything,  provided  allow- 

*  Bretonneau:  Kecherches  sur  l'lnflammation  Speciale  du  Tissu  Muqueux  et 
en  particulier  sur  la  Diphtherite      Paris,  1826. 


446  SPECIFIC    ELEMENT    IN    DISEASE. 

ance  be  made  for  diversity  of  organs  and  variety  of  organization  :  gener- 
ally speaking,  in  the  phlegmasia^,  as  in  the  pyrexiae,  as  well  as  in  the 
majority  of  diseases,  we  have  to  consider  the  quantity  less  than  the  quality 
of  the  morbific  cause. 

Let  me  use  as  my  illustrations  facts  which  admit  of  being  stated  with 
absolute  precision,  and  are  consequently  facts  the  least  likely  to  be  disputed. 

A  small  vesicle  appearing  at  the  base  of  the  glans  penis  after  impure 
intercourse  is  certainly  in  appearance  a  thing  of  trivial  importance:  if 
judged  only  by  its  appearance,  it  is  a  much  less  serious  affection  than  a 
group  of  vesicles  of  herpes  preputialis,  which  is  liable  to  appear  under 
similar  circumstances.  In  fact,  if  the  inflammation-element  only  be  taken 
into  account,  the  herpetic  is  the  more  formidable  of  the  two  affections.  But 
how  vast  the  difference,  when  we  proceed  beyond  that  element  which  they 
have  in  common !  While  the  herpetic  vesicle,  if  left  to  itself,  becomes 
filled  with  pus,  dries  up,  and  leaves  in  its  place,  after  the  formation  and 
fall  of  a  crust,  an  insignificant  cicatrix,  the  syphilitic  vesicle  runs,  rapidly 
perhaps,  through  its  stages;  but  in  the  place  it  occupied,  you  will  soon 
observe  an  induration  of  the  subjacent  cellular  tissue,  which  you  will  at 
once  recognize  as  establishing  a  distinction  between  the  syphilitic  and  non- 
syphilitic  affection — a  distinction  which  you  will  consider  as  of  the  very 
highest  importance.  In  this  you  will  assuredly  be  right ;  for  after  recover v 
from  the  herpes,  you  need  have  no  anxiety  regarding  your  patient :  when 
the  local  malady  has  disappeared,  a  radical  cure  has  taken  place.  Is  it 
so  after  the  cicatrization  of  the  chancre  ?  No !  for  after  two  or  three 
months,  and  sometimes  after  a  longer  interval,  manifestations  will  appear 
on  the  skin  and  mucous  membranes,  which  you  will  connect  with  the 
previous  existence  of  the  little  insignificant-looking  vesicle.  You  will 
see  appear  a  special  cutaneous  eruption  and  ulcerations  of  the  throat ; 
or,  if  energetic  medical  treatment  does  not  prevent  it,  you  will  have  the 
successive  development  of  other  affections  originating  in  the  first — affec- 
tions of  the  cellular  tissue,  tubercles  on  the  skin,  condylomata,  diseases 
of  the  bones,  such  as  ostalgia,  caries,  and  necrosis — which  if  not  checked 
in  their  progress  will  lead  to  terrible  disorders.  In  addition,  therefore, 
to  the  characters  which  the  syphilitic  chancre  had  in  common  with  the 
herpetic  vesicle,  it  had  specific  characters  deserving  great  consideration. 

The  clinical  study  of  diseases  furnishes  innumerable  examples  similar  to 
that  now  adduced  :  what  I  have  said  of  syphilitic  chancre,  I  might  repeat 
in  substance  of  a  host  of  other  affections. 

A  small  pimple  forms  on  the  hand  of  a  butcher  who  has  been  skinning 
a  slice))  which  lias  died  of  malignant  pustule  [mug  <le  rati'].  Ii  occasions 
only  a  disagreeable  feeling  of  tickling  in  the  part:  in  comparison  with  a 
boil,  which  is  often  exceedingly  painful,  it  appears  to  he  scarcely  deserving 
of  notice.  Bui  by  and  by  this  pimple,  so  insignificant  and  apparently  m> 
mild  in  its  character,  begins  to  enlarge:  a  small  slough  forms  in  (he  situa- 
tion which  was  occupied  by  the  pimple:  an  erysipelato-cedematous  tume- 
faction, commencing  in  the  affected  part,  gradually  invades  the  whole 
member :  the  lymphatic  glands  of  the  arm  and  axilla  become  engorged  :  at 
the  Mime  time,  U'\vv  sets  iii,  which  increases  from  day  to  day  :  then  delir- 
ium supervenes:   and  at  last,  sooner  or  later,  the  individual  dies,  in  a  stale 

of  extreme  debility,  with  aggravated  typhoid  symptoms.     The  little  pimple 

was  a  malignant   pustule.      The  boil,  on  the  other  hand,  which  almost  from 
the  very  lirst  caused  violent   pain,  and    in  which    the   inllammat  ion-elenieiit 

attained  a  much  more  intense  degree  than  in  the  case  of  the  malignant 

pustule,  gets  well  spontaneously:  the  patient,  who  has  Buffered  a  -real  deal 

of  pain  bas  nothing  to  fear.     The  inflammation,  therefore,  did  not  plaj  a 


SPECIFIC    ELEMENT    IN    DISEASE.  447 

very  important  part  :  the  quantity  of  that  element  was  of  no  consequence — 
its  quality  was  everything. 

TJic  characters  which  put  their  special  seal  on  specific  diseases  are  univ- 
ocal  and  constantly  met  with,  irrespective  of  the  degree  in  which  exists 
the  common  element  with  which  they  are  associated.  Thus,  small-pox, 
whether  distinct  or  confluent,  benignant  or  malignant,  normal  or  modified, 
will  always  be  found  to  have  its  pustules,  its  own  special  pustules,  which 
constitute  its  character,  a  character  as  essentially  invariable  and  as  specific 
as  the  distinctive  marks  of  the  natural  families  of  plants,  or  the  natural 
division  of  the  classes  of  animals. 

That  which  is  true  in  human,  is  equally  true  in  comparative  pathology. 
Thus,  you  will  see  tag-sore  [clavelie]  that  eruptive  disease  of  sheep  regard- 
ing which  I  spoke  in  a  previous  lecture  [vol.  i,  p.  90],  comparing  it  with 
small-pox  in  the  human  subject,  show  itself  by  an  eruption  presenting  char- 
acters perfectly  precise  and  univocal,  which  enables  it  to  be  distinguished 
from  all  the  other  eruptive  diseases  of  sheep. 

Even  plants,  so  much  inferior  to  animals  in  the  scale  of  organization, 
exhibit  in  their  pathological  disorders  the  influence  of  the  quality  of  the 
cause,  by  the  form  of  the  disease.  The  insects  which  wound  the  leaves  or 
stems  of  plants  excite  at  the  point  of  contact  the  growth  of  morbid  ex- 
crescences, the  univocal  character  of  which  points  out  the  agent  by  which 
the  wound  was  made.  On  plants  the  same  kind  of  scurf  always  follows 
the  wound  inflicted  by  the  same  kind  of  insect ;  and  this  occurs  with  such 
constancy,  that  the  experienced  naturalist  can  always  determine  from  the 
form,  color,  and  volume  of  the  excrescence  the  kiud  of  insect  to  which  the 
contained  larvae  belong. 

Exactly  the  same  thing  occurs  in  respect  of  an  internal  or  external  in- 
flammation of  the  human  subject.  In  dothinenteria,  there  is,  in  addition 
to  the  characters  possessed  by  it  in  common  with  all  other  intestinal  phleg- 
masia, an  inflammation  occupying  a  circumscribed  locality — a  locality 
which  is  limited,  determinate,  and  always  the  same :  there  is  the  furuncu- 
lar  eruption  of  the  agminate  and  solitary  glands,  and  as  this  furuncular 
eruption  is  always  found  in  dothinenteria,  it  is  very  properly  regarded  as 
the  specific  character,  the  special  anatomical  manifestation  of  the  disease. 

In  dystentery,  wdiich  is  in  reality  a  form  of  colitis,  special  characters  are 
also  found  :  they  exist  in  the  intestinal  secretions,  in  the  symptoms,  and  in 
the  anatomical  lesions,  enabling  us  to  distinguish  this  form  of  inflammation 
of  the  large  intestine  from  other  species  of  colitis,  and  to  establish  the 
specific  character  of  the  disease. 

Let  me  remark,  gentlemen,  that  the  specific  characters  of  which  I  have 
been  speaking  must  not  be  confounded  with  the  characters  which  consti- 
tute mere  varieties :  in  nosology,  as  well  as  in  natural  history,  it  is  neces- 
sary to  keep  the  two  distinct  from  one  another. 

To  continue  my  comparisons :  there  is  a  great  difference  between  the 
lady's  pocket-dog  and  the  large  dog  [molosse]  of  the  Pyrenees :  still,  the 
two  do  not  belong  to  different  species,  but  are  merely  varieties  of  the  same 
species  of  the  genus  canis.  The  same  instincts,  the  same  anatomical  and 
physiological  characters  are  invariably  found  present  in  both.  Ingenious 
breeders,  by  skilful  crossing,  can  produce  animals  very  different  from  the 
parent  stock,  can  produce  breeds  in  wdiich  the  wool,  the  fat,  or  the  muscle 
predominates  according  to  the  use  for  which  the  animal  is  destined ;  yet 
these  different  breeds  are  merely  varieties  of  one  type,  all  of  which  preserve 
the  typical  specific  characters.  So  it  is  also  in  plants ;  you  know  how  com- 
pletely we  have  it  in  our  power  to  multiply  varieties  of  a  vegetable  species, 
and,  so  to  speak,  to  create  monstrosities.     Thus,  from  the  simple  pink,  a 


448  SPECIFIC    ELEMENT    IN    DISEASE. 

i 

skilful  horticulturist  produces  innumerable  varieties,  just  as  from  the  wild 
brier  he  obtaius  the  beautiful  roses  which  adoru  our  gardens. 

But  both  in  the  animal  and  vegetable  kingdoms,  we  only  produce  va- 
rieties— diffe rent  forms  of  the  same  species — and  we  have  no  power  com- 
pletely to  change  the  characters  of  species,  far  less  to  create  new  species.  It 
is  long  since  the  horse  and  the  ass  have  been  crossed  :  stallions  have  been 
coupled  with  female  asses,  and  male  asses  have  been  coupled  with  mares : 
mules  have  been  the  only  resulting  progeny — that  is  to  say,  varieties  par- 
taking of  the  characters  of  both  species  of  the  genus  equus,  accidental 
varieties,  however,  which  are  not  reproduced,  and  which  do  not  perpetuate 
themselves. 

In  nosology,  no  more  than  in  natural  history,  ought  variety  of  type  to 
be  taken  for  difference  in  species.  Varioloid,  or  modified  small-pox,  is  nut 
a  different  species  of  small-pox,  but  merely  a  modification  or  variety : 
varicella  or  chicken-pox  is  an  entirely  distinct  species. 

Gentlemen,  I  insist  on  this  point  because  some  are  disposed  to  see  in  the 
specific  character  of  diseases  onhr  a  question  of  more  or  less,  while  in  re- 
ality, there  is  as  absolute  a  difference  between  different  species  in  nosology 
as  in  botany  or  zoology.  Do  what  you  will,  you  will  never  succeed  in 
transforming  roseola  into  measles,  chicken-pox  into  small-pox,  or  simple 
catarrhal  bronchitis  into  hooping-cough.  All  these  diseases  have  their  ab- 
solute and  invariable  specific  character  sharply  distinguishing  them  from 
one  another,  whatever  may  be  the  degree  of  their  severity.  The  existence 
of  specific  character  is  so  indisputable,  and  is  everywhere  so  clearly  indi- 
cated, that  it  is  not  necessary  for  the  recognition  of  a  nosological  species 
to  have  before  us  an  assemblage  of  all  the  symptoms :  as  is  seen  in  "  de- 
faced scarlatina  "  [scarlatine  fruste],  a  single  word  will  often  be  sufficient 
to  enable  the  physician  to  recompose  the  entire  pathological  phrase,  just  as 
Cuvier  recomposed  lost  species  of  animals  by  the  study  of  a  few  fragments 
of  antediluvian  skeletons. 

Specific  diseases  derive  their  invariable  characters  not  from  the  quantity, 
but  from  the  quality  of  the  morbific  cause:  this  is  invariable  in  its  nature, 
whatever  may  be  the  influence  under  which  it  is  developed. 

The  class  of  special  diseases  is  so  vast  as  to  fill  the  greater  part  of  the 
nosological  table.  If  we  study  the  different  causes  of  diseases,  whether 
these  causes  are  irritants,  or  agents  of  an  entirely  different  kind,  we  shall 
see  results  produced  which  are  so  invariably  characterized  by  the  same 
forms,  according  to  the  nature  of  the  causes,  that  it  will  be  impossible  uol 
to  recognize  the  specific  element  at  every  step  as  we  proceed  in  our  obser- 
vation of  patients. 

A  blister  on  the  skin  differs  in  its  character  according  to  the  cause  in 
which  it  originates;  according,  for  example,  to  its  being  the  result  of  the 
application  of  cantharides,  of  a  sunburn,  of  erysipelas,  or  of  cauterizatiou 
with  ammonia.  You  know  how  smarting  is  the  pain  of  a  sunburn:  it  is 
not  the  same  kind  of  pain  which  is  caused  by  blistering  with  caul  harides 
or  ammonia — it  is  more  acute  and  lasts  longer;  but  nevertheless,  the  cu- 
taneous inflammation  caused  by  blistering  with  either  substance  is  much 
more  intense  than  that  which  results  from  a  burn    by  the  sun:   each    cause 

produces  its  own  special  effect. 

Lei  mi'  illustrate  the  subject  by  facts  still  simpler — by  the  effects  of  chem- 
ical agents,  which  are  very  easily  ascertained.  Each  of  these  agents,  when 
applied  to  the  human  body,  has,  according  to  its  individual  nature,  its  own 

special    action.      The    pain    produced    by   hydrochloric   acid    is    much    more 
transient  than  that  occasioned  by  nitric  acid;  and  nitric  acid,  although  it 

occasions  Bloughing  of  the  part-  which  it   touches,  causes  less  acute  and  less 


SPECIFIC    ELEMENT    IN    DISEASE.  449 

stent  pain  than  cauterization  with  sulphuric  acid,  although  the  destruc- 
tion of  tissues  may  be  less  extensive.  Every  medical  student  know.-  that 
the  application  of  potassa  fusa  and  the  alkaline  can-tics  is  much  less  pain- 
ful than  the  application  of  the  chloride  of  zinc,  chloride  of  antimony,  or 
arsenical  preparations.  To  sum  up  in  a  few  words  all  that  there  is  to  say 
on  the  subject :  the  different  chemical  agents  produce  so  distinctive  an 
action  that  even  a  person  of  little  experience  can  declare  the  substance 
which  has  been  used  from  observation  of  the  effects  produced.  In  these 
cases,  one  cannot  argue  from  the  quantity  of  the  cause,  for  experience  has 
shown  that  it  is  impossible  to  produce  similar  eli'ects  with  caustic  potash 
and  chloride  of  antimony,  whatever  proportions  of  these  agents  may  be  em- 
ployed. That  this  depends  on  their  respeetive  chemical  properties,  and  on 
the  manner  in  which  the  agents  combine  with  the  tissues,  I  admit;  but  that 
does  not  signify,  if  there  lie  a  difference,  and  if  that  difference  be  constant. 

Let  us  now  examine  the  action  of  poisons.  All  poisons  have  their  own 
peculiar  mode  of  action,  and  so  characteristic  is  it  that  nearly  always  the 
slightest  examination  of  the  symptoms  suffices  to  determine  the  nature  of 
the  poison.  There  is  certainly  no  one  at  all  acquainted  with  toxicology 
who  cannot  distinguish  by  the  symptoms  poisoning  by  opium  from  poison- 
ing by  stramonium,  veratria,  or  strychnia  ;  or  who  is  unable  to  discriminate 
the  differences  in  the  consequences  of  absorption  of  the  venom  of  the  rattle- 
snake, the  viper,  the  scorpion,  the  tarantula,  the  bee,  or  the  mad  dog. 

To  every  specific  morbid  cause,  the  organism  responds  by  the  manifesta- 
tion of  effects  having  a  specific  character. 

A  man  comes  into  hospital  with  paralysis  of  the  extensor  muscles :  the 
edges  of  his  gums  have  a  bluish  fringe :  his  skin  has  a  somewhat  jaundiced 
hue:  he  complains  of  violent  colic,  and  of  shooting  pains  in  the  course  of 
the  nerves  of  the  limbs :  in  such  a  case  a  prolonged  examination  is  not  re- 
quired to  diagnose  poisoning  by  lead.  The  nature  of  the  case  is  so  palpable 
that  one  cannot  entertain  the  idea  of  its  being  the  subject  of  any  doubt. 
The  disease  has  characters  so  essentially  specific  that  it  is  recognized  at  a 
glance,  just  as  a  tree  is  recognized  at  first  sight  by  its  leaves  and  general 
appearance.  You  can  at  once  lay  hold  of  the  distinctive  characters  of 
poisoning  with  lead  and  copper,  just  as  you  can  distinguish  at  the  first 
glance  the  different  species  of  the  animal  and  vegetable  kingdom. 

Another  patient  comes  into  hospital  affected  with  general  tremors ;  his 
gums  are  ulcerated  and  bleeding,  and  the  teeth  shake  in  their  sockets :  his 
mind  is  enfeebled.  Our  first  question  is  asked  to  ascertain  whether  he  is  a 
looking-glass  manufacturer,  a  gilder  on  metals,  or  engaged  in  any  other 
occupation  in  which  mercury  is  employed :  we  have  at  once  suspected  mer- 
curial poisoning.  There  was,  in  fact,  something  so  characteristic  in  the 
symptoms  that  we  could  not  mistake  them. 

You  are  acquainted,  gentlemen,  with  the  symptoms  which  characterize 
the  disease  produced  in  the  workers  in  vulcanized  caoutchouc  factories  by 
inhaling  the  vapors  of  sulphuret  of  carbon.  The  interesting  inquiry  of  my 
colleague  Dr.  Delpech  has  recently  directed  attention  to  this  species  of  poi- 
soning.* 

This  sagacious  observer,  by  marking  with  care  the  specific  character  of 
the  phenomena  in  the  case  of  a  workman  in  a  caoutchouc  factory,  phenom- 
ena which  could  not  be  attributed  to  any  known  disease,  was  able  to  estab- 

*  Delpech  (A.)  :  Memoire  sur  les  Accidents  que  developpe  ehez  les  Ouvriers  en 
Caouchouc  ('inhalation  du  iSulture  de  Carbone  en  vapeur.      Taris,  185G. 

N^ouvelles  Recherehes  sur  1' Intoxication  Speciale  que  determine  le  ttulfure  de  Car- 
bone.     [Annates  <V 'Hygiene  Publique,  1863;  2e  Serie,  t.  xix.] 

vol.  I. — 29 


450  SPECIFIC    ELEMENT    IN    DISEASE. 

lish  the  existence  of  a  new  disease,  of  which  he  has  since  met  with  a  certain 
number  of  cases,  all  of  them  presenting  the  same  characteristic  symptoms. 
The  symptoms  of  this  new  disease  are — disturbance  of  the  mental  faculties, 
particularly  loss  of  memory ;  headache,  which  is  more  or  less  acute,  and  is 
sometimes  Very  intense  ;  vertigo,  occasionally  in  an  extreme  degree ;  pains 
in  the  limbs,  accompanied  by  a  sensation  of  general  formication  and  anal- 
gesia, and,  in  very  exceptional  cases,  with  cutaneous  hyperesthesia  :  im- 
paired power  of  the  organs  of  sense  and  reproduction  ;  disturbance  of  the 
motor  powers,  characterized  at  first  by  cramps  and  then  by  muscular  con- 
tractions ;  muscular  debility,  appearing  first  in  the  inferior  and  then  in  the 
superior  extremities ;  finally,  anorexia  and  vomiting.  Under  the  influence 
of  these  symptoms  the  patient  falls  into  a  state  of  more  or  less  profound 
cachexia. *  An  important  character  of  the  disease  is  the  tendency  of  the 
symptoms  to  diminish  in  severity,  and  to  disappear  entirely  after  a  suffi- 
ciently long  removal  from  the  cause  which  produced  them. 

Since,  twenty  years  ago,  chemical  replaced  sulphuric  and  chlorinated 
matches,  physicians  have  had  too  many  opportunities  of  studying,  in  the 
workmen  who  make  these  articles,  affections  caused  by  phosphorus,  affec- 
tions consisting  in  necrosis  and  caries  of  the  maxillary  bones,  and  haying 
this  peculiar  feature,  that  they  are  invariably  localized  in  these  bones,  and 
never  show  themselves  in  any  other  part  of  the  skeleton.  The  lesions  of 
the  bones,  then,  which  result  from  poisoning  with  phosphorus,  have  char- 
acters altogether  peculiar  and  specific. 

Gentlemen,  in  the  specific  diseases  produced  by  physical  or  chemical 
agents  to  which  I  have  now  directed  your  attention,  we  can  lay  hold  of  and 
see  the  morbific  cause;  we  can  also  lay  hold  of  it,  as  it  were^in  virulent 
and  poison-diseases.  We  know  that  morbid  poisons  exist  in  fluids  secreted 
by  persons  laboring  under  diseases :  the  virus  of  rabies  exists  in  the  saliva 
of  the  mad  dog,  and  the  virus  of -small-pox  in  the  pustule,  although  the 
fluids  containing  these  poisons  are  identically  similar  in  appearance  to  the 
fluids  which  produce  no  specific  effects.  We  know  that  a  morbific  cause 
exists  in  particular  secretions  of  certain  plants  and  animals  ;  for  example, 
in  the  venom  secreted  by  the  gland  placed  at  the  base  of  the  hooked  dart 
of  the  rattlesnake,  and  in  the  juice  secreted  by  the  glands  at  the  has.'  of 
the  hairs  of  the  stinging  nettle.  Though  in  the  majority  of  diseases  we 
cannot  thus,  as  it  were,  lay  our  hands  on  the  morbific  cause,  we  are  never- 
theless entitled,  as  in  natural  history,  to  admit  its  existence.  If  we  found 
a  plant  for  the  first  time  in  a  certain  district,  a  plant  till  then  unknown  in 
that  district,  and  if  we  afterwards  found  in  the  same  locality  a  great  number 
of  plants  all  presenting  precisely  the  same  characters,  we  should  lie  entitled 
to  affirm  that  they  all  proceeded  from  one  identical  seed,  although  we  had 
not  actually  3een  thai  primitive  seed.  No  comparison  could  in  my  opinion 
ho  better  chosen,  I'M-  nosological  have,  very  properly,  been  likened  to  vege- 
table species  :  the  living  body  has  been  considered  as  a  field,  in  which,  under 
certain   conditions    inherent    in    the   body,  morbific  seeds  germinate,  which 

spring  up  with  their  specific  characters,  reproducing  the  species,  like  the 
seeds  of  different  specie- of  plant-  confided  to  congenial  soil.  This  com- 
parison is  perhaps  more  applicable  to  inoculable  contagious  diseases  than 

to  other-,  for  ol  them  we  may  with  strict  propriety  -ay  that  the  see.l  is 
-own  ami  the  original  reproduced  ;  but  it  also  applies  to  infectious  diseases. 
When  we  see  infection-  diseases  always  characterized  by  Birailar symptoms, 
we  are  led  to  recognize  the  existence  of  special  causes  t<>  account  tor  the 
special  effects,  although  we  cannol  actually  lav  hold  of  these  causes;  jusl 
as,  in  tic  illustration  I  have  already  employedj  we  are  constrained  to  admit 
that  all  the  plant-  came  from  the  same  seed. 


SPECIFIC    ELEMENT    IN    DISEASE.  451 

Thus,  gentlemen,  we  all  believe  in  the  existence'  of  what  are  called  mias- 
mata; although  we  can  only  form  an  opinion  of  them  by  their  effects:  we 
admit  that  there  are  several  species  of  miasmata,  because  there  are  cor- 
responding phenomena,  peculiar,  special,  and  invariable,  which  characterize 
the  diseases  which  we  suppose  originate  in  them.  Could  any. of  you  mis- 
take marsh  fever,  which  is  generally  characterized  by  intermittent  par- 
oxysms, varying  in  type,  and  sometimes  by  oeuralgic  affections?  Could 
any  of  you,  seeiug  such  a  case,  fail  to  conclude  that  the  patient  had  been 
exposed  to  marsh  emanations? 

But  here,  although  the  morbific  cause  elude  observation,  we  are  at  least 
acquainted  with  the  conditions  under  which  it  has  been  developed.  It  often 
happens,  however,  that  these  conditions  are  not  known  ;  and  yet  circum- 
stances convince  us  that  a  special  cause  exists  in  which  originate  the  special 
effects  which  we  observe. 

We  are  not  acquainted  with  the  meteorological  and  terrestrial  conditions 
under  which  cholera  occurs,  and  our  ignorance  as  to  the  cause  of  that  dis- 
ease is  still  greater ;  nevertheless,  no  one  seeing  the  disease  invariably 
manifesting  the  same  phenomena,  will  deny  that  it  has  a  specific  character. 
We  are  not  acquainted  with  the  cause  of  dothinenteria,  but  yet  its  specific 
character  is  admitted  by  every  physician  who  sees  it  constantly  presenting 
the  same  symptoms  during  life,  and  the  same  special  anatomical  lesions 
after  death  :  these  specific  characters  are  so  precise  and  predominant  that 
confusion  is  impossible.  Every  one  can  distinguish  dothinenteric  from 
simple  enteritis,  when  he  has  before  him  the  anatomical  lesions;  and  during 
life  also,  the  symptoms  enable  the  one  to  be  diagnosed  from  the  other. 

To  sum  up,  gentlemen,  the  remarks  which  I  have  now  made :  we  must 
consider  that  in  every  disease  there  is  a  common  element  which  may  be 
termed  the  physiological  element — inflammation,  irritation,  &c. ;  and  like- 
wise that  which  may  be  termed  the  nosological  element,  imprinting  itself 
upon  the  former,  giving  to  the  whole  disease  a  special  character,  and  assign- 
ing to  it  a  unity  of  origin,  a  special  principle,  a  nature  more  or  less  deter- 
mined, aud,  in  a  word,  constituting  a  morbid  species. 

The  common  element  predominates  in  diseases  which  are  accidental :  a 
burn  produced  by  fire  is  an  absolute  type  of  this  class.  Here,  quantity  of 
morbific  cause  is  everything,  allowance  being  made  for  difference  of  organs 
and  diversity  of  organization.  Although  in  a  great  number  of  diseases, 
the  nosological  element  dominates  over  the  common  element,  it  would  be 
as  absurd  to  exclude  quantity  of  morbific  cause  from  all  participation  in 
the  production  of  effects,  as  it  would  be  not  to  take  into  account  diversity 
of  organs  and  variety  of.  organization  :  but  quantity  of  cause,  diversity  of 
organs,  and  variety  of  organization,  are  here  all  dominated  by  quality  of 
cause,  and,  therefore,  we  require  chiefly  to  consider  the  nature  of  that 
quality. 

In  certain  cases,  we  can  lay  hold  of  the  special  cause,  and,  almost  at  will, 
produce  the  effects  which  are  its  natural  consequences.  So  it  is,  in  respect 
of  the  special  phlegmasia?  produced  by  special  physical  and  chemical  agents, 
the  diseases  originating  in  a  virus,  in  the  poison  of  venomous  creatures,  or 
in  the  absorption  of  any  poison :  so  it  is  also,  in  respect  of  certain  diseases 
with  the  causes  of  which  we  are  not  acquainted,  but  with  the  conditions 
under  which  the  causes  act  we  are  familiar,  as  for  example,  in  marsh  fevers. 
In  these  cases,  the  existence  of  a  specific  cause  cannot  be  disputed  :  and  it 
is  not  less  present  in  other  diseases  in  which  the  causes,  as  well  as  the  con- 
ditions under  which  the  causes  act,  elude  our  observation :  the  specific  cause 
is  established  quite  as  well  by  the  invariability  of  the  symptoms  and  forms 
of  the  affection,  as  if  we  were  also  equally  cognizant  of  the  effects  and  the 


452  SPECIFIC    ELEMENT    IN    DISEASE. 

causes :  from  the  constancy  of  the  one,  it  is  logical  to  infer  the  constancy 
of  the  other. 

Gentlemen,  perhaps  some  of  you  may  think  that  I  have  already  spoken 
at  too  great  length  upon  the  subject  of  the  specific  element  in  disease ;  and 
may  be  of  opinion  that  its  discussion  would  be  more  appropriate  in  a  course 
on  general  pathology  than  in  my  clinical  lectures.  I  have  not,  however, 
been  at  all  afraid  of  going  out  of  my  province  in  thus  discoursing  to  you, 
for  though  it  be  perfectly  true  that  the  subject  belongs  to  the  domain  of 
pathology,  it  is  equally  certain,  as  I  have  already  remarked,  that  it  meets 
us  every  moment  at  the  patient's  bedside,  inasmuch  as  it  is  dominant 
throughout  the  whole  of  practical  medicine.  Its  clinical  importance  ap- 
pears to  me  to  be  so  great,  that  I  desire  still  to  make  some  additional  re- 
marks upon  it,  with  a  view  to  show  you  how  useful,  nay  how  necessary  for 
diagnosis,  prognosis,  and  treatment  it  is,  to  understand  the  specific  element 
of  diseases.  By  placing  before  you  additional  details,  I  shall  show  you  that 
a  knowledge  of  the  specific  element  in  disease  is  the  key  of  medicine,  with- 
out which  it  is  impossible  to  proceed  successfully  in  the  practice  of  our  art. 

To  deny  the  existence  of  nosological  species,  or,  in  other  words,  not  to 
take  into  account  the  quality  of  the  morbific  cause,  and  to  consider  only  its 
quantity,  to  subordinate  the  nosological  to  the  physiological  element,  is  to 
maintain  the  uselessness  of  every  differential  diagnostic  except  that  which 
is  limited  to  the  determination  of  the  state  of  the  organ  affected,  and  the 
extent  of  the  affection  ;  since  the  nature  of  the  disease,  varying  only  in 
degree  without  changing  its  species,  is  necessarily  known. 

To  push  the  argument  to  its  ultimate  consequences :  what  advantage  is 
there  in  seeking  to  distinguish  small-pox  from  measles,  if  the  pustular  erup- 
tion which  characterizes  the  former  is  only  a  degree  of  inflammation  of  the 
skin  more  advanced  than  the  exanthem  which  characterizes  the  latter? 
The  partisans  of  the  dichotomic  schools — if  any  such  persons  exist  in  the 
present  day — would  refuse  to  push  the  doctrine  as  far  as  this.  When  such 
persons  have  to  do  with  diseases  manifesting  themselves  by  cutaneous  erup- 
tions, their  first  anxiety  is  to  discover  whether  they  have  a  case  of  small- 
pox, roseola,  measles,  or  scarlatina:  in  spite  of  themselves,  they  admit  the 
specific  element,  for  their  diagnosis  is  based  on  the  specific  characters  of 
the  eruptions. 

If  all  accept  this  principle  in  respect  of  diseases,  the  anatomical  mani- 
festations of  which  appear  on  the  skin,  I  ask,  why  was  it  necessary  for 
Bretonneau  and  his  pupils,  physicians  and  surgeons,  to  use  such  great  exer- 
tions to  generalize  and  apply  to  other  diseases,  the  doctrine  of  specific 
causes?  Why,  I  ask,  in  the  different  phlegmasia,  in  those  tor  example 
affecting  the  mucous  membranes,  has  there  been  so  obstinate  a  determina- 
tion to  sec  inflammations  identical  in  their  nature,  and  varying  only  in  seal 
and  degree? 

Thus,  according  to  the  system  which  I  am  now  combating,  dothinenteria 
and  dysentery  are  both  forms  of  enteritis,  as  arc  also  intestinal  catarrh, 
colitis,  and  other  inflammatory  affections  of  the  intestines  produced  by  the 
action  of  sulphuric  acid,  arsenic,  croton   oil,  or  any  other  irritant    poiSOU. 

The  anatomical  characters  nf  these  diseases  is  essentially  different  :  and  do 

what    you  will,  you  will    never   he  able   t<>   produce   by  means  of  sulphuric 

acid  the  Lesions  produced  by  arsenious  acid,  or  croton  nil;  ami  still  more 
obvious  is  it,  that  by  none  of  these  agents  could  you  produce  the  lesion-  of 

dothinenteria.      In    respect    of  the   other   characters,    the   existence   of  the 

specific  clement  is  still  more  conspicuous.  Dysentery  and  colitis  possess  a 
similitude  in  kind :  both  arc  ulcerative  inflammations  of  the  large  intestine; 

hut  still  they  have  character.-  so  distinctive  that  it  IS  impossible  to  mistake 


SPECIFIC    ELEMENT    IN    DISEASE.  453 

the  one  for  the  other.  I  shall  have  occasion  to  point  out  their  respective 
characters  during  the  course  of  these  lectures. 

The  same  remarks  are  applicable  to  affections  of  the  respiratory  organs. 

In  the  simplest  catarrh,  in  hooping-COUgh,  and  in  asthma,  the  dichotomists 
see  onlv  bronchial  phlegmasia,  and  do  not  stop  to  consider  the  individual 
peculiarities  by  which  they  are  distinguished  from  one  another.  When  1 
come  to  speak  to  you  of  these  different  diseases,  I  shall  take  care  to  describe 
their  characters;  hut,  for  the  present,  let  it  suffice  to  say,  that  it  is  of  the 
utmost  importance  to  be  acquainted  with  them,  so  as  to  be  able  to  avoid 
confounding  simple  enteritis  with  follicular  enteritis  or  dothinenteria,  or 
hooping-cough  and  asthma  with  simple  bronchitis. 

The  importance  of  this  kind  of  knowledge  is  very  great  in  relation  both 
to  prognosis  and  treatment.  I  have  already  called  your  attention  to  this 
poiut  when  speaking  of  dothinenteric  catarrh  of  the  intestinal  canal.  I  then 
told  you  that  that  affection  was  one  of  great  danger ;  that  the  progress  of 
simple  enteritis  and  dothinenteric  enteritis  was  quite  different;  and  that 
when  the  practitioner  is  not  acquainted  with  the  natural  course  of  each 
species,  he  cannot  form  a  correct  prognosis.  Take  another  example.  A 
patient  comes  with  sore  throat :  he  states  that  on  the  previous  evening,  con- 
sequent on  a  chill,  he  was  seized  with  general  discomfort,  pains  in  the  back 
and  limbs,  rigors,  loss  of  appetite,  and  fever.  Next  day  he  complains  of 
difficulty  of  deglutition,  and  there  is  swelling,  but  only  slight  swelling,  of 
the  submaxillary  glands.  Upon  examination  of  the  pharynx,  it  is  found 
that  there  is  swelling  of  the  tonsils,  with  redness  of  the  pillars  of  the  veil  of 
the  palate,  and  that  a  secretion  having  exactly  the  appearance  of  false 
membrane  covers  the  affected  surface.  Let  us  suppose  that  you  were  sent 
for  at  the  same  time  to  see  another  patient  also  affected  with  plastic  sore 
throat,  but  in  whom  there  was  a  different  development  of  the  disease.  With- 
out any  appreciable  cause,  he  had  experienced  for  some  days  general  un- 
easiness accompanied  by  fever :  the  sore  throat  was  much  less  painful  in 
this  patient  than  in  the  other.  If  you  only  take  into  account  the  anatomi- 
cal element  common  to  both  cases,  the  resemblance  between  the  two  is  com- 
plete. The  scalpel,  the  microscope,  and  chemical  analysis  will  all  demon- 
strate that  in  both  cases  the  false  membranes  are  identically  the  same :  to 
judge  from  appearances,  the  last-mentioned  patient  seems  the  least  unwell 
of  the  two.  But  if  you  allow  the  diseases  of  both  to  run  their  course  with- 
out interference,  you  will  see  that  the  malady  which  set  in  with  the  greatest 
violence  and  most  acute  pain,  and  was  accompanied  by  a  degree  of  fever 
absent  in  the  second  case — you  will  see,  I  say,  the  acute  sore  throat  get 
quite  well  spontaneously  and  quickly,  leaving  no  trace  behind ;  while  the 
other  may  carry  off  the  patient  with  symptoms  of  general  poisoning,  or  by 
suffocation  consequent  upon  the  development  of  pseudo-membranous  laryn- 
gitis or  croup.  In  both  cases,  however,  there  was  plastic  sore  throat ;  but 
with  this  difference,  that  in  the  one  case  the  malady  was  common  membra- 
nous sore  throat,  that  is  to  say,  herpes  of  the  pharynx,  which  is  seldom  a 
serious  disease,  while  the  other  was  malignant  membranous  sore  throat — 
diphtheritic  sore  throat — which  is,  as  a  general  rule,  a  very  formidable 
malady.  You  see  then,  gentlemen,  that  under  such  circumstances,  as  I 
have  now  been  supposing,  it  was  important  to  be  acquainted  with  the  specific 
character  of  the  two  diseases  so  similar  in  appearance;  for  you  might  in  the 
one  case  mistake  a  malady  naturally  benignant  for  one  of  formidable  char- 
acter, and  in  the  other  you  might  prognosticate  a  mild  attack,  while  the 
case  was  destined  to  terminate  in  death,  or  in  a  long  and  checkered  conva- 
lescence, retarded  perhaps  by  paralysis  more  or  less  general,  and  more  or 
less  persistent. 


454  SPECIFIC    ELEMENT    IX    DISEASE. 

I  need  not  on  this  occasion  multiply  examples  to  illustrate  this  point; 
for  we  shall  only  have  too  many  opportunities  of  returning  to  the  subject 
of  the  specific  element  of  disease,  which,  as  I  have  said,  constantly  presents 
itself  in  the  course  of  the  clinic.  I  now  come  to  that  aspect  of  the  subject 
which  bears  on  therapeutics. 

Gentlemen,  to  cure,  and,  when  that  cannot  be  done,  to  alleviate  the  suf- 
ferings of  patients,  is  the  object  of  medicine.  The  fact  that  the  term  medi- 
cine is  derived  from  the  Latin  verb  mederi,  signifying  to  take  care  of,  to  apply 
a  remedy,  to  cure,  sufficiently  points  out  the  nature  of  our  mission.  Thera- 
peutics, as  it  comprises  the  study  of  the  means  by  which  we  hope  to  carry 
this  out,  is  consequently  the  most  important  department  of  our  art,  and.  as 
you  know,  it  is  by  far  the  most  difficult.  While  treatment  is  dependent 
upon  the  experience,  talent,  and  tact  of  the  physician,  it  is  still  more  sub- 
ordinate to  the  nature  of  the  disease  which  he  wishes  to  cure,  to  particular 
conditions  under  which  the  disease  exists,  to  the  peculiarities  iu  the  organi- 
zation of  the  patient,  and  to  a  host  of  circumstances  too  frequently  unknown. 
The  treatment  of  diseases  necessarily  rests  upon  a  knowledge  of  their  symp- 
toms, but  it  is  also  based  in  a  special  manner  upon  a  knowledge  of  their 
causes  and  their  natural  history;  and  it  is  from  the  latter  description  of 
knowledge  that  a  just  appreciation  is  obtained  of  the  important  part  per- 
formed in  disease  by  the  specific  element. 

How  is  it  possible  to  estimate  the  value  of  a  method  of  treatment,  or 
form  an  opinion  as  to  the  efficiency  of  a  remedy,  if  the  operations  of  nature 
— to  use  an  expression  of  our  predecessors — are  ignored,  operations  which 
are  different  in  the  different  species  of  diseases '?  By  not  discriminating 
between  these  different  species,  do  we  not  incur  the  risk  of  attributing 
great  virtues  to  medicines  which  have  in  reality  no  remedial  power,  and 
of  refusing  to  admit  that  others  possess  any  therapeutic  properties,  al- 
though their  utility,  when  administered  under  suitable  circumstances,  is 
undoubted. 

It  is  thus  that  we  explain  the  fact  that  some  have  extolled  pretended 
substitutes  for  cinchona,  while  others  have  blamed  cinchona  for  transform- 
ing intermittent  fever  into  malignant  dothinenteria.  The  former  had  to 
do  with  simple  cases  of  common  continued  fever,  which  would  have  got 
well  of  themselves,  and  which  were  at  the  commencement  invested  with 
the  intermittent  form  ;  the  latter  had  to  do,  not  with  marsh  fevers,  but 
with  cases  of  dothinenteria  which  had  an  intermittent  type  at  the  onset — 
such  were  the  eases  of  fever  the  fatal  progress  of  which  was  not  arrested 
by  cinchona.  This  is  a  topic  to  which  1  have  already  directed  your  atten- 
tion when  lecturing  on  dothinenteria. 

In  the  same  way,  if  a  simple  colitis  accompanied  by  bloody  stools  is  mis- 
taken for  dysentery — a  mistake  which  I  see  committed  every  day — il  is 
impossible  to  avoid  very  erroneous  conclusions  in  therapeutics.  It  is  sup- 
posed, for  example,  that  dysentery  has  been  cured  by  a  few  leeches  and 
emollient  enemata,  because  in  the  cases  in  question  there  existed  profuse 
bloody  discharge,  frequenl  stools,  much  straining,  and  high  fever;  whereas, 
in  reality,  the  affection  was  one  from  which  there  would  have  been  recovery 
in  a  few  days,  without  any  treatment  whatever  having  been  employed. 
Confronted  with  a  case  of  real  dysentery,  the  practitioner  applies  the  same 
treatment  he  followed,  as  he  thoughl  with  such  amazing  success,  in  the  case 
of  colitis,  which  would  have  got  well  had  he  refrained  from  all  treatment, 
and  he  is  astonished  at  il-  failure. 

You  are  called  in  to  a  patient  suffering  from  great  dyspnoea.  His  respi- 
ration is  accompanied  by  a  whistling  in  the  larynx,  which  at  once  attracts 
your  attention  :  on  carrying  your  finger  behind  the  base  of  the  tongue,  you 


SPECIFIC    ELEMENT    IN    DISEASE.  455 

discover  thai  there  is  swelling  of  the  epiglottis  and  aryteno-epiglottidean 
ligaments;  on  making  pressure  over  the  larynx,  pain  is  caused.  Y<>n  are 
told  thai  the  person  began  to  lose  his  voice  two  or  three  months  ago,  and 
thai  from  that  period,  it  had  become  feebler  and  feebler,  till  at  lasl  there 
was  complete  aphonia.  Inspiration,  at  first  whistling  only  during  sleep, 
or  after  walking  rather  quickly  or  ascending  a  stair,  has  become  similarly 
characterized  when  the  patient  is  in  repose:  the  oppression  of  the  breath- 
ing has  increased  so  rapidly,  that  when  yon  are  summoned,  you  see  that 
unless  a  change  for  the  better  very  soon  take  place,  tracheotomy  will  he 
the  sole  remaining  means  of  preventing  death.  Upon  inquiry,  yon  learn 
that  the  cedeina  of  the  glottis,  depending  upon  serious  lesions  of  the  larynx, 
the  cartilages  of  which  are  perhaps  necrosed,  or  at  least  the  mucous  mem- 
brane of  which  is  ulcerated — you  learn  that  the  laryngeal  affection  was 
some  considerable  time  preceded  by  other  local  symptoms.  The  individual 
is  stated  to  have  had  chronic  coryza,  characterized  by  a  bad  nasal  dis- 
charge, to  have  thrown  off  crusts  from  the  mucous  membrane  of  the  nose, 
from  which  organ  a  fetid  odor  is  exhaled :  you  find  that  he  has  also  had 
tumors  on  the  bones.  Without  proceeding  any  further,  you  diagnose 
syphilis,  aud  forthwith  institute  a  system  of  treatment  under  which  re- 
covery proceeds.  From  the  suffocative  seizures  having  been  of  so  formi- 
dable a  kind  as  to  place  the  life  of  the  patient  in  imminent  peril,  you  have 
performed  tracheotomy  ;  and  in  doing  so,  you  have  been  aware  that  your 
operation,  by  retarding  death,  justified  the  hope  of  the  patient  being  re- 
stored to  perfect  health. 

By  a  fortuitous  concurrence  of  circumstances,  such  as  often  happens  in 
practice,  you  may  at  the  same  time  have  been  sent  for  to  attend  another 
patient  also  affected  with  oedema  of  the  glottis,  but  in  whom  you  have 
found  the  disease  associated  with  the  tubercular  diathesis.  Now,  if  in  the 
latter  case,  taking  into  account  only  the  condition  of  the  larynx,  if,  ignor- 
ing the  specific  cause  of  the  disease,  you  try  to  obtain,  by  the  same  means, 
results  similar  to  those  obtained  in  the  other  case,  you  will  inevitably  fail. 

You  may  see  in  the  same  ward  of  an  hospital,  three  patients  with  neu- 
ralgia of  the  fifth  pair :  in  one,  the  paroxysms  return  every  day,  and  are 
characterized  by  horrible  pains  which  continue  for  six  or  ten  hours,  accom- 
panied by  lachrymation,  coryza,  and  salivation:  in  another,  the  neuralgia 
retui'ns  four  or  five  times  in  the  twenty-four  hours,  is  accompanied  by  the 
same  phenomena  as  in  the  first  case,  but  only  lasts  for  two  hours :  in  the 
third  patient,  the  fits  recur  at  least  every  two  or  three  hours,  and  last  at  the 
most  for  a  minute,  but  they  occasion  agonizing  pain,  and  are  accompanied 
by  convulsive  movements  of  the  face.  The  three  affections  are  apparently 
similar,  and  occupy  the  same  seat:  the  first,  being  an  intermittent  fever  in 
a  metamorphosed  form  will  yield  to  cinchona :  the  second  will  be  advan- 
tageously attacked  by  preparations  of  iron,  if  connected  with  a  ehlorotic 
condition  of  the  patient,  or  by  veratria,  colchicum,  or  the  external  use  of 
belladonna,  if  the  case  is  rheumatic  neuralgia  consequent  upon  a  chill:  but 
the  third  will  resist  every  kind  of  treatment,  for  it  is  tic  douloureux  or  epi- 
leptiform neuralgia. 

A  great  many  similar  facts  might  be  adduced,  but  from  those  now  stated 
you  can  understand  that  in  treating  diseases  it  is  absolutely  necessary  to 
bear  in  mind  their  specific  element.  I  must  state,  however,  that  in  some 
cases  a  knowledge  of  this  element  proves  of  very  little  consequence.  In 
eruptive  fevers,  for  example,  following  their  regular  course,  the  interven- 
tion of  art  is  either  quite  useless,  or  very  rarely  of  any  benefit. 

I  have  hitherto  spoken  only  of  the  specific  character  of  diseases;  and  now 
I  have  a  few  words  to  say  regarding  the  specific  properties  of  medicines.   AVe 


456  SPECIFIC    ELEMENT    IN    DISEASE. 

need  not  be  long  detained  by  this  subject,  if  we  adopt  Parr's  definition  of 
specific  remedies,  and  understand  by  that  term  only  those  medicines,  which, 
like  quinine  in  intermittent  fever  and  mercury  in  syphilis,  produce  always, 
and  in  all  patients,  the  salutary  effects  attributed  to  them — acting  upon  the 
malady  in  virtue  of  an  unknown  power,  attacking  in  a  direct  manner  its 
very  essence,  without  its  being  necessary  for  the  prescriber  to  take  into  ac- 
count the  form  in  which  the  symptoms  appear.  We  should  veiy  soon  ex- 
haust the  list  of  specifics,  were  we  to  restrict  iii  this  manner  the  application 
of  the  term;  for  there  is  not  a  specific  remedy  for  every  disease  which  has 
a  specific  character.  Again,  in  practice,  we  do  not  always  find  specific 
remedies  so  efficacious  as  we  have  expected  them  to  prove.  Indeed,  it  some- 
times happens  that  medicines  very  justly  called  specifics  not  only  fail,  but 
even  aggravate  a  malady,  which,  judging  from  their  usual  action,  they 
ought  to  have  cured.  In  such  cases,  we  must  abandon  them,  and  have 
recourse  to  the  use  of  remedies  called  rational,  or  in  other  words,  to  those 
which  are  indicated  by  the  symptoms. 

Two  women,  who,  at  an  interval  of  some  months,  successively  occupied 
the  same  bed  in  St.  Bernard's  Ward,  furnished  facts  in  support  of  this 
proposition.  They  both  had  syphilis  :  mercury  administered  according  to 
rule,  and  in  a  very  guarded  manner,  had  checked  the  progress  of  the  symp- 
toms, when  it  became  necessary  to  suspend  the  use  of  the  medicine:  the 
patients  had  fallen  into  a  very  bad  state  of  chl orotic  cachexia,  rendering 
obligatory  recourse  to  preparations  of  iron,  under  the  influence  of  which 
their  health  was  rapidly  re-established.  In  other  patients  you  will  see  still 
more  formidable  symptoms  arise:  you  will  see  an  extension  of  ulcerations 
which  the  mercurial  treatment  ought  to  have  cicatrized;  at  other  times  the 
alimentary  canal  becomes  irritable,  fever  is  set  up,  and  a  pseudo-syphilis 
supervenes,  complicating  and  altering,  without  curing,  the  true  syphilis. 

In  short,  gentlemen,  the  action  of  specific  remedies  does  not  materially 
differ  from  the  action  of  those  called  rational.  The  curative  action  of  both 
is  preceded  by  a  vital  action,  which  they  excite:  this  may  be  called  their 
immediate  or  physiological  effect.  The  difference  between  their  operation 
consists  in  the  specifics  exerting  a  special  and  direct  influence  upon  the 
pathological  actions  which  they  modify,  their  immediate  effects  merging 
into  the  remote  or  curative  effects;  while  in  respect  of  the  remedies  called 
rational,  the  two  kinds  of  effects  appear  distinct  from  one  another. 

Without  stopping  longer  to  consider  this  scholastic  distinction,  suffice  it 
to  say,  that  medicines  which  modify  the  organism  in  a  pathological  state, 
in  the  same  way  that  hygienic  agents  modify  the  organism  in  a  stale  of 
health,  have  properties  common  to  the  whole  class  of  medicines  to  which 
they  belong;  and  only  excite  in  the  economy  a  common  or  general  action, 
such  as  stimulating  or  depressing,  irritating  or  calming.  But  along  with 
these  common  properties,  they  each  possess  special  properties  which  pro- 
duce specific  effects;  and  the  two  kinds  of  properties,  iuasmuch  as  they 
exist  in  very  variable  proportions,  also  manifest  themselves  in  very  ditler- 
ent  ways,  according  to  the  individual  predispositions  of  the  subjects  to 
whom  the  medicines  are  administered.  This  is  what  I  understand  by  the 
specific  action  of  medicines. 

To  develop  fully  this  subject,  which  embraces  the  whole  domain  of  thera- 
peutics, would  carry  me  far  beyond  the  limits  which  I  have  prescribed  for 
myself,  as  it  would  oblige   me  to  review,  it'  not  all  medicinal  substances,  at 

Least  all  systems  of  medicinal  treatment.  I  refer  you,  therefore,  to  the  treatise 

On  therapeutics  which  1  have   published    in   conjunction  with   my  colleague 
and   Learned  friend  Dr.  Pidoux;   and    in   particular  I  ask  yon  to  read  that 


CONTAGION.  457 

portion  of  it  in  which  we  speak  of  substitutive  treatment  [medication  sub- 
stitutive], a  method  of  proceeding  entirely  based  on  the  existence  of  a 
specific  element  in  disease,  the  doctrine  which  we  have  now  been  briefly 
considering. 


LECTURE  XXIII. 

CONTAGION. 

Definition. — Parasitical  Diseases  are  not  included. — /Spontaneous  Development 
of  Morbific  Germs. — Infection. — Infectious  Diseases  may  become  Conta- 
gious.— Dormant  State  of  Germs. — Difference  between  Infection  and  Con- 
tagion.— Morbific  Matter. —  Conditions  of  Contagion:  inherent  in  Indi- 
viduals and  in  Germs. — Immunity,  Temporary  and  Absolute. —  Conditions 
as  to  Age  and  Previous  Contamination. — Acclimation  and  Habit. — Ap- 
parent Immunity. — Modes  of  Transmission. —  Contact. — Direct  Inocula- 
tion.— Inhalation. 

Gentlemen:  The  question  of  contagion  is  so  intimately  connected  with 
that  of  the  specific  element  in  disease,  as  to  form  its  necessary  complement. 

The  term  contagion  has  been  very  variously  defined ;  but  the  definition 
which  seems  to  me  to  be  the  most  accurate  is  that  of  Dr.  Anglada,  of  Mon- 
pellier.  It  may  be  objected  to  on  account  of  its  length,  but  if  this  be  a 
fault,  it  is  one  which  must  be  attributed  to  the  nature  of  the  subject,  and 
not  to  the  author :  in  fact,  it  is  on  account  of  its  completeness  that  I  prefer 
it  to  other  definitions. 

Contagion,  adopting  the  definition  of  Dr.  Anglada,  I  regard  as  "  the 
transmission  of  a  disease  from  one  person  affected  with  that  disease  to  one 
or  more  other  persons  through  the  medium  of  a  material  cause  [principe 
materiel],  the  product  of  a  specific  morbid  elaboration  :  this  material  cause 
communicated  to  an  individual  in  a  state  of  health  determines  the  same 
phenomena  and  symptoms  in  him  as  were  observed  in  the  individual  from 
whom  the  germ  proceeded."* 

The  necessity  of  the  transmitted  material  cause  being  elaborated  excludes 
from  this  definition  parasitic  diseases,  which  have  been  considered  conta- 
gious by  some  physicians.  In  fact,  itch,  porrigo  decalvans,  thrush,  &c, 
though  communicated  from  person  to  person,  cannot  be  looked  on  as 
contagious  affections.  Were  we  to  admit  that  the  acarus  scabiei,  tricho- 
phyton tonsurans,  and  oidium  albicans  are  transmissible  by  contagion,  it 
would  likewise  be  necessary  to  hold  that  the  parasitic  animals  which  infest 
the  exterior  of  the  body,  such  as  bugs,  fleas,  and  the  different  kinds  of  lice, 
are  also  similarly  communicated.  But  it  has  never  occurred  to  any  one  to 
maintain  such  a  proposition.  I  grant,  however,  that  there  is  a  certain 
analogy  between  parasitic  and  contagious  diseases  ;  for  while  it  is  impossible 
for  any  one  to  say  that  lice  are  contagious,  such  a  statement  might  be  made 
with  some  verisimilitude  in  respect  of  the  trichophyton  of  porrigo  decalvans 
and  the  oidium  albicans  of  thrush.  Pushing  nutters  to  the  extreme,  it 
might  then  be  alleged  that  the  contagion  of  small-pox  is  simply  a  parasite, 

*  Anglada:  Traite  cle  la  Contagion,  pour  servir  a,  l'histoire  des  Maladies  Con- 
tagieusea  et  des  Epidemies.     T.  i,  p.  12.     Paris:  1853. 


458  CONTAGION. 

which,  like  the  oidium  albicans  is  transmitted  from  one  person  to  another. 
I  anticipate  the  objection  which  will  be  taken  to  this  line  of  argument,  and 
I  confess  that  I  am  in  a  rather  awkward  position  to  reply  to  it,  as  I  hold 
that  contagious  diseases  sow  themselves  by  seed,  and  are  consequently  trans- 
mitted by  germs.  Still,  I  stand  out  for  the  distinction  which  I  have  drawn, 
maintaining  that  it  is  established  by  the  capital  fact  that  there  is  this 
difference  between  contagious  and  parasitic  diseases,  that  in  the  former,  the 
material  morbid  cause  eludes  my  observation,  while  in  the  latter,  I  can  lay 
hold  of  it.  I  can  see,  and  I  can  isolate  the  mycelium  of  thrush,  the  tricho- 
phyton of  porrigo  decalvans,  and  the  acarus  of  scabies;  and,  placing  them 
in  the  field  of  my  microscope,  I  can  study  and  describe  their  characters. 
This  I  could  not  do  with  the  morbific  germs  of  small-pox,  measles,  or 
scarlatina,  which,  unlike  the  parasites,  have  not  an  independent  existence, 
but  require  an  organized  and  living  substratum,  to  enable  them  to  exist, 
and  to  show  that  they  exist. 

Other  affections,  which  by  an  overstrained  employment  of  the  term,  have 
been  called  contagious,  are  also  excluded  from  Anglada's  definition.  Every 
day  I  hear  people  say  that  laughing  and  yawning  are  contagious.  The 
expression  must  be  regarded  as  only  a  figure  of  speech:  according  to  the 
same  phraseology,  certain  nervous  diseases  are  contagious.  Who  does  not 
know  the  history  of  the  women  of  Abdere,  of  the  nuns  of  Loudun,  of  the 
choreomaniacs  of  the  middle  ages,  of  the  convulsionaries  of  St.  Medard, 
and  a  hundred  other  similar  histories,  which  have  been  a  hundred  times 
told.  In  these  cases  we  cannot,  speaking  the  language  of  medical  science, 
use  the  term  contagion;  we  must  employ  the  word  imitation. 

Infection,  when  used  to  signify  a  morbific  cause,  is  frequently  employed 
to  point  to  something  different  from  or  in  contrast  with  contagion:  it 
differs  from,  but  does  not  exclude  contagion.  Frascator  was  the  first  author 
who  thoroughly  appreciated  this  distinction:  his  researches  into  the  nature 
of  syphilis  led  him  to  study  the  question.  In  his  work  "De  Contagionibus," 
he  wrote  these  words:  "Qui  hausto  veneno  pereunt,  infecti  esse  dicimus, 
minime  autem  accepisse  contagiouem." — Of  those  who  die  alter  taking  a 
poisoned  draught,  we  say  that  they  are  infected:  we  do  not  say  that  they 
have  received  contagion.  Frascator  established  the  differences  which  he 
pointed  out :  I  am  also  now  going  to  establish  them. 

A  person  is  stung  by  a  wasp,  or  bitten  byaserpent:  the  venom  introduced 
into  the  system  forthwith  produces  symptoms  which,  according  to  the  circum- 
stances, are  more  or  less  serious,  or  fatal  :  this  is  infection.  If  it  lie 
objected,  that  the  genu  of  the  disease  coining  from  an  animal  and  being 
by  it  transmitted  to  a  mail,  contagion  might  be  averred  according  to  Dr. 
Anglada's  definition,  I  reply  by  quoting  the  very  terms  of  the  definition 
itself,  from  which  it  appeal's,  t  hat  while  there  has  been  t  rausmission  of  a  genu 
developed  within  a  living  organism,  that  transmission  has  not  taken  place 
from  a  sick  to  a  healthy  individual,  nor  has  there  been  anything  morbid 
in  its  elaboration  within  the  animal  which  produced  it.  To  use  Frascator's 
expression,  there  has  been  a  poisoned  draught,  ami  nothing  more:  the 
manner  in  which  the  haustus  or  the  absorption  has  taken  place  is  of  no 
consequence.  A  person  Buffers  from  symptoms  resulting  from  unwholesome 
diet,  from  the  daily  n-e,  for  example,  of  flour  containing  a  certain  admix- 
ture of  ergot  of  rye:  in  such  a  ease,  could  it  he  said  that   there  hail  been 

Contagion?      No:    hut    it    could    he    correctly    slated,    that    there    had    been 

infection.  Or  again,  in  place  of  entering  the  system  through  the  medium 
of  the  digestive  organs,  the  infection  may  have  effected  its  entrance  by  the 
respiratory  passagee,  as  takes  place  in  diseases  occasioned  by  various 
deleterious  gases.      Here  again   is  the  poisoned  draught:    he  it  venom, 


CONTAGION.  459 

poison,  or  deleterious  gas,  you  can  take  hold  of  the  morbific  cause;  but 
there  are  other  cases  in  which  the  cause  is  quite  unknown.  Take  the  case 
of  a  man  living  in  the  vicinity  of  a  marsh,  and  let  lis  suppose  thai  the 
ground  in  the  neighborhood  of  his  dwelling  has  been  recently  turned  up: 
the  mosl  acute  sense  of  smell  cannol  detect  any  unpleasant  odor,  vegetation 
is  everywhere  luxuriant,  the  air  seems  in  all  respects  salubrious :  the  man 
nevertheless  is  attacked  by  illness — by  intermittent  fever.  He  has  been 
infected  by  a  morbific  germ  contained  in  thai  air  apparently  so  pure:  the 
germ,  though  it  only  reveal  itself  by  its  effects  on  a  living  organism,  does 
not  the  less  certainly  exist.  In  this  ease,  we  should  not  say  that  there  had 
been  contagion,  but  that  there  had  been  infection  ;  for  here,  as  in  the  other 
illustrations  which  I  have  adduced,  there  was  no  transmission  of  a  disease 
from  a  diseased  to  a  healthy  person:  the  morbid  cause  which  engendered 
the  malady  was  not  the  result  of  a  morbific  elaboration  within  another 
animal.  The  definition  of  Dr.  Anglada  is  sufficiently  comprehensive  to 
meet  all  these  differences. 

When  the  diseases  which  are  designated  "infectious  "  originate  under 
the  conditions  which  I  have  just  been  pointing  out,  under  conditions  of  a 
manifestly  vitiated  atmosphere,  as  well  as  when  the  vitiation  is  not  cogniz- 
able by  our  senses,  we  say  that  there  has  been  infection.  But  our  science 
is  completely  at  fault,  when,  without  any  apparent  change  in  the  telluric 
or  atmospheric  conditions  of  a  locality,  there  supervene  what  are  called 
epidemics. 

Thus,  at  the  end  of  March,  1832,  when  cholera  came  for  the  first  time 
to  commit  its  ravages  among  us,  the  weather  was  cold  and  dry,  with  beau- 
tiful sunshine  :  there  was  no  apparent  change  in  the  geological  constitution 
of  the  soil,  nor  in  the  meteorological  constitution  of  Paris ;  and  yet  the  dis- 
ease as  soon  as  it  was  developed  spread  with  frightful  rapidity.  If  trans- 
mission by  contagion  had  been  given  as  the  explanation  of  this  rapid  spread 
of  the  disease,  it  would  most  certainly  have  been  at  once  confuted  by  the 
manner  in  which  the  epidemic  dealt  its  first  blows.  It  would  have  been 
necessary  to  seek  the  explanation  in  some  general  influence  existing  in  the 
external  world  ;  or,  in  other  words,  to  admit  infection,  without  being  able 
to  demonstrate  the  cause. 

There  is  another  circumstance  which  it  is  necessary  to  take  into  account. 
If  a  malady  believed  to  be  contagious  is  only  propagated  in  the  same  place, 
and  does  not  extend  beyond  the  locality,  even  when  a  large  number  of  con- 
taminated persons  are  assembled  together  and  are  in  contact  with  healthy 
persons,  the  contagiousness  of  the  disease  is  disproved,  and  we  say  that  it 
is  only  infectious.  But  I  have  often  asked  myself,  whether  sojourn  in  an 
infected  place  does  not  induce  a  predisposition  in  virtue  of  which  the 
slightest  contagion  might  act  energetically,  although  the  same  contagion 
increased  tenfold  in  power  would  be  incapable  of  affecting  an  organism 
not  predisposed  by  local  infection?  I  have  always  been  astonished  at  the 
immunity  sometimes  enjoyed  in  a  town  where  there  prevailed  an  epidemic 
reputed  not  to  be  contagious,  by  persons  who  carefully  avoided  communi- 
cation with  the  sick. 

Here,  gentlemen,  arises  the  great  question  of  spontaneous  origin  of  epi- 
demic and  eontagious  diseases  simultaneously  affecting  large  numbers  of 
persons. 

Can  diseases  really  arise  spontaneously?  Or,  are  they  in  some  sort  of 
way  innate  in  the  human  species?  Are  they,  as  our  predecessors  said, 
originally  present,  their  power  remaining  in  posse,  ready  to  manifest  itself, 
waiting  to  enter  in  actu,  upon  favoring  circumstances  arising?  Home  phy- 
sicians adopt  this  latter  proposition  :  in  their  opinion,  the  germs  of  disease 


460  CONTAGION. 

are  coeval  with  the  human  race,  every  individual  having  them  iu  his  body, 
apoihecam  hoc  virus  recondentem  guivis  homo  in  se  gerit,  aud  they  suppose 
that  sooner  or  later  these  germs  develop  fermentem  morbosum,  nunc  citrus 
nunc  serius  aetuosum  redditur.  This  opinion,  in  former  times  maintained 
by  men  of  the  greatest  eminence,  though  opposed  by  others  of  equal  repute, 
has  still  some  supporters.  It  does  not,  however,  require  a  prolonged  study 
of  the  question  to  side  with  those  who  deny  the  pre-existence  of  morbid 
germs,  and  believe  in  their  spontaneous  development.  To  arrive  at  this 
conclusion,  it  is  only  necessary  to  remember  that  some  of  the  most  con- 
tagious diseases,  such  as  pox  and  small-pox,  were  unknown  to  Hippocrates, 
Celsus,  Aretreus,  and  Galen,  and  consequently,  were  non-existent  in  the 
times  of  these  great  observers.  As  I  formerly  remarked,  when  discussing 
this  subject  in  relation  to  vaccination,  they  could  not  possibly  have  failed 
to  describe  diseases  possessing  such  precise  characters,  had  they  seen  them. 
Pox,  as  you  are  aware,  was  not  very  well  known  till  after  the  fifteenth 
century,  although  historiaus  mention  its  existence  in  the  times  of  the  Cru- 
sades. There  is  no  positive  mention  of  small-pox  till  the  seventh  century,  as 
is  stated  by  Sprengel  in  noticing  an  epidemic  of  that  disease  which  occurred 
in  565,  and  another  which  occurred  in  Arabia  in  572.*  Is  it  possible  to 
believe  that  the  germs  of  the  disease  were  coexistent  with  the  human  race, 
and  remained  for  so  many  ages  in  a  state  of  incubation  *? 

Spontaneous  development,  then,  in  respect  even  of  the  most  contagious 
diseases,  must  be  admitted.  As  contagion  necessarily  implies  the  presence  of 
two  individuals,  the  one  the  giver  and  the  other  the  receiver  of  the  morbid 
germ,  it  is  a  truth,  so  self-evident  as  not  to  require  to  be  stated,  that  in  the 
first  sufferer  from  the  disease  its  origin  must  have  been  spontaneous,  though 
wholly  under  the  influence  of  unknown  causes. 

"While  there  is  reason  to  believe  that  at  present  some  diseases,  such  as 
syphilis,  small-pox,  and  measles,  are  always  reproduced  by  contagion,  that 
that  is  now  their  sole  mode  of  originating,  there  are  other  maladies  which 
we  constantly  see  arise  spontaneously.  Does  not  rabies  become  developed 
in  animals  of  the  canine  and  feline  species  under  the  influence  of  particular 
causes,  irrespective  of  any  contagion  or  antecedent  inoculation?  The  cases 
are  numerous  and  indisputable.  It  is  so  likewise  with  the  malignant  car- 
buncle [sang  de  rate]  in  animals  of  the  ovine  species:  this  disease  is  spon- 
taneously developed  by  sheep  under  the  influence  of  certain  telluric  atmos- 
pheric, and  alimentary  conditions.  Interesting  observations  made  by 
physicians  of  the  department  of  Eure-et-Loir,  an  account  of  some  of  which 
you  will  find  reproduced  in  the  pain-taking  work  on  Anthrax:  Carbo,  by 
Dr.  Raimbert  of  Chateaudun,  establish  this  fact  in  a  most  conclusive  man- 
ner^ and  also  show  that  special  conditions  of  soil  and  air  were  inherent  in 
the  localities  where  the  sang  de  rate  was  decimating  the  folds,  while  the 
disease  did  not  Bhow  itself  in  other  districts  unless  imported  into  them  by 
infected  Bheep. 

But  whatever  may  have  been  the  causes  which  originated  these  diseases, 
they  have  the  power  of  reproducing  themselves  by  contagion.  The  mor- 
bific germ,  which  in  its  first  generation  was  of  necessity  spontaneous,  repro- 
duces itself  within  the  body,  and,  in  \\<  turn,  furnishes  other  identically 
similar  germs  capable  of  continuing  the  morbid  species,  always  producing 
in  the  individuals  who  receive  them  effects  the  same  as  those  which  were 

*  Sprengel:  Bistoire  (]>■  la  Me'decine  depuie  boti  origine  jusqu'au  19*  sidcle ; 
traduite  de  1'allcmand  par  Jourdan,  1    ii,  pp.  198,  L99      Paris,  1816. 

;    Raimbert:  Nonveau  Dict.de  Bieaecine  et  de  Chirurgie  Pratiques.    Article 
<  barbon."    T.  vii.  Paria,  L867. 


CONTAGION.  461 

manifested  in  the  individuals  whence  the  germs  came;  and  being  capable 
in  the  same  manner,  without  any  change  of  character,  of  perpetuating 
themselves  in  indefinite  succession. 

For  the  accomplishment,  however,  of  this  transmission,  it  is  necessary 
that  it  should  take  place  between  individuals  of  the  same  species.  When 
there  is  diversity  of  species,  the  germ  either  ceases  to  be  transmissible,  or, 
when  it  does  pass  from  the  one  species  to  the  other,  it  produces  different 
effects. 

In  relation  to  the  first  point :  rabies,  for  example,  is  communicable  from 
the  dog  or  cat  to  man,  and  from  the  dog  to  other  animals,  producing  in  all 
of  them  symptoms  similar  to  those  observed  in  the  animal  from  which  they 
were  transmitted  ;  hut  there  stops  its  capability  of  transmission:  it  is  only 
communicable  by  man  and  individuals  of  the  genera  cards  or  felis.  In 
1826,  during  my  internat  at  Charenton,  I  several  times  received  on  the 
face,  lips,  and  eyes,  the  saliva  of  patients  affected  with  rabies,  without  any 
resulting  inconvenience.  Recently,  also,  my  chef  de  clinique,  Dr.  Dumont- 
pallier,  having  punctured  himself  with  an  instrument  which  he  had  used 
in  making  the  autopsy  of  a  patient  who  had  died  of  rabies,  did  not  expe- 
rience any  consecpiences  from  this  accident,  though  he  dreaded  their  occur- 
rence. M.  Raynal  of  Alfort  inoculated  several  dogs  with  the  saliva  of  the 
same  patient,  collected  both  before  and  after  death  ;  but  in  none  of  the 
cases  was  there  any  result. 

In  relation  to  the  second  point — let  me  recall  to  your  recollection  the 
remarks  I  made,  when  lecturing  to  you  on  vaccina,  regarding  the  transfor- 
mation of  the  disease  in  horses  called  grease  [eaux-aux-jambes]  into  cow-pox, 
and  of  cow-pox  into  vaccina ;  and  let  me  also  recall  to  your  recollection 
the  mutation  of  ovine  malignant  carbuncle  into  anthrax  carbo  and  malig- 
nant pustule.  It  would  appear  that  in  these  cases,  by  being  cast  into  a 
particular  soil,  the  morbific  seed  is  changed,  and  the  resulting  species  mod- 
ified :  so  obviously  is  the  change  dependent  on  the  nature  of  the  soil  or 
substratum,  that  malignant  anthrax  inoculated  from  cow  to  sheep — inoc- 
ulated under  certain  conditions — appears  in  the  latter  as  ovine  malignant 
carbuncle  [sang  de  rate]. 

Let  us  now  resume  the  subject  of  infection.  In  whatever  manner  infec- 
tion takes  place,  wdiether  it  be  by  a  miasm  or  a  virus,  or  by  the  agency  of 
an  unknown  cause,  contagion  is  not  excluded.  I  have  just  proved  to  you 
that  rabies  and  ovine  malignant  carbuncle  undoubtedly  become  contagious, 
and  I  could  establish  the  same  proposition  in  respect  of  other  diseases  which 
like  them  are  from  the  first  infectious. 

Dysentery  and  the  typhus  of  camps  are  striking  and  unchallengeable  ex- 
amples of  this.  Our  latest  and  glorious  campaign — the  Crimean  campaign 
— unfortunately  furnished  us  with  a  new  opportunity  of  judging  the  merits 
of  this  question.  The  typhus  which  so  cruelly  struck  down  our  soldiers  w:as, 
as  is  usual,  developed  under  the  influence  of  overcrowding,  or,  to  speak 
more  correctly,  under  the  influence  of  the  assemblage  of  a  large  number  of 
men  in  one  place.  The  morbid  germ,  produced  spontaneously  amid  con- 
ditions belonging  to  the  external  world,  and  elaborated  within  living  organ- 
isms, passed  by  contagion  to,  and  produced  typhus  in,  other  persons  who 
had  not  been  subjected  to  the  same  conditions  as  those  originally  attacked : 
through  the  sole  influence  of  contagion,  the  typhus  seized  the  victims,  not 
only  in  the  country  where  it  arose,  but  likewise  in  countries  distant  eight 
hundred  leagues:  it  was  brought  among  us  by  invalided  soldiers,  and  at- 
tacked persons  who  had  never  left  Paris.  As  you  know,  gentlemen,  the 
nursing  sisters  and  servants  at  the  military  hospital  of  Val-de-Grace  fell 
under  this  scourge  when  ministering  to  soldiers  of  our  army  of  the  East  who 


462  CONTAGION. 

were  under  treatment  for  typhus  in  that  institution.  You  will  find  the  facts 
to  which  I  refer  stated  in  a  work  on  the  subject  by  Dr.  Godelier,  Professor 
of  Clinical  Medicine  at  the  Val-de-Graee.*  Thus  you  see  that  typhus,  which 
was  originally  caused  by  infection,  ultimately  becomes  quite  as  contagious 
as  small-pox.  The  same  statement  is  true  in  respect  of  dysentery  and  other 
epidemic  diseases. 

It  is  necessary,  however,  to  guard  against  a  misunderstanding  of  this 
question.  Sometimes,  diseases  are  regarded  as  infectious  which  are  exclu- 
sively contagious.  This  mistake  arises  from  not  investigating  into  their 
starting-point,  or  from  not  being  able  to  discover  it.  In  tins  way,  the  view 
that  they  are  not  contagious,  and  have  been  spontaneously  developed,  is 
adopted.  Xo  doubt,  as  I  have  remarked,  these  diseases  were  at  some  par- 
ticular period  produced  under  influences  totally  unconnected  with  conta- 
gion ;  but  that  period  is  very  remote  from  the  present  time,  and  since  that 
time,  whenever  it  may  have  been,  they  have  always,  as  now,  been  repro- 
duced by  contagion. 

I  admit  that  it  is  often  exceedingly  difficult  to  discover  the  source  of  the 
malady.  A  person  takes  small-pox:  in  spite  of  all  the  care  with  which 
you  set  yourself  to  find  out  where  he  contracted  it,  you  fail  to  do  so  ;  the 
patient  tells  you  positively  that  he  has  seen  no  one  who  had  the  disease, 
that  in  the  house  where  he  lives,  among  his  acquaintance  and  among  all 
with  whom  he  comes  in  contact,  he  knows  of  no  case  of  small-pox.  You 
then  say  the  disease  has  been  spontaneously  developed.  But  this  indi- 
vidual has  perhaps  touched  the  garments  of  a  man  who  died  of  small-pox  ; 
perhaps  he  had  gone  into  a  room  where  there  had  been,  at  a  more  or  less 
distant  date,  persons  suffering  from  small-pox.  The  contagion  of  the 
malady,  difficult  to  demonstrate  in  the  great  centres  of  population,  can  be 
more  easily  followed  up  in  small  places  ;  on  a  former  occasion,  I  was  at 
some  pains  to  establish  this  point. 

Even  in  Paris,  however,  we  sometimes  have  an  opportunity  of  tracing 
back  the  contagion  to  its  source.  In  1827,  I  attended,  in  the  Rue  de 
l'Echiquier,  in  Paris,  a  young  woman  with  small-pox.  She  lived  with  her 
mother,  a  poor  linen-draper.  Both  women  inhabited  the  ground-floor, 
which  consisted  of  one  room  divided  by  a  high  screen.  The  division  next 
the  street  was  the  shop,  in  the  compartment  behind  the  screen  was  the  one 
bed  in  which  mother  and  daughter  slept.  During  the  entire  duration  of 
the  case  of  small-pox,  the  neighbors  came  as  of  wont  to  make  their  pur- 
chases, and  none  of  them  had  any  suspicion  of  the  danger  which  they 
thus  incurred.  At  that  time  I  lived  in  the  Rue  de  l'Echiquier,  and  BO 
was  enabled  to  watch  carefully  the  development  of  a  perfectly  local  little 
epidemic.  In  less  than  six  weeks,  seventeen  of  the  patient's  neighbors 
were  attacked  with  small-pox  :  and  1  ascertained  from  the  mother,  that  the 
persons  first  seized  in  each  family  were  persons  who  had  come  to  make 
purchases  at  her  shop.  Now,  as  no  one  knew  how  the  disease  had  spread, 
the  different  medical  men  who  were  called  in  remained  convinced  that  it 
had  been  spontaneously  developed. 

It  is  necessary  to  enter  -till  further  into  details,  so  as  to  enable  me  satis- 
factorily to  explain  my  opinions. 

In  1854,  the  Wellington,  an  English  -hip, -ailed  for  the  East,  having  on 
board  a  regiment  of  infantry.    Some  day-  after  Leaving  port,  small-pox 

broke  out,  and  in  a  .-hort  time  a   greal    many  soldiers  were  infected.      This 
-hip  put  hack  to  Plymouth,  where  .-he  \va.-  thoroughly  cleaned  in  every  part, 

dklier:    Menu  .ire  gur  le  T\  phua  observe  au  Val -de-Grace  de  Janvier  a  mai, 
1856.     [Bulletin  de  V Acad&mie dc Midecine^  t.  \\i,  p,  887.] 


CONTAGION.  463 

and  in  feet  made  as  good  as  new.  Some  time  afterwards,  when  supposed 
in  be  quite  purified,  she  sailed  for  tin-  Crimea  with  troops.  Alter  being 
fifteen  days  at  sea.  small-pox  reappeared  on  board,  and  made  new  victims: 
cases  also  occurred  among  the  wounded  whom  the  Wellington  borught 
back  to  England  from  the  Black  Sea.  A  second  time,  this  ship  was  sub- 
jected t<>  purifying  processes:  it  was  supposed  that  every  possible  precau- 
tion had  heen  taken,  and  it  was  Imped  that  she  had  been  rendered  a  salu- 
brious habitation:  nevertheless,  <»n  her  third  voyage,  the  disease  declared 
itself  a  third  time.  It  matters  little  howtbe  first  epidemic  was  developed: 
but  let  us  examine  into  the  source  of  the  disease  in  the  second  and  third 
voyages.  When  the  first  soldier  took  small-pox,  more  than  nine  days, 
that  is  to  say,  more  than  the  ordinary  period  of  that  disease's  incubation 
had  elapsed  since  the  ship  had  left  England, so  that  one  might  come  to  the 
conclusion  that  the  pestilence  had  been  spontaneously  developed.  But, 
would  it  not  be  more  reasonable  to  infer  that  the  Wellington  had  retained 
contagious  germs  since  her  previous  voyage? 

Has  not  Dr.  Melier,  in  his  learned  report  on  the  yellow  fever  which 
raged  at  St.  Nazaire  in  1861,  proved  that  the  ship  Sainte-Marie,  from 
Havana,  was  the  source  of  the  contagion  of  the  yellow  fever  which  broke 
out  among  the  men  employed  in  unlading  her  at  St.  Nazaire  ?*  He  has 
shown  you  the  disease,  transported  to  a  great  distance  from  its  original 
home  to  a  new  locality,  and  there  passing  by  contagion  from  man  to  man. 
My  honorable  colleague,  Dr.  Chaillon,  fell  a  victim  to  it,  having  con- 
tracted the  contagion  from  remaining  some  hours  in  attendance  upon  one 
of  the  workmen  engaged  in  discharging  the  cargo  of  the  Sainte-Marie. 

During  last  century,  there  was  ordered  the  judicial  exhumation  of  a  per- 
son who  had  died  of  small-pox  a  great  many  years  previously.  The  grave- 
digger  who  performed  the  exhumation,  and  some  persons  who  were  present 
when  it  was  being  done,  took  the  disease :  it  soon  afterwards  broke  out  in 
the  little  parish  in  which  occurred  the  events  now  mentioned,  and  where 
for  many  years  small-pox  had  not  been  seen.  This  history  has  an  apocry- 
phal appearance  ;  but,  nevertheless,  it  is  related  by  authors  fully  deserving 
of  credit.  It  teaches  us  that  the  variolous  germ,  wrapt  in  a  shroud  so  to 
speak,  but  in  reality  only  deposited  on  the  planks  of  a  coffin,  was  capable 
of  affecting  a  considerable  number  of  persons,  and  of  developing  itself  with 
formidable  energy  whenever  it  met  with  conditions  favorable  to  develop- 
ment. The  preservation  of  the  morbid  cause  on  board  the  Wellington  is  a 
not  less  credible  fact. 

Morbific  germs  may  remain  inactive  for  a  certain  time,  adherent  to  inor- 
ganic bodies,  as  is  illustrated  by  the  practice  of  former  days  of  inoculating 
by  means  of  a  thread  impregnated  with  variolous  matter.  In  this  way, 
they  may  remain  hidden  for  days,  months,  or  years,  waiting  to  manifest 
their  presence,  till  they  meet  with  conditions  favorable  to  their  evolution. 

Have  not  the  experiments  of  Spallanzani  and  of  Reaumur  disclosed 
facts  quite  as  extraordinary,  relative  to  the  development  of  animal  and 
vegetable  germs  ?  Did  not  the  first  named  of  these  illustrious  inquirers 
into  the  secrets  of  nature  observe  the  development  of  infusoria  in  dust  col- 
lected from  the  gutters  of  roofs  exposed  to  the  rays  of  an  intensely  ardent 
sun?  One  drop  of  water  sufficed  to  bring  about  the  resurrection.  And 
have  we  not  recently  been  present  at  spectacles  equally  marvellous?  Are 
not  you  all  acquainted  with  the  history  of  the  seeds  found  in  the  tomb-  of 
the  Pharaohs,  which  germinated  and  fructified  after  a  lapse  of  more  than 

*  Melier:  Relation  de  la  Fievre  Jaime  survPDue  a  Saint-Nazaire  en  1861. 
\Memoire&  de  V Academic  Impiriale  de  Medechie,  t.  xxvi.     Paris,  1803.] 


464  CONTAGION. 

three  thousand  years,  just  as  if  they  had  been  gathered  on  the  previous  day 
from  their  parent  plants  ? 

Those  among  you  who  take  an  interest  in  botanical  studies  have  observed  a 
well-known  appearance  presented  by  the  flora  of  the  woods.  By  the  cutting 
down  of  the  wood,  this  flora  is  so  greatly  modified,  that  after  the  interval 
of  a  year  it  is  impossible  to  recognize  it.  In  the  situation  where  you  pre- 
viously found  plants  of  a  particular  species,  others  of  a  totally  different 
kind  have  appeared,  which  have  not  been  seen  since  the  first  time  the  wood 
was  cut  down  twenty-five  years  previously.  During  twenty-five  years,  the 
germs  have  remained  buried  in  the  ground,  waiting  for  the  air  and  sun 
requisite  for  their  developing  themselves.  It  may  be  said  that  the  seeds  have 
been  sown  by  the  wind,  or  that  they  have  been  brought  from  afar  by  birds, 
just  as  we  see  crows  and  magpies  carrying  kernels  and  nuts  which  they 
have  gathered,  and  accidentally  dropping  them  here  and  there.  But  how 
are  we  to  explain  the  number  and  variety  of  the  plants  which  appeal 
under  the  circumstances  which  I  have  described  ?  In  particular,  how  are 
we  to  explain  the  fact  that  according  as  the  wood  is  thick  or  cut  down,  we 
always  have  the  one  and  not  the  other  kind  of  plants? 

Let  me  now  return  to  the  consideration  of  morbid  germs.  I  have 
referred  to  what  occurred  long  ago  at  Gibraltar.  In  1802,  the  English 
troops,  on  their  return  from  Egypt,  brought  ophthalmia  with  them  to  Spain, 
a  disease  which  had  till  then  been  unknown  on  the  coasts  of  the  Peninsula. 
From  that  time,  ophthalmia  attacked  in  succession  the  different  regiments 
which  constituted  the  garrison  of  Gibraltar.  Such  at  least  was  the  state  of 
matters  in  1828,  when  I  was  sent  there  on  a  mission:  the  English  surgeons 
showed  me  soldiers  affected  with  Egyptian  ophthalmia,  although  during 
the  preceding  twenty-six  years  the  bedding  and  furniture  of  the  barracks 
had  been  frequently  renewed:  everything  had  been  done  that  could  be 
thought  of  to  improve  the  sanitary  condition  of  the  barracks. 

Here  is  another  case  in  point.  The  history  of  contagion  abounds  in  such 
cases.  In  1845,  a  woman  was  admitted  to  my  wards  at  the  Necker  Hos- 
pital with  all  the  symptoms  of  glanders,  of  which  she  died.  Where  did 
she  contract  this  disease?  She  worked  at  the  establishment  of  a  merchant 
of  horsehair,  where  her  occupation  was  to  twist  hair  which  Game  from 
Buenos  Ayres.  Mark  well  this  circumstance:  it  is  a  fact  of  chief  im- 
portance that  all  the  hair  in  that  establishment  came  from  Buenos  Ayres. 
Well,  the  woman  contracted  glanders,  and  the  only  way  in  which  we  could 
account  for  this  was  the  nature  of  her  occupation  :  she  had  never  had  the 
care  of  horses,  nor  had  she  ever  had  any  communication  with  persons  bo 
employed.  If  there  are  any  cases  in  which  we  can  suppose  that  an  infec- 
tious germ  was  spontaneously  developed,  this  is  certainly  one  of  them  :  and 
yet,  extraordinary  though  it  be,  the  cause  of  the  contagion  seemed  to  me 
quite  evident — the  contagium  of  glanders  existed  in  the  South  American 
horsehair. 

Nor  does  this  case  stand  alone:  it  is  well  known  that  glanders  unfor- 
tunately too  often  attacks  workers  in  horsehair,  just  as  malignant  pustule 
attack-  workers  in  wool.  To  me,  and  others,  the  facts  now  stated  are  irre- 
sistibly convincing,  and  prevenl  disbelief  in  the  possibility  of  a  prolonged 
conservation  of  contagious  germs. 

In  following  out  the  detail-  of  the  evolution  of  these  germs,  1  must 
constantly  real  upon  analogies,  a  proceeding  always  necessary  when  direct 
facte  are  wanting.     J   propose  to  take  my  analogies  from  natural  history 

and  agricull  ore. 

Smne  Beeds  will  grow  anywhere.  Place  them  under  certain  conditions 
in   respect  of   heat  and   moisture,  and   they    will  spring  up  in  all   places 


CONTAGION.  465 

and  at  all  seasons.  But  there  are  other  seeds  which  do  not  behave  in  this 
manner. 

Make,  for  example,  in  February,  a  seed-bed  of  cherry  trees,  casting  a 
thousand  cherry-stones  into  a  thoroughly  prepared  soil.  During  April, 
you  will  Bee  some  stems  coming  up;  if  the  twentieth  part  of  your  seed 
spring  up,  you  ought  to  be  satisfied.  In  the  following  April,  more  of  your 
seed  will  germinate  ;  and  again,  in  the  April  of  the  succeeding  year,  an 
additional  quantity  of  your  seed  will  arise.  If,  in  these  successive  (volu- 
tions at  intervals  of  twelve  months,  occurring  always  at  the  same  time  of 
year,  you  look  to  the  influence  of  the  seasons  for  an  explanation,  I  a.-k — 
by  appealing  to  what  influence  can  you  explain,  why  seeds  placed  under 
precisely  the  same  conditions  of  soil,  air,  sun,  and  water  have  not  ger- 
minated simultaneously  ? 

The  germs  of  some  animals  offer  similar  examples.  Reaumur,  wishing 
to  study  the  habits  of  the  bombyx pavonia  major  kept  several  chrysalides  of 
this  kind  of  butterfly  in  the  sand-box  of  his  writing-table.  Some  of  them 
hatched,  and  others  seemed  as  if  they  were  dead,  till  he  touched  them  with 
the  point  of  his  penknife,  when  he  found  that  he  excited  slight  movements. 
He  kept  them :  and  next  year  at  the  same  period,  almost  to  the  very  day, 
he  saw  an  additional  number  of  butterflies  come  forth  :  also  twelve  months 
later,  and  again  almost  to  the  day,  a  third  hatching  took  place. 

Is  there  not  something  very  curious  in  this  repose  of  germs?  Is  it  not 
singular  that  chrysalides  of  the  same  butterfly,  of  the  same  age,  and  placed 
under  precisely  similar  conditions,  should  have  been  hatched  at  intervals 
of  exactly  one  and  two  years?  Why  may  not  the  seeds  of  disease  comport 
themselves  in  this  respect  like  the  seeds  of  plants  and  the  larvae  of  insects? 
Conditions  of  air,  sun,  water,  and  place  can  no  more  explain  the  successive 
evolutions  of  the  germs  of  contagion  than  they  can  explain  the  successive 
hatchings  of  the  larvae  of  Reaumur's  bombyx.  It  would  appear  that  the 
germs  of  many  diseases  like  the  germs  of  some  animals  and  vegetables  are 
only  developed  at  determinate  epochs.  Yellow  fever,  for  example,  has 
never  prevailed  in  Europe  except  from  July  to  September,  whatever  may 
have  been  the  meteorological  constitution  of  the  other  months  of  the  year. 
The  disease  has  always  appeared  within  that  period,  whether  it  has  been 
a  period  of  heat  or  cold,  of  drought  or  rain.  It  has  in  this  respect  a  pecu- 
liarity similar  to  that  of  some  birds  which  always  moult  at  the  same  season 
of  the  year,  in  whatever  climate  they  may  be  living.  The  parrots  of  the 
southern  hemisphere  change  their  plumage  in  March,  the  time  when  the 
temperature  begins  to  be  lower  in  their  native  regions :  they,  when  brought 
to  France,  remembering  their  origin,  if  I  may  be  allowed  the  expression, 
still  moult  in  March,  though  in  our  latitude,  at  that  season,  the  warm 
weather  is  only  beginning,  and  though  the  birds  of  our  country  do  not 
moult  till  September. 

But  it  may  be  said  that  no  one  has  ever  seen  these  morbid  germs  of 
which  I  have  been  speaking:  no  one  has  ever  collected  any  of  the  poisons, 
the  absorption  of  which  gives  rise  to  cholera,  yellow  fever,  influenza,  inter- 
mittent fever,  and  dothinenteria.  That  is  quite  true ;  and  yet  the  persons 
who  deny  the  existence  of  the  germs  really  accept  the  essence  of  the  propo- 
sition, and  take  exception  only  to  a  term,  for  they  speak  of  miasmata  and 
morbid  causes,  which  they  have  not  seen  any  more  than  they  have  seen  germs. 

The  recent  labors  of  Professor  Charles  Robin,  of  which  I  shall  speak 
immediately,  seem  to  put  us  on  the  track  to  discover  these  germs  of  disease. 

The  miasmata,  or  morbific  causes,  or  germs — the  term  matters  little — 
may  remain  latent,  slumbering  for  a  longer  or  shorter  period,  buried  in 
inorganic  substances:  then,  at  a  particular  moment,  under  certain  telluric 
vol.  i.— 30 


466  CONTAGION. 

and  atmospheric  conditions,  with  the  nature  of  which  we  are  unacquainted, 
but  the  influence  of  which  no  one  denies,  they  develop  themselves  in  per- 
sons predisposed  to  receive  them. 

I  ask  those  who  refuse  to  admit  the  pre-existence  and  slumber  of  germs, 
if  they  have  found  the  intervening  conditions  which  alone  they  put  forward, 
and  under  the  influence  of  which,  yellow  fever,  after  having  been  absent 
from  a  district  for  ten,  twenty,  or  thirty  years,  all  at  once  begins  to  rage 
with  an  intensity  equal  to  that  manifested  at  its  first  appearance  ten,  twenty, 
or  thirty  years  before.  During  this  long  interval,  have  you  detected  any 
change  in  the  atmospheric  constitution  of  the  locality?  Have  its  meteoro- 
logical conditions  appeared  to  be  modified  ?  Do  not  deny  that  germs 
exist,  because  their  existence  is  incapable  of  direct  demonstration ;  for  you 
cannot  prove  in  any  more  satisfactory  manner  the  intermediate  influences 
which  you  unhesitatingly  admit.  Have  I  not  sufficiently  established  my 
proposition  by  citing  the  successive  epidemics  of  small-pox  on  board  the 
Wellington,  and  the  installation  of  Egyptian  ophthalmia  in  the  barracks 
of  Gibraltar? 

If  we  admit  the  existence  of  germs,  to  argue  against  their  slumber,  to 
explain  their  spontaneous  appearance,  by  alleging  that  they  have  been 
borne  by  winds  from  one  country  to  another,  would  be  to  substitute  for  one 
hypothesis,  another  hypothesis  based  on  entirely  false  premises. 

Let  me  illustrate  this  point  by  referring  to  the  yellow  fever  which  pre- 
vailed at  Gibraltar.  The  winds,  it  has  been  said,  carried  thither  the  germs 
of  the  disease :  if  so,  why  was  there  not  one  case  in  Spain,  over  which  the 
north  wiud  had  passed,  not  one  in  Morocco,  whence  comes  the  south  wind, 
not  one  in  the  islands  of  the  Mediterranean  Sea,  nor  in  the  countries  which 
are  nearest  to  it  on  the  east  and  the  west?  Still  more,  if  we  take  into  con- 
sideration the  manner  in  which  yellow  fever  stations  itself,  ravaging  for  ex- 
ample, a  locality,  and  yet  sparing  places  immediately  adjoining,  we  are 
obliged  to  reject  the  hypothesis  in  which  ignorance  has  tried  to  take  shelter. 
Here,  in  a  few  words,  is  an  account  of  the  occurrences  observed  at  Gibral- 
tar. You  know  the  geographical  position  of  the  place.  Gibraltar  i>  seated 
upon  a  rock,  which  terrestrial  convulsions  of  an  antediluvian  era  have  sep- 
arated by  a  strait  from  Africa,  and  is  connected  with  Spain  only  by  a  slip 
of  sandy  soil,  called  the  "neutral  ground."  The  particular  locality  where 
yellow  fever  raged  with  greatest  fury  was  that  designated  the  "sea-gate," 
beyond  which  lies  the  neutral  ground,  where  the  pestilence  stopped  short. 
The  population  emigrated  to  that  narrow  sandy  flat,  and  there  established 
itself  in  tents,  at  a  pistol-shot  from  the  town.  The  emigrants,  who  never 
entered  the  town,  had  not  one  case  of  yellow  fever  among  them  ;  yet,  they 
were  so  near  the  hot-bed  of  the  disease,  in  such  close  proximity  to  the 
ditches  of  the  fortress,  that  they  could,  so  to  speak,  converse  with  the  sick 
shut  up  within  its  walls.  Does  not  this  fact  absolutely  demonstrate,  that 
the  winds  have  no  influence  whatever  in  propagating,  nor,  <)  fortiori,  in 
causing  the  outbreak  of  an  epidemic? 

The  remarks  which  I  have  been  making  apply  equally  t"  infectious  and 
contagious  germs.  The  difference  between  the  two  I  consider  to  be  this: 
The  infectious  germs,  engendered  under  unknown  influences,  produce  cer- 
tain effects  in  the  individuals  who  receive  them  :  hut  there  the  effects  stop — 
the  germs  die  within  the  organisms  which  they  infected.  <  >riginally  engen- 
dered also  under  influences  which  equally  elude  us,  the  contagious  germs 
develop  themselves,  and  fructify  within  the  organism  which  ha-  received 

them.  The  contagious  germ  is,  80  to  speak,  conceived  a-  the  infant  is  con- 
ceived iii  its  mother's  WOmb:  hut  more  than  this  occurs — the  germ  assimi- 
lates  the  entire  substance  of  the  economy — totua  homo  morbus  ///—the  man 


CONTAGION.  467 

who  has  received  the  contagion  becomes  a  new  centre  of  morbific  emana- 
tions. 

Gentlemen,  Van  Swieten,  in  his  Commentaries  on  the  Aphorisms  of 
Boerhaave,  a  book  filled  with  many  good  things,  gives  his  opinion  on  the 
matter  now  before  us.  In  several  places,  particularly  in  treating  of  small- 
pox and  gout,  he  speaks  of  the  materia  morbosa.  In  his  chapter  on  gout, 
you  will  find  the  following  passage: 

"Certe,  videmus  toties  in  morbis  aliquid,  non  nisi  effectis  suis  in  corpore 
humano  cognitum,  turbare  totum  corpus,  et  assimilare  in  suam  naturam 
humores  antea  sanos  :  qui  humores  sic  mutati  constituunt  materiam  mor- 
bosam  dictam  medicis,  et  quse  materies  morbosa  potentiam  s?epe  habet 
propagandi  eundem  morbum.  In  dysentericis  putridum  miasma  recipitur 
ab  adstantibus  et  quamvis  illud  infinite  parvum  fuerit,  omnes  humores 
hominis  sani  in  tubum  dysentericum  convertit.  Parvo  vulnusculo  cutaneo 
tantum,  applicatur  filum  pure  varioloso  imbutum :  susceptum  illud  con- 
tagium  silet  per  plures  dies,  dein  febrem  accendit,  totum  corpus  turbat,  et 
convertit  humores  sanos  in  suam  indolem  ita  ut  quandoque  numerosse  pus- 
tulse,  omnes  pure  contagioso  plense,  per  omnem  corporis  superficiem  nas- 
cantur." 

This  something,  which  reveals  itself  only  in  the  effects  which  it  produces, 
this  putrid  miasm,  this  morbific  matter,  is  not  perhaps  any  better  known 
to  us  than  it  was  to  the  medical  observers  of  old  times  ;  although  recently 
one  of  our  most  distinguished  men  of  science  believes  that  he  has  demon- 
strated its  existence.  According  to  Professor  Ch.  Robin,  morbid  germs  are 
formed  by  bodies  holding  a  first  place  both  in  respect  of  their  material 
importance  and  their  properties.  These  bodies  are  the  coagulable  com- 
pounds called  organic  substances,  natural  animal  and  vegetable  substances, 
formed  both  accidentally  and  artificially. 

I  am  sure,  gentlemen,  that  you  will  be  pleased  by  my  quoting  some  of 
the  views  on  this  subject  which  have  been  enunciated  by  Professor  Ch. 
Robin.     He  says  : 

"Whether  solid  or  liquid,  or  whether  suspended  in  the  vapor  of  water, 
these  organic  substances  present  this  peculiarity,  that  when  they  become 
altered,  they  transmit  by  simple  contact  to  healthy  organic  substances,  the 
kind  of  alteration  which  they  have  undergone,  or  a  similar  kind  of  altera- 
tion. For  the  accomplishment  of  this,  it  is  not  necessary  that  the  quantity 
of  the  altered  organic  substance  offer  a  determinate  relation  in  bulk  to  the 
substances  modified  by  them  ;  as  is  requisite  in  the  chemical  actions  exerted 
on  one  another  by  crystallizable  compounds.  Organic  substances,  the 
alteration  of  which  has  begun  under  certain  conditions  of  temperature, 
moisture,  &c,  transmit  this  state  by  mere  contact,  or  in  consequence  of 
molecular  admixture  with  healthy  substances,  even  when  in  extremely 
minute  quantity,  because  the  modification  proceeds  gradually  from  mole- 
cule to  molecule. 

"  It  is  by  altered  vegetable  and  organic  substances  that  there  are  pro- 
duced certain  epidemic  diseases,  such  as  typhus,  dysentery,  paludal,  and 
other  affections  termed  general  diseases.  Through  the  operation  of  the 
same  cause,  and  by  means  of  altered  organic  substances  received  into  the 
stomach  along  with  beverages  and  food,  arise  the  majority  of  maladies 
similar  to  those  I  have  just  named,  in  which  the  entire  economy  is  impli- 
cated ;  or,  to  speak  with  more  exactness,  in  which  every  organ  presents 
disorders  of  nutrition,  and  consequently  of  every  function  performed  by 
the  organs. 

"  As  examples  may  be  cited  the  typhoid,  variolous,  and  scarlatinous 


468  •  CONTAGION. 

fevers.  In  the  same  category  may  likewise  be  included  the  diseases  which 
result  from  putrid  and  purulent  infection. 

"  Among  these  diseases  are  some  which  are  pre-eminently  contagious  : 
others  which  have  not  been  proved  to  be  contagious  :  and  also  a  different 
class  of  which  it  may  be  said  that  they  are  not  in  any  degree  contagious, 
so  far  as  existing  experience  can  be  accepted  as  decisive  on  the  point." 

"  There  exist,"  says  Professor  Ch.  Robin,  "peculiar  conditions  in  virtue 
of  which  one  individual  exposed  to  the  action  of  these  organic  substances 
is  attacked,  while  another  escapes:  while  one  exhibits  the  symptoms  in  the 
place  of  his  attack,  another  shows  no  symptoms  till  immediately  after  he 
has  left  the  locality,  or  not  till  after  the  lapse  of  some  days."* 

We  shall  return  to  this  subject. 

In  conjunction  with  this  ably  propounded  hypothesis,  I  must  mention 
M.  Pasteur's  new  theory  of  fermentation.  This  eminent  man  of  science 
has  come  to  the  conclusion,  from  experiments  performed  with  extreme 
care,  that  fermentation  is  dependent  upon  sporules  diffused  in  the  air }  and 
that  each  kind  of  sporule,  recognizable  by  certain  characters,  possesses  the 
property  of  originating  in  a  particular  medium  a  different  species  of  fer- 
mentation. According  to  him,  there  are  different  sporules  for  the  different 
fermentations — the  alcoholic,  lactic,  &c.  May  there  not  also  exist  morbific 
sporules?  May  we  not  in  this  way  explain  the  morbid  fermentation  spoken 
of  by  the  older  authors  ?  Bearing  in  mind  the  researches  of  Eidvelt  of 
Prague,  and  those  of  Reveil  and  Chalvet  into  the  composition  of  the  at- 
mosphere in  the  Parisian  hospitals,  St.  Louis  and  Xecker,  I  concur  with 
Professor  Pasteur  in  believing  that  it  would  be  very  interesting  to  institute 
an  extensive  examination  of  this  subject,  to  compare  the  organized  corpus- 
cles disseminated  in  the  atmosphere  of  the  same  place  at  different  times, 
and  of  different  places  at  the  same  time.  It  appears  to  me  that  such  in- 
quiries would  throw  light  upon  the  phenomena  of  contagion,  particularly 
during  periods  when  epidemics  are  prevailing. 

A  sporule  diffused  in  the  atmosphere  can  live  only  in  a  latent  form,  like 
the  grains  of  wheat  in  the  Egyptian  tombs.  But  if,  like  the  latter,  you 
place  the  sporule  in  a  place  suitable  for  its  living,  it  will  then  develop  itself, 
multiply  at  the  expense  of  the  elements  with  which  it  meets  in  the  favorable 
medium,  and,  according  to  its  species,  originate  the  phenomena  of  the  differ- 
ent fermentations.  May  it  not  be  the  same  with  the  sporules  of  disease, 
which,  floating  free  in  the  atmosphere,  may  be  only  waiting  for  certain 
favoring  circumstances  to  enable  them  to  reveal  their  existence,  develop 
themselves,  multiply,  and  produce  the  supposed  morbific  fermentation? 
Has  it  not  been  said  that  pus  generates  pus  ?  Perhaps  there  is  a  pus-sporule 
to  explain  purulent  infection  ;  and  perhaps  there  is  also  a  dysenteric  sporule, 
and  a  choleraic  sporule.  If  these  sporules  could  be  detected  in  the  atmos- 
phere, the  facts  relating  to  contagion  would  be  materially  explained.  To 
make  that  discovery  it  will  be  uecessary  to  follow  in  the  track  indicated  by 
Professor  Pasteur,  proceeding  by  experiments  conducted  with  the  same 
ability  and  patience  which  he  has  shown. 

I  have  pointed  . .lit  to  you  the  pan  played  by  the  organic  substratum, 
and  by  the  specific  nature  of  the  ferments  in  the  acl  of  fermentation.  I 
oii-hi  to  Btate  that  Dr.  Jules  Lemaire,  an  eminenl  physician,  bas  very  re- 
cently demonstrated  the  essential  importance  of  the  nature  of  the  medium 

Robin  (Charles):  "  Dictionnaire  de  Mddecine  :"  dixieme  edit.,  1855:   Article, 
Maladies  ou  Affections  Generates ;  el    r..e.  1866:   Article,  Substances  Organiquea, 
Iso,  "  Gazette  des  Bdpitaux,"  2d  August,  1866,  p.  ■ 


CONTAGION.  469 

in  the  intimate  mechanism  of  fermentation.*  In  opposition  to  M.  Pasteur, 
who  considers  that  there  is  a  special  ferment  for  each  kind  of  fermentation, 

M.  Jules  Lemaire  makes  out  that  there  are  neither  special  microphytes  nor 
microzoa  in  particular  fermentations,  and  that  the  existence  of  one  or  other 
is  contingent   upon  the  medium.     Thus,  in  a  liquid  which   is  neutral  or 

slightly  oxidated,  and  contains  organic  substances  in  infusion,  microzoa 
(bacteria  and  vibriones)  appear,  and  by  their  aid  fermentation  is  accom- 
plished. But  if  the  substances  are  acid,  it  is  then  microphytes  which  are 
developed,  and  it  is  then,  by  their  assistance,  that  fermentation  takes  place. 
But  that  is  not  all:  in  acid  substances  fermentation  begins  with  microphytes, 
and  when  the  acids  have  to  a  great  extent  become  transformed,  microzoa 
appear,  the  smell  at  the  same  time  becoming  extremely  fetid :  the  changes 
take  place  in  an  inverse  order  when  an  originally  neutral  medium  becomes 
acid,  that  is  to  say,  the  appearance  of  microphytes  precedes  the  appearance 
of  microzoa. 

These  experiments  have  only  a  remote  analogy  to  the  much  more  com- 
plex phenomena  of  the  contagion  of  diseases:  I  have  only  brought  them 
under  your  notice  to  enable  you  to  appreciate  the  very  great  difficulty  of 
the  subject.  In  fermentation,  where  the  whole  process  is  seen,  the  specific 
character  of  the  ferments,  or  of  the  living  agents  of  fermentation,  is  recog- 
nized :  the  contagion  of  diseases,  on  the  other  hand,  proclaims  the  unim- 
portance of  these  agents  and  the  omnipotence  of  the  medium.  In  the  act 
of  contagion  we  can  scarcely  perceive  the  material  agent,  and  are  obliged 
to  prove  its  existence  by  induction,  or  from  analogy. 

Can  morbific  germs,  infectious  or  contagious,  remain  in  a  latent  state 
external  to  all  organic  life  ?  Recollect  the  epidemics  of  small-pox  on  board 
the  Wellington,  and  the  cases  of  ophthalmia  at  Gibraltar :  remember  the 
woman  who  died  of  glanders  from  having  worked  among  horsehair  from 
Buenos  Ay  res.  In  the  same  way  a  contagious  disease  desolates  a  family  at 
a  particular  period,  and  then  disappears,  to  reappear,  however,  after  a  cer- 
tain time  with  equal  severity,  but  independent  of  any  new  contagion  from 
without,  there  being  in  fact  nothing  to  which  the  reappearance  can  be  at- 
tributed, excepting  that  the  germ  of  the  disease  had  remained  concealed 
where  the  family  was  living,  in  the  hangings  of  the  furniture  and  of  the 
apartment,  just  as  the  variolous  germ  remained  in  the  structures  of  the 
Wellington,  as  the  germ  of  ophthalmia  remained  in  the  barracks  of  Gibral- 
tar, as  the  virus  of  glanders  remained  in  the  horsehair  from  Buenos  Ayres. 

A  girl  of  nine  years  of  age  was  carried  off  by  malignant  diphtheria.  On 
the  first  manifestation  of  the  symptoms,  her  two  sisters  were  removed  to  a 
distance  from  the  house,  and  did  not  take  the  disease.  But  eight  mouths 
afterwards,  on  returning  home,  the  elder  of  the  two  was  seized  with  diph- 
theria, which  invaded  the  larynx,  and  I  was  called  in  to  perform  tracheot- 
omy. This  child  died,  as  her  sister  had  died,  from  diphtheritic  poisoning. 
Again,  on  this  occasion,  as  soon  as  the  disease  was  recognized,  the  surviving 
sister,  aged  five  years,  was  sent  off  to  the  residence  of  her  grandmother,  but 
she  carried  with  her  the  germ  of  the  malady.  Sore  throat  very  soon  declared 
itself,  and  in  seven  days  croup  necessitated  tracheotomy,  which  was  in  this 
case  a  complete  success. 

Two  circumstances  in  the  history  of  these  children  require  to  be  looked 
at  separately,  viz.,  the  preservation  of  the  germ,  external  to  the  organism, 
and  the  incubation  of  the  malady.  By  the  term  incubation,  we  must  under- 
stand the  time  which  elapses  from  the  entrance  of  the  morbific   cause 

*  Lemaire  (Jules)  :  Nouvelles  Eecherches  sur  les  Ferments  et  les  Fermentations. 
[Lu  a  Academie  des  Sciences,  en  Septembve  et  Octobre,  18G3.] 


470  CONTAGION. 

into  the  economy  till  it  manifests  itself  by  producing  the  symptoms  of  the 
disease  which  it  determines.  It  is  probable  that  the  last  of  the  three  chil- 
dren received  the  diphtheritic  poison  at  the  same  time  as  her  deceased  sister, 
the  evolution  of  the  malady  being  slower  in  the  one  case  than  in  the  other. 
The  period  of  incubation  is,  at  least  in  some  diseases,  as  you  know,  longer 
or  shorter  in  different  persons  according  to  their  individual  peculiarities. 

But  however  long  the  period  of  incubation  may  be,  its  duration  is  not 
indefinite;  and  if  sometimes  it  appear  to  be  prolonged  beyond  the  ordinary 
term,  there  has  not  really  been  incubation.  The  morbific  germ  had  not 
entered  the  organism,  but  had  remained  on  the  surface  of  the  external 
tissues,  exactly  as  in  the  cases  we  have  now  been  considering,  in  which  it 
was  preserved*  in  the  clothes  of  a  patient,  the  drapery  of  an  apartment,  or 
the  woodwork  of  a  ship.  This  explanation  will  be  accepted  when  it  is 
seen,  that  in  epidemics,  of  small-pox  for  example,  persons  living  in  the 
very  centre  of  contagion  are  not  all  simultaneously  seized  ;  but  that  some 
are*  attacked  immediately,  and  others  much  later,  and  too  late  to  allow  us 
to  believe  that  the  incubation  began  at  the  same  date;  while  others  again 
are  not  attacked  for  a  longer  or  shorter  interval  after  leaving  the  centre  of 
contagion. 

In  considering  the  question  of  contagion,  it  is  necessary,  not  only  to  bear 
in  mind  the  element  of  contagion  itself,  but  also,  and  even  more,  the  con- 
ditions necessary  for  its  action. 

There  are  two  factors :  one  is  the  morbific  germ  coming  from  without, 
and  the  other  is  the  economy  about  to  receive  it.  Here,  as  in  every  patho- 
logical and  physiological  act,  there  is  required  a  stimulus,  and  also  support 
for  that  stimulus,  which  Recamier  called  the  reciprocative  power;  or,  in 
other  words,  there  is  required  a  special  aptitude  in  the  organism  to  respond 
to  the  action  of  the  stimulus.  Permit  me  to  return  to  these  points,  which 
I  have  already  glanced  at  in  my  lectures  on  small-pox. 

Except  bv "the  relation  between  the  stimulus  and  the  support,  how  are 
we  to  explain  the  occurrences  attributed  to  that  which  is  called  predisposi- 
tion? How  are  we  to  explain,  why  an  individual  may  expose  himself  a 
hundred  times  to  an  icy  cold,  to  sudden  changes  of  temperature,  without 
experiencing  the  least  detriment,  whilst  the  same  person  will  take  a  severe 
catarrh,  an  inflammation  of  the  lungs,  or  a  pleurisy,  from  having  been 
touched  in  a  hot  day  by  a  current  of  mild  air  coming  in  behind  him  at  a 
half-open  window.  The  explanation  is  this:  in  the  first  case,  there  was  a 
capacity  for  resistance,  and,  as  we  say,'/  negation  of  receptivity ;  while  in 
the  other  case,  the  economy  was — excuse  the  expression — quite  open  to 
receive  the  disease.  It  is  therefore  said  with  truth,  that  one  does  not  gener- 
ally take  a  pneumonia  proportionate  to  the  intensity  of  the  cause,  unless 
there  exist  a  predisposition  to  the  disease. 

During  the  prevalence  of  what  are  called  the  common  "medical  con- 
stitution-:," all  morbific  influences  act  in  the  same  way,  in  virtue  of  the 
common  aptitudes  which  these  "constitutions"  have  imparted  to  different 
individual. — then,  causes  small  and  great  produce  similar  effects.  During 
an  epidemic  of  influenza,  for  example,  a  current  of  cool  air,  and  a  dull 
wlicn  in  a  -talc  of  copious  perspiration,  occasion  catarrh,  which  assumes 
the  specific  character  of  the  prevailing  epidemic.  When  cholera  i>  epi- 
demic, the  slightest  indigestion  will  become  the  starting-point  of  an  attack 

of  cholera.       IOU   BBS,  therefore,  thai    both   contagious  and    QOn-COntagioUS 

diseases  are  contracted  only  when  there  is  a  special  predisposition  of  the 

economy  to  receive  them. 

When  there  is  no  such  predisposition,  the  morbific  germ  perishes.    There 

Occurs   exactly  what    occurs   in    respect   of  the   act    of   reproduction    in    the 


CONTAGION.  471 

animal  and  vegetable  kingdoms,  where  it  is  essential  that  there  exisl  a 

special  lit n ess  in  the  germs,  and  a  special  disposition  in  the  individual  who 
ought  to  receive  them — a  condition  the  nature  of  which  it  is  often  impossible 
to  discover.  So  it  is,  that  on  one  side  or  the  other,  there  is  something 
Wanting  which  is  essential.  When  fecundation  does  not  take  place,  although 
the  individual  seem  to  possess  the  conditions  necessary  for  conception,  one 
cannot  in  an  absolute  manner  attribute  this  result  to  a  defect  in  the  germ, 
and  can  only  say,  that  in  the  ease  there  was  a  want  of  the  necessary  apti- 
tude. When,  on  the  other  hand,  fecundation  does  not  take  place,  although 
the  germ  possesses  the  necessary  aptitude,  it  cannot  be  said  that  there  is  an 
incapacity  of  being  fecundated,  but  only  that  at  that  particular  time  the 
individual  was  not  in  a  state  suited  to  the  accomplishment  of  the  act. 
Finally,  should  fecundation  not  take  place,  notwithstanding  that  there 
exist  both  an  aptitude  of  the  germ  and  of  the  individual,  it  ought  to  be 
said,  that  the  failure  is  occasioned  by  special  conditions  impossible  to  deter- 
mine. It  is  essential  that  there  exist  the  favorable  conditions  which  belong 
to  the  germ,  and  also  those  which  pertain  to  the  individual  who  ought  to 
receive  the  germ,  besides  favoring  circumstances  external  to  both. 

A  study  of  generation  in  plants  and  animals  shows  that  numerous  cir- 
cumstances occur  unfavorable  to  the  accomplishment  of  reproduction.  In 
certain  species  in  which  this  is  particularly  the  case,  the  Creator  has  given 
an  exceedingly  lavish  supply  of  reproductive  organs.  In  hermaphrodite 
plants,  the  stamina,  whose  office  it  is  to  furnish  the  fecundating  principle, 
are  much  more  numerous  than  the  female  organs :  for  a  single  pistil,  an  in- 
finite number  of  organs  secrete  pollen.  In  the  plants  in  which  the  male 
and  female  flowers  are  distinct,  the  number  of  male  flowers  is  enormously 
in  excess  of  the  female. 

In  animals,  in  fish  for  example,  it  is  not  unusual  for  the  female  to  deposit 
a  quantity  of  ova  so  vast  that  if  all  were  fecuudated,  or  at  least  if  all  were 
hatched,  the  rivers  would  hardly  be  able  to  contain  the  produce. 

It  is  the  same  in  respect  of  morbific  germs.  Thank  God  !  when  they  are 
sown  broadcast  among  populations,  they  do  not  all  grow  up:  if  they  did, 
the  world  would  speedily  become  an  immense  desert.  But  because  all  mor- 
bific germs  do  not  prove  contagia,  we  are  not  entitled  to  deny  that  they 
possess  a  contagious  principle. 

Here  is  what  occurs  when  diseases  essentially  contagious  are  epidemic: 
although  I  have  already  narrated  the  following  facts,  I  must  again  cite 
them.  The  tag-sore,  or  small-pox  of  sheep  [clavelee]  broke  out  in  a  flock  of 
five  hundred  sheep :  fifty  were  seized,  and  remained  with  the  rest  of  the 
herd.  The  diseased  sheep  lay  in  the  same  fold  with  the  unaffected,  and 
both  ate  their  forage  from  the  same  rack :  the  litter  common  to  the  affected 
and  unaffected  sheep  was  soiled  by  the  slime  and  pus  from  the  former.  A 
month  later,  fifty  other  sheep  had  the  disease,  and  in  five  or  six  months, 
the  epizootic  malady  had  ravaged  the  herd:  only  fifty  sheep  were  not  at- 
tacked. There  can  be  no  doubt  that  the  virus  possessed  its  special  apti- 
tude, since  it  affected  nine-tenths  of  the  flock.  Why,  then,  was  not  the 
remaining  tenth  attacked?  Why  were  fifty  sheep  spared?  No  one  can 
deny  their  individual  aptitude.  The  existence  of  this  aptitude  may  indeed 
have  been  thus  shown:  of  the  fifty  sheep  which  escaped  the  contagion  when 
lying  in  the  same  litter  with  the  diseased,  eating  from  the  same  rack  with 
them,  constantly  coming  into  the  closest  contact,  mingling  fleeces,  soiling 
their  noses  with  the  discharges  of  the  contaminated,  one  or  more,  long  after 
the  outbreak  has  terminated,  will  take  the  disease,  simply  from  passing 
along  a  road  which  had  been  traversed  by  a  flock  in  which  there  was  per- 
haps only  a  single  case  of  tag-sore. 


472  CONTAGION. 

Human  pathology  affords  similar  examples.  We  every  day  see  hooping- 
cough,  measles,  and  scarlatina  establishing  themselves  in  a  family  by  at- 
tacking one  or  two  of  its  members;  at  a  later  period,  after  an  interval  of 
perhaps  some  months,  the  disease  reappears,  seizing  individuals  who  escaped 
on  the  occasion  of  the  first  outbreak,  though  duriug  it  they  were  living  in 
the  midst  of  the  contagion.  Such  is  the  history  of  an  epidemic  of  diph- 
theria of  which  I  have  already  spoken  to  you,  as  well  as  of  epidemics  of 
small-pox.  In  these  cases,  I  again  repeat,  the  seizures  occur  at  so  great  an 
interval  after  the  first  exposure  of  the  individuals  as  to  make  it  impossible 
for  us  to  suppose  that  the  disease  was  during  all  that  period  in  a  state  of 
incubation. 

When  persons  in  the  first  instance  escape,  but  do  not  ultimately  resist  the 
influence  of  the  morbific  cause,  it  is  because  they  had  at  first  a  power  of  re- 
sistance, an  absence  of  receptivity;  that  is  to  say,  they  did  not  till  a  later 
period  possess  that  predisposition  which  is  necessaiy  for  the  reception  and 
conception  of  the  morbific  germ.  Some  females  conceive  in  consequence  of 
the  least  possible  amount  of  connection  with  the  male;  while  others,  after 
having  had  many  times  unfruitful  connection,  conceive  by  the  same  male 
on  some  particular  occasion,  there  being  no  apparent  difference  in  the  con- 
ditions under  which  the  fruitful  and  the  unfruitful  intercoui'se  occurred. 
What  happens  in  respect  of  persons,  happens  also  in  respect  of  diseases. 
You  may  unsuccessfully  on  two  or  three  different  occasions  inoculate  a  per- 
son with  a  virus,  the  vaccine  virus  for  instance,  and,  on  making  a  fourth 
trial,  employing  virus  obtained  under  conditions  exactly  similar  to  those 
in  which  that  was  taken  which  you  used  in  the  three  unsuccessful  attempts, 
you  may  see  the  vaccina  develop  itself,  in  one  whom  you  were  inclined  to 
believe  was  devoid  of  aptitude  to  receive  it. 

The  remarks  now  made  respecting  contagious,  are  equally  applicable  to 
infectious  diseases ;  it  matters  little  whether  the  morbific  germ  is  developed 
under  the  influence  of  particular  telluric  conditions,  such  as  marsh  miasma, 
or  whether  it  has  been  conceived  by  an  animal,  as  is  the  case  with  glanders, 
malignant  pustule,  or  small-pox :  in  both  classes  of  cases  there  must  be  a 
suitable  relation  between  the  stimulus  and  the  support  with  which  it  meets. 

Infection  and  contagion,  then,  do  not  take  place  proportionately  to  the 
quantity  of  the  morbific  germ,  as  some  physicians  profess  to  believe.  As 
Professor  Charles  Robin  has  told  )rou,  quality  is  paramount  over  quantity; 
but  it  is  still  more  important  to  take  into  account  the  aptitude  of  the  germ, 
and  the  aptitude  of  the  receiving  organism.  Not  only  is  quantity  of  small 
consequence,  but  the  history  of  generation  in  animals  would  actually  seem 
to  show  that  the  active  power  of  germs  is  in  a  ratio  inverse  to  quantity,  or 
at  least  inverse  to  the  degree  of  concentration  of  the  principles  which  con- 
stitute them. 

Here,  again,  let  me  borrow  my  analogies  from  Spallanzani.  Passionately 
devoted  to  the  study  of  the  wonders  of  nature,  proceeding  in  the  path  of 
discovery  unincumbered  by  preconceived  ideas,  happy,  as  he  advanced,  to 
find  difficulties  which  stimulated  his  inquiring  genius,  the  search  for  a  par- 
ticular truth  leading,  as  lie  himself  said,  to  the  discovery  of  other  truths 
spontaneously  presenting  themselves,  Spallanzani  belonged  to  that  illustri- 
ous generation  of  ingenious  attentive  observers  which  embraced  Pontana, 
Redi,  Reaumur,  Swammerdam,  ami  Senebier,  and  which  is  continued  iu 
our  day  by  our  great  scientific  physiologist,  Claude  Bernard.  The  perusal 
of  the  work  of  the  Italian  naturalist  carries  along  the  reader,  and  affords 
more  charming  recreation  than  the  raosi  attractive  romance.  Many  of  you 
are  acquainted  with  Spallanzani's  works  on  the  subject  of  generation,  and 


CONTAGION.  473 

his  experiments  on  artificial  fecundation,  made  not  only  on  the  inferior 
classes  of  animals,  but  also  on  the  mammalia. 

Spallanzani  found  that  he  could  fecundate  the  spawn  of  the  frog  and  the 
toad  by  spreading  over  it  the  semen  of  the  male,  either  by  evacuating  it  by 
pressing  on  the  abdomen  of  the  animal,  or  by  taking  it  from  the  spermatic 
vesicles  j  but  that  the  fecundation  of  the  ova  of  aquatic  salamanders  could 
not  be  accomplished  in  that  manner.  He  was  well  aware  that  in  them 
natural  fecundation  does  not  take  place  after  the  laying  of  the  ova  as  in 
frogs  and  toads,  but  within  the  body  of  the  mother;  consequently,  he  was 
obliged  to  have  recourse  to  other  means,  for  he  could  not,  as  he  himself 
remarks,  fecundate  foetuses  after  their  birth.  He  repeated  his  experiments 
many  times,  "varying  the  proceedings  in  a  thousand  ways  in  respect  of  the 
quantity  of  semen  employed,  and  in  respect  of  the  manner  in  which  it  was 
applied  to  the  ova,  sometimes  touching  them  slightly  with  it,  sometimes 
gently  bathing  them  in  it, and  at  other  times  quite  soaking  them  in  it;  but 
he  was  always  equally  unsuccessful."  Discouraged  by  his  unavailing  efforts, 
he  was  about  to  discontinue  them  as  hopeless,  when  it  occurred  to  him  that 
he  had  forgotten  an  important  circu instance.  He  recollected  that  in  his 
experiments  on  frogs  and  toads,  fecundation  was  accomplished  by  bringing 
the  semen  into  contact  with  the  ova  immediately  upon  their  being  discharged 
from  the  cloaca.  The  male,  coupled  to  the  female,  holds  her  in  a  close  em- 
brace, so  that  their  posterior  parts  are  kept  in  contact.  In  the  salamander 
copulation  proceeds  on  another  plan,  the  ova  being  fecundated  whilst  they 
are  within  the  body  of  the  female ;  whereas  in  the  frog  and  toad  the  ova 
are  external  to  the  female  during  fecundation.  This  condition  of  distance 
Spallanzani  had  lost  sight  of.  During  copulation  the  male  salamander  so 
places  himself  that  the  lower  part  of  his  head  touches  the  upper  part  of  the 
head  of  the  female,  their  bodies  forming  an  angle,  the  apex  of  which  is  con- 
stituted by  the  union  of  the  two  heads ;  or  else  the  male  and  female  place 
themselves  nose  to  nose,  in  such  a  way  as  to  have  their  bodies  in  close  prox- 
imity, forming,  however,  a  very  acute  angle.  The  male  then  shakes  himself 
about,  and  squirts  a  copious  jet  of  seminal  fluid  from  his  anal  orifice,  which, 
mingling  with  the  water,  becomes  greatly  diluted,  and  in  that  state  reaches, 
and  enters,  the  anus  of  the  female.  Bearing  in  mind  this  peculiarity,  Spal- 
lanzani resumed  his  experiments.  Suspecting  that  the  pure  semen  was  not 
in  a  state  fitted  to  produce  fecundation,  and  that  its  dilution  with  water  was 
an  essential  condition,  he  caused  salamanders  to  discharge  their  ova  by 
pressing  them  on  the  abdomen  with  his  fingers :  he  then  placed  the  eggs  in 
water  in  which  he  had  dissolved  a  small  quantity  of  semen  :  of  twenty-seven 
eggs  so  treated,  seventeen  became  developed. 

The  failures,  therefore,  had  not  in  this  case  depended  upon  a  deficiency 
in  the  quantity  of  the  germ.  Now,  what  is  true  of  physiological  germs, 
may  be  said  likewise  of  contagious  and  infectious  morbific  germs.  I  do 
not  mean  to  say,  that  we  are  entitled  to  conclude  from  the  facts  now  stated, 
that  the  active  power  of  germs  is  in  an  inverse  ratio  to  their  quantity  :  I 
only  conclude  that  we  must  take  more  or  less  into  account  the  condition  of 
quantity:  quality  is  the  condition  of  principal  importance.  This  statement, 
I  now  reiterate,  although  I  insisted  upon  it  when  lecturing  upon  specific 
influence. 

Thus,  gentlemen,  it  appears,  that  quantity  of  germ,  but  still  more 
quality  of  germ,  aptitude  of  the  individual  by  whom  the  germ  ought  to 
be  received  and  conceived,  and  the  relative  circumstances  in  which  the 
individual  is  placed,  are  the  conditions  which  influence  contagion  and  in- 
fection. 

These  conditions,  as  I  have  said,  are  far  from  being  always  met  with  : 


474  CONTAGION. 

upon  this  point,  experience  has  given  a  distinct  verdict.  Some  persons 
possess  an  absolute  power  of  resistance  :  there  are  individuals  who  pass 
unharmed  through  every  kind  of  epidemic,  be  it  influenza  or  cholera,  scar- 
latina or  measles,  small-pox  or  dothinenteria,  typhus  or  yellow  fever :  there 
are  individuals  whom  it  is  impossible  to  affect  with  the  vaccine  virus — in- 
oculate them  twenty  times,  and  you  will  obtain  no  l'esult :  in  them,  if  I 
may  use  the  expression,  the  soil  is  barren — in  it  the  seed  cannot  germinate. 
There  are  others  again,  in  whom  the  power  of  resistance  is  only  temporary. 
It  is,  in  general,  difficult  to  find  out  the  conditions  upon  which  this  power 
of  resistance  depends  :  in  some  cases,  however,  they  can  be  got  at,  though 
we  can  never  become  intimately  acquainted  with  them. 

Every  farmer  will  tell  you  that  pregnant  ewes  are  less  liable  than  other 
sheep  to  contract  contagious  diseases,  but  that  as  soon  as  they  have  brought 
forth  their  young,  they  return  to  a  state  of  liability  similar  to  that  of  other 
sheep.  The  same  remark  is  to  a  certain  extent  applicable  to  women.  Ma- 
gendie  explained  this  fact  by  saying  that  the  sanguineous  plethora,  which 
is  usually  more  or  less  decided  in  pregnant  women,  renders  absorption  more 
difficult ;  and  that  after  parturition,  it  again  becomes  more  easy,  in  conse- 
quence of  the  plethora  being  diminished  by  depletion  of  the  vascular  sys- 
tem, and  by  the  comparative  emptying  of  the  abdomen  caused  by  the  de- 
crease in  the  volume  of  the  uterus,  so  that  after  parturition  women  and 
female  animals  resume  their  aptitude  to  receive  the  germs  of  contagious 
diseases.  That  is  the  physiological  explanation.  It  is  not  for  me  to  dis- 
cuss it.  It  is  easy  to  understand  why  it  should  be  accepted  :  but  it  mat- 
ters little  whether  it  be  received  or  rejected,  as  the  fact  will  still  remain. 

It  has  been  alleged  that  great  overflowings  of  the  heart,  such  as  arise 
from  emanations  of  joy  and  maternal  love,  fortify  the  system  against  con- 
tagion, while  depressing  moral  emotions,  such  as  fear,  increase  its  suscep- 
tibility. 

It  is  known  that  the  ability  to  resist  contagion  varies  with  the  age  of 
the  individual ;  there  is  less  power  of  resistance  in  the  youth  than  in  the 
old  man  ;  and,  all  other  conditions  except  age  being  equal,  old  men  resist 
contagion  better  than  adults. 

Again,  it  is  well  known  that  an  anterior  contamination  generally  confers 
an  absolute  immunity  from  any  subsequent  contamination.  In  respect  of 
small-pox,  this  is  the  case  with  very  few  exceptions.  Though  instances  do 
occur  of  persons  contracting  indurated  chancres  several  years  after  a  first 
attack:  though,  consequently,  there  are  examples  of  second  attacks  of 
syphilis  similar  to  those  published  by  Dr.  Follin  and  other  conscientious 
observers  of  unquestionable  credit,  such  examples  are  rare,  and  do  not  con- 
trovert in  the  least  degree  the  law  of  immunity  as  enunciated  by  Dr.  Ricord. 
In  fact,  the  statement  applies  to  syphilis  in  the  same  manner  that  it  applies 
to  small-pox,  measles,  scarlatina,  dothinenteria,  and  yellow  lever  ;  thai  IS 
to  Bay,  that  while  the  immunity  acquired  by  a  first  attack  is  universally 
admitted  to  be  the  rule,  it  is  also  equally  admitted  that  the  rule  presents 
a  considerable  number  of  exceptions. 

1  have  laid  before  you  accounts  of  second  attacks  of  small-pox,  and  you 
have  yourselves  seen  such  cases  iii  the  hospitals.  "S  on  have  also  seen  a 
well-marked  similar  occurrence  in  respect  of  dothinenteria.      Some  months 

ago,  the  patient  to  whom  I  refer  occupied  bed  No.  7  of  St.  Bernard's  Ward. 

She  came  into  hospital  with  fever,  genera]  pains  in  the  limbs,  lumbar  pains 
and  headache  ;   she    complained    of  sleeplessness.      The   appearance  of  the 

tongue,  copious  diarrhoea  accompanied  by  gurgling  in  the  right  iliac  fossa, 

and  finally  an  eruption  of  rosy  lenticular  spots,  left  no  room  for  doubl  a-  to 
the  diagnosis.   This  woman,  however,  .-aid  I  hat ,  four  years  previously,  she  bad 


CONTAGION.  475 

lia<l  pr  cisely  similar  symptoms.  At  that  time  she  was  attended  by  my 
honorable  and  accomplished  colleague  Professor  Rostan,  in  whose  wards 
she  remained  for  four  months.  The  duration  of  the  illness  enables  us  to 
come  to  a  probably  correct  conclusion  as  to  its  nature;  but  the  circum- 
stance which  removes  all  doubt  on  the  point  is  the  patient  distinctly  recol- 
lecting to  have  heard  it  suited  by  those  around  her  at  the  time,  that  she 
bad  "  typhoid  fever."  I  have  in  my  private  practice  met  with  an  example 
of  a  person  twice  taking  this  disease.  A  girl,  twelve  years  old,  took  doth- 
inenteria  :  the  case  was  very  severe,  and  the  illness  lasted  fifty-seven  days. 
In  the  following  year,  she  had  another  serious  attack  of  the  same  disease. 
The  symptoms  were  quite  as  distinctively  characteristic  as  on  the  first  occa- 
sion ;  and  the  duration  of  the  disease  was  fifty  days. 

Hooping-cough,  which  generally  confers  immunity  for  the  future,  may 
likewise  occur  more  than  once  in  the  same  subject.  A  girl  of  three  and  a 
half  years  of  age,  whom  I  had  attended  ten  months  previously  for  this  dis- 
ease, again  came  under  my  care  with  hooping-cough,  of  which  she  had  a 
second  attack  as  severe  as  the  first. 

These  exceptional  facts  do  not  at  all  invalidate  the  general  rule,  that 
one  attack  of  a  contagious  disease  generally  protects  the  individual  from 
it  for  the  future.  It  would  appear  that  the  virus  or  morbific  matter,  upon 
its  entering  the  economy  for  the  first  time  puts  in  motion  all  therein  that 
is  fermentable  [tout  ce  qu'ilpeut  \j  avoir  de  fermenteseible],  and  so  thoroughly 
destroys  it,  that  the  leaven — the  contagion — when  introduced  again,  finds 
nothing  whereupon  to  exert  its  action. 

A  similar  immunity  from  the  virus  of  contagious  diseases  is  conferred 
by  habitual  exposure  [aecoutumance]  ;  and  also,  immunity  from  infectious 
germs  is  bestowed  by  acclimation.  In  resjject  of  both,  however,  the  im- 
munity is  more  apparent  than  real.  A  European,  for  example,  comes  into 
a  region  where  yellow  fever  is  endemic:  should  he  have  the  good  fortune 
to  sojourn  there  for  a  certain  time  without  there  being  an  epidemic  of  the 
disease,  he  will  have  acquired  such  immunity  by  his  residence,  that  when 
the  fever  breaks  out,  his  immunity  will  be  equal  to  that  of  the  indigenous 
inhabitants.  This  is  what  is  alleged  by  those  who  hold  that  immunity  is 
derived  from  acclimation.  According  to  them,  it  is  well  known  that  the 
native  inhabitants  of  a  country  enjoy  so  great  a  degree  of  immunity  that 
even  when  they  remove  to  another  climate  they  may  come  back  to  their 
own  locality  without  incurring  any  risk  from  contagion,  although  it  might 
be  supposed  that  during  their  absence  they  had  lost  part  of  their  power  of 
resisting  it. 

The  same  remarks  apply  to  marsh  fevers.  At  our  stations  on  the  Senegal, 
where  our  troops,  when  they  penetrate  inland,  are  cruelly  decimated  by 
terrible  attacks  of  pestilential  fever,  the  indigenous  negroes  suffer  very 
little  in  this  way.  So  it  is  in  our  Algerian  possessions :  although  very  few 
Europeans  escape  the  African  fevers,  the  Arabs  suffer  less  from  them  al- 
though they  are  not  original  inhabitants  of  the  country:  like  our  colonists 
and  soldiers,  they  have  emigrated  to  it,  but  having  dwelt  in  it  for  seven  or 
eight  hundred  years,  the  race  has  become  acclimated.  In  the  case  of  the 
Europeans,  on  the  other  hand,  there  has  not  yet  been  time  for  acclimation, 
for  they  have  only  been  in  Algiers  since  the  conquest. 

It  would  appear  then  that  acclimation  in  a  certain  number  of  cases  con- 
fers absolute  immunity  from  marsh  fevers;  but  that  in  other  cases  the  im- 
munity is  only  relative.  The  Arabs  themselves  take  the  disease,  though  in 
a  less  degree  than  Europeans.  In  the  departments  of  France  forming  the 
old  province  of  Sologne,  where  fevers  always  prevail,  the  inhabitants  pay 
them  a  heavy  tribute,  as  appears  from  the  statistics  drawn  up  by  comruis- 


476  CONTAGION. 

sions  of  the  recruiting  department.  Sologne,  indeed,  is  never  able  to  fur- 
nish its  proper  annual  contingent  to  the  conscription,  so  small  is  the  num- 
ber of  its  really  efficient  men  :  nearly  the  whole  population  lias  a  consti- 
tution deteriorated  by  the  infectious  miasmata  to  the  influence  of  which 
they  have  been  more  or  less  subjected.  Many  have  a  bistre  color  of  the 
skin,  with  engorged  spleen  and  liver,  the  characteristics  of  marsh  cachexia. 
To  this  fact,  so  opposed  to  their  opinions,  the  reply  made  by  the  believers 
in  immunity  acquired  by  acclimation  is,  that  the  Solognese  enjoy  a  relative 
immunity.  They  say,  let  a  Solognese  and  a  Parisian  go  to  live  in  a  place 
where  these  fevers  are  at  the  time  prevailing:  the  first  will  take  a  tertian 
or  quartan  ague,  while  the  second  will  take  a  pernicious  fever.  When  we 
come  to  consider  the  subject  of  marsh  fever,  we  shall  see,  that  the  immu- 
nity about  which  I  have  now  been  speaking  appears  to  belong  to  certain 
races,  while  there  are  other  races  which  do  not  possess  it,  and  are  incapable 
of  being  acclimated. 

In  respect  of  a  contagious  virus,  it  is  not  a  question  of  immunity  pro- 
duced by  acclimation,  but  by  habitual  exposure  [accowtumance].  This  is 
the  explanation  given  of  the  fact,  that  nursing  sisters  and  physicians  can 
live  in  the  midst  of  contagious  diseases  without  contracting  them.  This 
fact  has  been  compared  with  that  immunity  from  poisoning  by  arsenic  and 
opium  respectively  acquired  by  arsenic  eaters  and  opium  smokers — a  new 
version  of  the  more  apocryphal  story  of  King  Mithridates.  Poisonous 
doses  of  the  most  dangerous  substances  may  be  taken  without  harm  by 
persons  who  have  been  long  accustomed  to  their  use  in  small  doses. 

The  alleged  facts  now  mentioned  in  respect  of  acclimation  and  habitual 
exposure  have  not  been,  in  my  opinion,  by  any  meaus  demonstrated;  aud 
there  are  many  other  facts  which  are  contradictory  to  them.  From  among 
the  latter,  I  shall  only  cite  oue  example.  During  the  Crimean  war.  typhus 
made  a  relatively  larger  number  of  victims  among  the  medical  men  than 
among  the  soldiers.  Yet  the  medical  men  were  placed  in  the  conditions 
alleged  to  confer  immunity,  for,  from  the  beginning  of  the  epidemic,  they 
were  in  contact  with  the  sick. 

If  there  be  any  ground  whatever  for  holding  the  opinion  which  I  am 
now  combating,  it  is,  as  I  have  just  said,  that  the  immunity  spoken  of  is 
more  apparent  than  real,  except  in  some  exceptional  cases.  This  does  not 
arise  from  the  individuals  possessing  a  natural  capacity  to  resist  morbid  in- 
fluences, but  upon  their  having  acquired  such  a  capacity  at  the  cost  of  an 
attack  of  the  disease,  of  which  there  remained  neither  trace  nor  recollec- 
tion, or  of  which  the  characteristic  symptoms  had  been  mistaken.  Having 
spoken  to  you  of  variola  sine  variolis,  of  measles  without  eruption,  and  of 
"defaced"  scarlatina  [searlatine fruste],  you  can  understand  that  attacks  of 
these  exceedingly  contagious  diseases,  by  passing  unnoticed,  though  con- 
ferring immunity  from  subsequent  attacks,  make  it  appear  as  if  certain  in- 
dividuals were  originally  exempt  from  the  risk  of  contagion,  whereas  their 
exemption  has  been  acquired  by  their  having  had  the  disease  in  question. 

Let  me  state  the  facts.  Drs.  Chervin,  Louis,  and  1  were  senl  to  Spain 
to  study  yellow  fever,  when  it  was  prevailing  as  an  epidemic  at  ( ribraltar.* 
You  know  with  what  rigorous  precision  inv  honorable  colleague,  Dr.  Louis, 
was  in  the  habit  of  observing  patient-  and  drawing  up  the  reports  of  their 
cases:  nothing  could  escape  him.  To  enable  him  to  draw  up  his  statistics 
satisfactorily,  he  wished  to  see  the  whole  population.  This  was  easily  ac- 
complished at  Gibraltar,  where  the  inhabitants  are  few.     We  therefore  -;nv 

a  kkvin.  Louis,  Troi  bseau.     Documents  rccueillis  par  la  Commission  M  <<1  i- 
cale  Francaise  envoyfie  ;i  Gibraltar.     Paris,  1830. 


CONTAGION.  477 

everybody;  making  diligent  inquiry  at  the  same  time  for  those  who  had 
had  yellow  fever  in  the  previous  epidemics  of  1  S( )4  and  1813.  Upon  inves- 
tigating the  question,  whether  a  previous  attack  had  conferred  the  immunity 
which  many  seemed  to  enjoy,  wc  found  that  among  those  who  took  the  fever 
in  18.!*,  there  were  only  twenty-four  persons  who  had  previously  had  it. 
It  is  a  remarkable  fact  that  in  reference  to  some  of  those  whom  the  scourge 
spared,  we  were  assured  by  persons  who  spoke  from  personal  observation, 
that  they  had  "imbibed  a  former  epidemic  with  their  mothers'  milk," 
having  had  a  mild  attack  of  yellow  fever  which  had  lasted  three  or  four 
days.  Similarly  mild  cases  we  ourselves  observed  in  the  epidemic  of  1828. 
For  some  days,  the  patients  experienced  a  general  feeling  of  discomfort, 
which  did  not  prevent  them,  however,  from  following  their  usual  occupa- 
tions. Under  such  circumstances,  it  is  easy  to  understand  how  the  disease 
might  remain  undiscovered. 

In  like  manner,  some  persons  owe  their  power  to  resist  vaccination  to 
their  having  had  at  some  anterior  period  an  exceedingly  slight  attack  of 
distinct  small-pox,  characterized  by  a  few  pustules,  to  which  no  attention 
was  paid,  or  by  pustules  confined  to  the  arch  of  the  palate,  as  occurred  in  a 
case  which  I  met  with  ;  or,  again,  the  exemption  may  be  conferred  by  the 
individuals  having  had  small-pox  during  intra-uterine  life.  However  mild, 
however  distinct  the  attacks  may  have  been,  they  suffice  to  confer  im- 
munity :  they  not  only  render  individuals  incapable  of  taking  small-pox, 
but  they  likewise  incapacitate  them  from  taking  vaccina. 

I  am  not,  however,  disposed  to  deny  that  there  are  individuals  who  pos- 
sess an  absolute  immunity.  To  employ  a  comparison  which  I  formerly 
used,  I  admit  that  in  some  individuals  the  soil  is  completely  barren,  and 
that  in  others  it  only  enables  the  seed  to  germinate  badly.  On  a  former 
occasion,  I  cited  examples  to  you  of  subjects  upon  whom  neither  exposure 
to  the  contagion  of  small-pox,  nor  even  inoculation  produced  any  effect :  I 
know,  also,  that  there  are  other  individuals,  who,  although  they  have  never 
been  vaccinated,  and  have  never  had  small-pox,  yet  when  they  do  take 
small-pox,  have  it  in  a  very  modified  form,  which  seems  to  demonstrate  the 
existence  of  at  least  a  relative  immunity.  The  point  upon  which  I  wish  to 
insist  is,  that  absolute  immunity  is  exceedingly  rare. 

One  word  more,  gentlemen,  on  the  transmission  of  germs. 

Some  germs,  such  as  that  of  syphilis,  are  transmitted  by  simple  contact. 
That  the  contagion  take  effect,  it  is  sufficient  that  the  venereal  virus  be  in 
contact  with  a  mucous  surface  like  that  of  the  glans  :  it  is  not  necessary 
that  there  should  be  any  lesion,  excoriation,  or  ulceration,  which,  however, 
if  present  would  open  a  wide  door  for  absorption.  An  often-repeated 
experiment  has  conclusively  determined  this  fact.  The  experiment  to 
which  I  refer  consists  in  placing  pus  taken  from  a  syphilitic  ulcer  under  a 
watch-glass,  and  in  contact  with  a  healthy  mucous  membrane  :  the  result  is 
another  ulcer — a  specific  chancre.  Malignant  pustule  is  also  transmissible 
by  simple  contact.  Shejmerds  often  become  affected  by  malignant  pus- 
tule by  skinning  sheep  which  have  died  of  sang  de  rate:  the  disease 
becomes  developed  in  the  eyelids,  the  cheeks,  and  other  parts  where  there 
is  no  lesion  of  the  integuments.  I  am  aware  that  it  has  been  said  that  in 
these  cases  the  contagious  pus  had  come  in  contact  with  some  slight  abra- 
sion of  the  skin  ;  but  this  is  a  mere  supposition,  for  individuals  the  most  scru- 
pulously careful  of  their  persons,  and  who  have  affirmed  that  they  had  not 
the  slightest  abrasion  anywhere,  have  taken  the  disease  from  sheep  in  the 
manner  I  have  now  described.  It  must  be  admitted,  however,  that  trans- 
mission by  simple  contact  is  the  rarest  manner  in  which  contagion  is  trans- 
mitted. 


478  CONTAGION. 

The  two  more  common  ways  are  transmission  by  inoculation,  and  trans- 
mission by  inhalation.  In  the  first  case,  the  virus  is  introduced  iuto  the 
system  by  a  denuded  surface,  or  by  an  artificial  opening :  to  the  latter 
mode,  the  use  of  the  term  inoculation  is  more  properly  restricted.  Inocu- 
lation is  the  most  certain  manner  of  transmission ;  for  the  virus  heing 
placed  beneath  the  epidermis  by  the  lancet,  or  brought  into  contact  with  a 
denuded  surface,  finds  the  open  mouths  of  the  absorbent  vessels,  and 
through  them  effects  an  entrance  into  the  organism.  The  diseases  of 
which  I  have  been  speaking,  though  contagious  by  simple  contact,  are  in 
a  much  greater  degree  contagious  by  inoculation. 

Take  small-pox,  measles,  and  scarlatina.  It  is  unnecessary  to  insist 
upon  the  inoculation  of  the  matter  of  small-pox.  As  you  are  aware,  for  a 
long  period  variolous  inoculation  was  the  only  means  employed  for  pro- 
tecting the  community  from  great  epidemics  of  small-pox.  At  present,  we 
hear  nothing  said  about  the  inoculation  of  eruptive  fevers  through  the 
blood  ;  but  nevertheless,  I  ought  to  remind  you  that,  although  the  experi- 
ments have  often  been  negative  in  their  results,  we  must  concede  an  impor- 
tant place  to  the  inoculation  of  the  blood  of  small-pox  patients  succesfully 
performed  by  Luigi  Sacco  in  1849 ;  and  of  the  blood  of  persons  having 
measles,  likewise  successfully  performed  by  Home  of  Edinburgh  in  1758 ; 
by  Speranza  of  Milan  in  1822 ;  and  by  Michael  of  Katona,  an  account  of 
whose  experiments  you  will  find  in  the  "Gazette  Medicale  de  Paris"  for 
1843. 

Finally,  you  are  aware  of  the  fact,  upon  which  I  have  already  suffi- 
ciently insisted,  that  syphilis  may  be  transmitted  by  vaccinatioiywhen  the 
vaccine  matter  has  been  taken  from  a  subject  in  whom  syphilis  is  either 
active  or  latent.*  Dr.  Rollet,  in  a  work  published  in  1861,'f  has  repro- 
duced and  supported  the  conclusions  formerly  arrived  at  by  Dr.  Viennois, 
his  pupil.t  The  cases  reported  by  Drs.  Rollet  and  Viennois  leave  no 
room  for  doubt  as  to  the  possibility  of  the  transmission  of  syphilis  by  vac- 
cination. The  two  cases  of  M.  Lecoq,  military  surgeon, still  further  confirm 
the  statements  of  the  physicians  of  Lyons,  previously  shown  to  1"-  correct 
by  facts  adduced  by  MM.  Waller,  Gibert,  and  Hubner.  From  these  data 
it  i-  apparent,  that  under  certain  conditions,  healthy  individuals  inocu- 
lated with  the  blood  of  persons  affected  with  syphilis  become  affected  with 
syphilis,  which  first  shows  itself  by  a  chancre  variable  in  form,  and  having 
a  special  form  of  induration.  It  is  called  by  Dr.  Rollet  the  vaceino-sypk- 
ilitic  chancre. 

In  tli!'  second  mode  of  transmission — transmission  by  inhalation — conta- 
gion take-  place  by  the  absorption  of  a  virus  or  a  miasm  by  the  mucous 
surface  of  the  respiratory  passages,  and,  possibly  also,  by  simple  contact 
therewith.  Here  I  must  pause  in  my  description,  that  I  may  make  some 
explanatory  remarks. 

This  manner  of  transmission  has  been  confounded  with  infection,  but  it 
much  more  nearly  approaches  transmission  by  direct  contact,  if  indeed  it  be 
not  identical  with  it.  To  explain  the  spread  of  certain  diseases  evidently 
Contagious,  it  has  been  said,  that  the  air  is  vitiated  by  etlluvia  from  the 
sick,  and  ha-  thus  become  infectious.  In  the  ward  of  an  hospital,  contain- 
ing patients  both  with  scarlatina  and  small-pox,  other  patient-,  occupying 

e  j..  118,  of  tfiis  translation:  see  :>1-"  a  communication  made  by   Pr< 
Trousseau  to  t  1  *  *  -  Academy  of  Medicine  in  1866,  ••  !>■•  In  Syphilis  Vaccinal**. " 
y   Rollet:   Recberches  Experimentaleset  Cliniqups  sur  la  Syphilis.     Paris, 
+  Viknnoib:   Rechercbes  but  le  Chancre  Primitif,  etles  Accidents  Consecutifa 
produits  par  In  Contagion  de  la  Syphilis  Secondaire,     ['/'/"' ><•] ;  Paris,  I860. 


CONTAGION.  479 

beds  far  removed  from  the  latter,  have  taken  scarlatina:  it  lias  then  been 
.-aid  that  the  original  scarlatina  patient-  vitiated  the  air,  that  the  second 
class  <>f  patients  were  infected  by  breathing  the  vitiated  air — in  the  same 

way,  fin'  example,  that  individuals  are  infected,  and  take  typhus,  in  the 
ambulances  of  armies.  I  do  not  think  that  this  doctrine  will  bear  the 
slightest  examination.  The  air  is  not  vitiated  :  it  is  simply  contaminated, 
ves  in  such  a  case  only  as  the  vehicle  by  which  are  transmitted  the 
volatile  emanations  from  variolous  and  scarlatinous  patients:  it  is  not  viti- 
ated any  more  than  is  the  pus  of  a  bubo  serving  as  the  vehicle  of  the  germ 
of  syphilis.  Air  and  pus  have  each  their  own  physical  and  chemical  prop- 
erties: ami  iu  addition,  the  most  delicate  analysis  and  the  best  microscope 
can  detect  nothing  more.  The  contaminated  air  serves  as  the  vehicle  for 
tin-  virus  of  small-pox,  just  as  the  scabs  from  the  pustules  were  iu  former 
times  pounded  down  and  dusted  over  the  bread  and  butter  intended  for 
children  subjected  to  inoculation,  or  introduced  according  to  the  Chinese 
fashion  into  the  nostrils;  or  as  threads  soaked  in  variolous  pus  were  used 
by  early  inoculators.  Though  in  these  cases,  the  contagion  is  transmitted 
in  a  more  direct  or  at  least  in  a  more  palpable  manner,  the  transmission 
is  similarly  effected,  when,  by  inhalation,  the  morbid  principles  transported 
in  the  air,  come  into  contact  with  the  nasal  fossa?  and  the  bronchial  tubes, 
penetrating  to  the  remotest  ramifications  of  the  respiratory  apparatus. 
Nevertheless,  the  third  mode  of  transmission — that  by  inhalation — has 
been  distinguished  from  the  two  others. 

Contagion,  whether  it  be  mediate  or  direct,  is  not  infection.  Both  may 
originate  in  telluric  or  atmospheric  influences ;  but  there  is,  I  repeat,  this 
essential  difference  between  them,  that  contagion  transmits  to  a  person  in 
health  morbid  germs  which  have  been  developed  in  a  diseased  person,  while 
this  is  not  the  case  in  respect  of  infection. 

In  conclusion,  let  me  recall  to  your  recollection  a  fact  which  I  have  just 
mentioned,  to  the  effect  that  contagious  diseases,  in  passing  from  one  to  an- 
other animal  species,  lose  their  power  of  transmission :  such  is  the  case  with 
hydrophobia.  There  are  other  contagious  diseases  which  change  their  form 
in  transmission.  I  dwelt  on  this  fact  at  so  much  length  when  speaking  to 
you  of  vaccina,  eaux  aux  jambes,  and  cow-pox,  *ang  cle  rate,  charbon,  and 
malignant  pustule,  that  I  need  not  resume  the  discussion.* 


*  See  page  96  and  following  pages  of  this  volume. 


480  oz^xa. 


LECTURE   XXIV. 

OZiENA. 

A  very  Common  Affection. — Must  not  be  confounded  with  Fetor  of  the  Month 
or  Throat. — Fetor  of  Ozcena  is  altogether  Peculiar. — Sometimes  Depend- 
ent on  Alteration  of  the  Secretions. — Fetor  of  Inflamrnatory  Secretions 
in  some  persons. —  Constitutional  Ozcena. — Symptoms. — Syphilitic  Ozwna 
very  frequent. —  Ulceration  of  the  Mucous  Membrane:  Necrosis. — Diseases 
of  the  Maxillary  Sinus. — Topical  Treatment  is  the  most  usual. —  ConstitUr 
tional  Treatment  is  very  useful  in  Syphilitic  Ozcena:  also  of  considerable 
benefit  in  Herpetic  and  Scrofulous  Ozcena. — Powder  for  snuffing  up  the 
Nose. — Injections. — Treatment  must  be  very  patient  and  very  varied. 

Gentlemen:  You  have  repeatedly  seen  patients  with  ozsena  [ozene, 
punaisie~]  in  the  clinical  wards ;  and  on  several  occasions  I  have  directed 
your  attention  to  the  different  causes  of  this  cruel  affection.  I  very  recently 
showed  you  a  young  girl  who  has  had  from  infancy  ozgena  which  I  consid- 
ered to  be  herpetic ;  and  almost  at  the  same  time,  I  had  under  treatment 
in  the  male  wards  a  patient  with  syphilitic  ozcena. 

Whenever  the  nasal  secretions  become  fetid,  we  say  that  the  patient  has 
ozama  ;  but  the  causes  of  the  fetor  are  so  different,  and  the  proper  treat- 
ment so  varied,  that  I  cannot  allow  the  occasion  to  pass  without  taking  a 
short  general  view  of  the  question. 

The  horrible  fetor  of  the  breath  which  constitutes  that  which  we  call 
bug-stench  [punaisie]  is  an  affection  so  disgusting,  and  yet  unfortunately 
so  common,  that  you  ought  from  the  very  beginning  of  your  career  to  be 
acquainted  with  its  causes  and  treatment. 

First  of  all,  gentlemen,  it  is  important  not  to  confound  the  ozsena  which 
proceeds  from  the  nasal  fossa?  with  fetor  of  the  breath  caused  by  an  affec- 
tion of  the  mouth  and  throat.  In  persons  who  have  had  frequent  attacks 
of  inflammatory  .-ore  throat  there  often  remains  submucous  fistulse  which 
secrete  fetid  pus,  and  wherein  accumulate  some  of  these  sebaceous  products, 
so  often  seen  in  the  furrows  of  the  tonsils,  and  which  are  ejected  in  the  form 
of  small,  whitish,  cheesy  concretions,  which  when  crushed  emit  an  intoler- 
able stench.  It  is  unnecessary  for  me  to  remind  you  of  what  takes  place 
in  cancerous  affections  of  the  pharynx,  larynx,  and  upper  part  of  the 
oesophagus. 

In  persons  whose  breath  is  most  free  from  taint,  the  normal  secretion  of 
the  mucous  membrane  of  the  mouth,  after  accumulating  during  the  night 
on  the  tongue  and  teeth,  acquires  a  disagreeable  odor.  If  there  be  an  in- 
flamed condition  of  the  gums  and  month,  the  secretion  becomes  more  abun- 
dant and  more  fetid,  and  unless  the  requirements  of  the  toilel  are  carefully 
carried  out,  this  disagreeable  Btate  continues  till  the  secretion  is  carried 
downward-  at  a  repast  Bu1  should  the  individual  have  carious  teeth,  sup- 
puration in  the  centre  of  the  caries,  or  around  the  diseased  teeth,  often 

occasions  a  fetor  which  ca t  be  gol   rid  of,  however  greal  may  be  the 

attention  given  to  the  mouth. 

Let  me  also  remark  that  in  some  individuals  the  secretions  of  the  mouth 


OZiENA.  .  481 

arc  naturally  fetid,  and  incapable  of  being  rendered  otherwise  by  the  most 
rigorous  cleanliness.  I  need  not  remind  you  of  an  analogous  condition  of 
the  feet,  ears,  and  axillae. 

What  I  have  now  said  will  I  think  suffice  to  prevent  you  from  falling 
into  any  confusion.  It  is  important  to  avoid  mistaking  that  fetor  of  the 
breath  which  proceeds  from  an  affection  of  the  throat  or  mouth  for  that 
which  originates  in  the  nasal  fossa3 ;  but  it  is  equally  important  to  avoid 
the  opposite  error.  Such  mistakes,  however,  are  always  easily  avoided. 
The  simplest  means  of  arriving  at  a  correct  diagnosis  is  to  ask  the  patient 
to  shut  alternately  the  nose  and  mouth  during  expiration :  when  this  is 
done,  there  is  no  difficulty  in  recognizing  the  source  of  the  fetor.  I  ought, 
however,  to  add  that  the  specific  bad  smell  is  chiefly  met  with  in  that  form 
of  ozama  called  constitutional,  and  which  is  peculiarly  allied  to  the  scrofu- 
lous or  herpetic  diathesis. 

The  two  cases  at  present  in  the  clinical  wards  give  you  a  sufficiently  cor- 
rect idea  of  the  nature  of  the  fetor  met  with  in  the  different  kinds  of  ozaena. 
In  the  young  girl  who  has  suffered  from  this  disease  from  infancy,  there  is 
something  in  the  smell  which  excites  sickness :  in  the  other  patient,  who  is 
suffering  from  constitutional  syphilis,  the  fetor  is  no  doubt  very  great,  but 
it  is  less  nauseating. 

I  shall  not  dwell  longer,  gentlemen,  upon  details  the  value  of  which  you 
will  be  better  able  to  appreciate  at  a  more  advanced  period  of  your  studies. 

Persons  attacked  with  ozsena  fortunately  possess  the  privilege  of  not  per- 
ceiving the  bad  smell,  except  in  rare  exceptional  cases,  as,  for  example, 
when  the  maxillary  sinus  is  alone  affected.  The  very  disease  of  the  mucous 
membrane  which  produces  the  ozaena  destroys  the  sense  of  smell.  It  con- 
sequently happens  that  the  affected  individuals,  without  being  aware  of  it, 
are  frequently  frightful  sources  of  misery  to  those  around  them,  who  some- 
times, from  politeness  or  pity,  conceal  their  disgust. 

Sufferers  from  ozsena  become  incapable  of  distinguishing  between  good 
and  bad  odors ;  and  at  the  same  time  lose  the  sense  of  taste,  or,  to  speak 
more  correctly,  that  portion  of  it  which  is  associated  with  the  sense  of 
smell. 

I  need  not  remind  you,  gentlemen,  of  the  fact  stated  in  all  your  books 
on  physiology,  that  certain  flavors  are  perceived  by  the  smell,  whilst  most 
flavors  are  either  not  perceived  at  all,  or  only  to  a  slight  degree,  when  the 
nostrils  are  closed,  or  when  the  sense  of  smell  is  lost.  Put  lemon-juice  into 
one  glass,  and  into  another  water  acidulated  with  acetic,  sulphuric,  hydro- 
chloric, or  other  acid,  and  you  will  find  it  impossible  to  distinguish  the  taste 
of  lemon-juice  from  that  of  the  other  acid  liquids,  if  you  hold  your  nose 
in  such  a  way  as  to  close  the  nostrils. 

All  secretions  in  contact  with  the  atmosphere,  unless  renewed,  become 
altered  in  composition.  This  alteration  is  more  considerable  in  some  per- 
sons than  in  others,  in  virtue  of  conditions  which  I  find  is  rather  difficult 
to  describe,  but  which  perhaps  belong  as  much  to  the  quality  of  the  secre- 
tion, at  the  time  of  its  formation,  as  to  the  special  state  of  the  secreting 
organ.  In  some  persons  the  nasal  secretions,  like  the  pharyngeal,  vaginal, 
and  anal  secretions,  undergo  rapid  change,  and  acquire  an  excessive  fetor, 
not  perceptible  in  other  individuals  much  less  particular  in  the  observances 
of  the  toilet. 

Sometimes  ozsena  is  solely  dependent  upon  the  odor  of  the  altered  nasal 

secretion.    When  the  mucous  accumulation  is  removed  from  the  nostrils  in 

such  cases,  the  breath  becomes  quite  pure ;  but  after  some  hours  the  fetor 

returns,  if  the  mucous  secretions  have  been  allowed  to  reaccumulate  in  the 

vol.  i. — 31 


482  oz^na. 

nasal  fossae.     It  is  obvious,  that  the  remedy  for  an  infirmity  of  this  kind 
consists  in  blowing  the  nose  frequently,  and  keeping  it  very  clean. 

It  appears  then  that  in  some  persons  it  is  normal  for  the  secretions  of  the 
mucous  membranes,  like  those  of  the  skin,  to  be  characterized  by  fetor. 
In  such  individuals,  when  the  mucous  membranes  or  the  skin  are  affected 
by  acute  or  chronic  inflammation,  this  normal  fetor  becomes  very  greatly 
increased.  You  know  how  easily,  particularly  in  fat  persons,  a  bad  smell 
is  produced  by  chafing  under  the  mammse,  in  the  folds  of  the  thighs,  or 
around  the  anus ;  and  that  sometimes  there  is  no  preventing  this  by  the 
most  scrupulous  attention  to  cleanliness.  So  it  is,  as  you- know,  in  inflam- 
matory affections  of  mucous  membranes;  for  you  must  have  been  often 
struck  with  the  fetor  of  gonorrheal  matter  in  some  individuals.  The  fetor 
la>ts  as  long  as  the  acute  stage  of  the  inflammation  ;  and  in  some  persons, 
even  after  the  inflammation  has  passed  into  the  chronic  stage,  the  inflam- 
matory secretions  continue  to  emit  an  intolerable  smell,  however  brief  may 
be  the  time  during  which  they  are  allowed  to  remain  in  the  situation  in 
which  they  were  secreted.  If  the  inflammation  of  the  mucous  membrane 
is  of  a  special  character,  the  secretion  may  be  fetid  from  the  very  first 
moment  of  its  formation. 

It  is  necessary,  gentlemen,  to  enter  into  these  details,  to  enable  you  to 
understand  the  history  of  ozsena.  There  are  many  persons,  who,  when  they 
have  coryza,  discharge  mucous  secretions  possessing  an  exceedingly  dis- 
agreeable odor  ;  it  is  not,  however,  the  odor  of  constitutional,  but  of  what 
may  be  called  the  first  stage  of  accidental  ozsena.  Should  the  coryza  be- 
come chronic,  the  secretion  will  undergo  change  whilst  remaining  in  the 
nasal  fossse,  and  the  fetor  may  resemble  that  which  is  met  with  in  certain 
specific  inflammatory  affections  of  the  pituitary  mucous  membrane. 

The  form  of  the  disease  designated  constitutional — a  term,  however,  which 
I  do  not  justify — is  not  in  general  met  with  till  after  the  years  of  childhood, 
even  when  there  have  existed  from  birth  some  of  these  anatomical  lesions 
of  which  I  shall  afterwards  speak,  and  which  almost  invariably  lead  to 
ozama.  The  malady  seldom  begins  to  make  its  appearance  in  subjects 
under  four  or  five  years  of  age;  but  towards  puberty  it  assumes  considerable 
proportions,  and  continues  considerable  during  adult  year.-,  decreasing,  but 
not  entirely  disappearing  at  a  more  advanced  period  of  life.  This  form  of 
ozama  is  characterized  by  a  repulsive  sickly  smell,  bearing  no  resemblance 
to  any  other  smell;  generally,  the  nasal  secretions  are  purulent,  sometimes 
they  desiccate,  forming  crusts  moulded  in  the  passages,  ami  when  this  is  the 
case,  they  are  almost  always  mixed  with  a  little  blood,  if  an  effort  has  been 
required  to  expel  them.  There  is  often  a  very  abundant  purulent  dis- 
charge; and  it  is  not  in  such  instances  that  the  stench  is  most  disagreeable, 
unless  the  ozana  proceed  from  disease  of  the  maxillary  sinus,  from  which, 
the  pus  having  therein  accumulated,  may  come  in  gushes,  consequent 
upon  certain  movements  of  the  patient.  Upon  examining  the  interior  of 
the'  nasal  fossse  by  the  aid  of  a  small  speculum,  some  redness  of  the  mucous 
membrane  is  nearly  always  found. 

Deformity  of  the  nose,  from  flattening  of  the  root,  is  pretty  frequently 
observed  in  ozsena.  It  has  for  thai  reason  been  assigned  as  a  cause  of  the 
disease:  it  has  been  supposed  thai  the  consequent  structure  of  the  nasal 

prevented    the   evacuation    of  the    mUCOUS   secretions,  which    become 

altered  from  being  long  pent  up.  Bear  in  mind  what  occur.-  in  syphilitic 
ozsena  of  the  adult  during  the  course  of  which  fetor  may  exi.-t,  and  in  fact 
generally  does  exist,  without  there  being  any  disease  or  the  bones  or  de- 
formity of  the  nasal  foSSSS  :  bear  in  mind  also,  l  hat  in  the  majority  of  adults 

attacked  by  ozsena  there  is  no  deformity  of  the  nose.     The  natural  infer- 


OZJENA.  483 

ence,  therefore,  is  that  the  flattening  of  the  root  of  the  nose  and  the  ozsena 
both  proceed  from  the  same  cause — that  is,  from  chronic  inflammation 
and  ulceration  of  the  mucous  membrane,  with  consecutive  necrosis  of  the 
vomer  and  some  portions  of  the  ethmoid  bone. 

Moreover,  persons  are  often  met  with  who  have  nostrils  so  exceedingly 
narrow  that  the  air  does  not  pass  through  them  in  quantity  sufficient  for 
the  requirements  of  respiration,  and  in  whom  nevertheless  the  nasal  secre- 
tions are  always  inodorous. 

There  are  other  and  rarer  cases,  in  which  there  is  no  deformity  of  the  root 
of  the  nose,  in  which  the  nasal  secretions  present  no  unusual  appearance, 
and  in  which  neither  is  there  pain  in  the  head  nor  tension  of  the  upper 
jaw  to  indicate  a  state  of  acute  or  chronic  inflammation.  The  mucous 
membrane  in  these  cases  is  also  without  any  of  the  characteristics  of  in- 
flammatory action. 

Again,  when  there  is  nothing  to  lead  one  to  suppose  that  there  is  inflam- 
mation of  the  pituitary  membrane,  or  necrosis  of  the  bones — when  the 
individual  attacked  by  ozsena  has  the  conditions  of  perfect  health — we  find 
ourselves  forced  to  admit  that  there  is  a  peculiar  fetor  of  the  nasal  secre- 
tion, like  that  observed  in  the  feet  of  some  people :  this  is  the  form  of  the 
disease  to  which  the  term  constitutional  ozsena  ought  to  be  restricted.  To 
follow  out  the  comparison  :  we  should  not  be  justified  in  confounding  the 
bad  smell  which  proceeds  from  the  feet  of  those  who  neglect  necessary  ab- 
lution and  have  no  skin  disease,  with  the  disagreeable  odor  so  often  ob- 
served in  the  feet  of  patients  suffering  from  chronic  eczema  of  the  feet,  and 
particularly  from  the  sequela  of  cutaneous  inflammation,  such  as  are  seen 
between  the  toes  in  the  course  of  venereal  diseases. 

Alongside  of  this  kind  of  ozsena,  which  is  really  constitutional,  we  must 
place  that  other  form  of  the  disease  which  depends  upon  the  herpetic  dia- 
thesis, and  which  is  usually  seen  along  with  the  ophthalmia  called  scrofu- 
lous, and  swelling  of  the  upper  lip.  It  must  not  be  supposed  that  every 
herpetic  affection  of  the  mucous  membrane  of  the  nasal  fossae  gives  rise  to 
ozsena  any  more  than  that  herpetic  affections  of  certain  parts  of  the  body 
are  necessarily  accompanied  by  fetor :  but  just  as  eczema  of  the  feet  and 
vulva  produce  secretions  of  most  disgusting  odor  in  some  persons,  so  does 
chronic  eczema  of  the  mucous  membrane  of  the  nasal  fossse  produce  in  some 
patients  a  secretion  emitting  a  most  revolting  smell. 

The  most  frequent  cause  of  ozsena  is  undoubtedly  syphilis.  When  the 
system  is  contaminated  by  the  venereal  disease,  coryza  is  very  common, 
and  although,  in  the  majority  of  cases,  it  does  not  cause  fetor  of  the  breath, 
yet  it  gives  rise  to  it  in  the  same  way  as  do  herpes  and  scrofula  in  some 
persons.  But  however  great  the  fetor  may  be  in  such  cases,  it  never  equals 
that  of  constitutional  ozsena.  Syphilitic  oza?na  gives  rise  to  ulceration  and 
necrosis,  and  is  the  severest  form  of  the  disease. 

A  membrane  so  delicate  as  the  pituitary  membrane  cannot  long  with 
impunity  be  the  seat  of  inflammation :  ulcerations  frequently  follow  ;  and 
Dr.  Cazenave  of  Bordeaux,  to  whom  we  are  indebted  for  interesting  re- 
searches on  the  subject  now  before  us,  has  seen  ulcerations  even  on  the  floor 
of  the  nasal  fossse  :  by  using  a  speculum,  similar  to  that  employed  for  the 
exploration  of  the  auditory  passage,  ulcerations  can  easily  be  detected  upon 
the  septum  and  those  parts  of  the  nasal  passages  nearest  to  the  opening  of 
the  nostrils.  These  ulcerations  become  a  new  cause  of  ozsena  in  a  way 
which  I  shall  now  explain. 

Whatever  may  be  the  cause  of  the  ulceration,  the  submucous  cellular 
tissue  is  easily  invaded  by  it,  and  the  bone  itself  soon  becomes  affected. 
From  the  very  first  moment  of  the  existence  of  this  lesion,,  it  becomes  a 


484  oz^na. 

new  cause  of  ozama  ;  and  even  when  the  original  disease  is  quite  cured, 
the  fetor  continues  till  the  necrosed  portion  of  the  hone  has  exfoliated,  or 
been  removed  by  surgical  interference. 

Although  the  smell  is  much  less  horrible  when  there  is  no  necrosis,  the 
infirmity  is  still  a  disgusting  one,  for  which  patients  often  seek  treatment  at 
our  hands. 

"When  the  arch  of  the  palate,  the  nasal  process  of  the  superior  maxilla, 
the  vomer,  and  the  nasal  bones  are  involved  in  the  necrosis — when  there  is 
actual  destruction  of  the  bones  of  the  nose — the  ichorous  suppurative  secre- 
tion is  profuse,  and  the  fetor  is  shocking,  although  it  does  not  possess  the 
peculiar  odor  of  constitutional  ozsena. 

Your  surgical  professors  have  taught  you  that  the  necrosis  which  follows 
gunshot  wounds,  fractures  of  the  bones  of  the  face,  and  sometimes  even 
that  which  depends  on  the  existence  of  polypi,  may  produce  ozsena.  But 
diseases  of  the  maxillary  antrum  are  still  more  frequent  causes.  I  was 
recently  consulted  by  a  man  of  forty  years  of  age,  who,  with  the  exception 
of  the  affection  now  under  examination,  was  in  good  health:  he  complained 
of  ozeena,  which  he  said  had  been  for  a  long  time  the  torment  of  his  life. 
He  was  standing :  I  caused  him  to  throw  his  head  backwards,  and  shut  his 
mouth,  so  as  to  be  compelled  to  breathe  through  the  nostrils:  to  my  sur- 
prise, I  could  detect  no  fetor  in  the  breath.  He  then  told  me  that  he 
could  produce  the  disgusting  smell  at  pleasure ;  and  sitting  down,  with  the 
head  inclined  very  much  downwards,  he  discharged  into' his  pocket-hand- 
kerchief a  large  quantity  of  pus,  which  exhaled  an  intolerable  stench  in 
my  consulting-room. 

I  have,  gentlemen,  but  imperfectly  sketched  the  picture  of  ozoena.  I 
have  only  attempted  to  give  you  a  summary  view  of  a  common  disease, 
which  is  of  a  rebellious  character,  and  not  very  well  understood:  I  am  now 
particularly  anxious  to  point  out  to  you  some  of  the  therapeutic  means  by 
which  we  sometimes  cure,  and  often  palliate  this  cruel  infirmity. 

First  of  all,  let  it  be  distinctly  understood,  that  we  can  do  nothing,  or 
next  to  nothing,  for  ozsena  dependent  on  necrosis:  it  is  only  ton  evident 
that  we  can  exercise  no  control  over  such  a  disease :  the  dead  bone  may 
become  detached  in  whole  or  in  part,  and  yet  the  odor  remain  as  long  as 
there  remains  a  fragment  of  necrosed  bone.  You  only  require  to  glance  at 
the  skeleton  of  the  nasal  fossa?  to  form  an  idea  of  the  difficulty  of  expelling 
some  of  the  portions  of  the  dead  bone.  When  the  necrosis  is  very  exten- 
sive, the  ozsena  may  last  for  a  long  series  of  years,  surgery  generally  being 
unable  to  afford  any  relief. 

At  the  end  of  May,  1863,  I  saw  at  the  Hotel  du  Louvre,  in  consultation 
with  my  honorable  colleagues  Drs.  Higgings  and  Shrimpton,  a  young  Eng- 
lish officer  of  the  Indian  army,  who  had  for  a  long  time  been  suffering  from 
syphilitic  ozsena.  lie  had  had,  on  the  preceding  evening,  a  sudden  and 
terrible  suffocative  attack,  caused  by  the  presence  in  the  posterior  cares  of 

a  foreign  body,  which  had  subsequently  fallen  into  the  throat.  Ill  the 
midst  of  bis  suffocative  convulsions,  he  seized  with  his  fingers,  and  finally 
drew  forth  a  large  irregularly  shaped  and  rough-edged  piece — aboul  a 
fourth  part — of  the  ethmoid  bone.  <  >n  the  same  day,  cerebral  symptoms 
supervened, under  which  he  died  within  twenty- four  hours,  h  is  probable 
that  there  were  suppuration  of  the  meninges  of  the  brain,  at  the  points 
corresponding  to  the  cribriform  plate  of  the  ethmoid  bone.  ^  ou  perceive, 
gentlemen,  that  when  there  exists  oecrosis  of  tlii-  description,  expulsion  of 
the  dead  bone  is  almosl  impossible,  and  exfoliation  can  only  take  place  in 

Small  -plinters,  and  therefore  very  .-lowly. 

Ulceration  or  necrosiB  of  the  walls  of  the  antrum,  or  chronic  intlamma- 


OZiENA.  485 

t ion  of  the  mucous  membrane  which  lines  it,  will  also  produce  a  kind  of 
ozaena  for  which  we  can  do  little.  In  the  majority  of  such  cases,  the  only 
means  of  cure  is  to  make  an  opening  into  the  antrum,  through  the  superior 
dental  arch,  and  thereby  directly  introduce  therapeutic  agents. 

In  all  cases  in  which  we  can  direct  our  treatment  to  the  cause  of  the 
inflammation  of  the  pituitary  membrane,  and  in  which  there  is  no  affection 
of  the  Bones,  the  cure  is  easy :  thus,  for  example,  in  syphilitic  coryza  without 
ulceration,  mercurials,  and  the  iodide  of  potassium  are  generally  efficacious, 
in  the  same  way  that  they  cure  chronic  syphilitic  inflammations  of  the 
pharynx  and  larynx:  but  when  the  ozsena  is  herpetic,  we  have  no  longer 
specific  remedies  as  in  syphilis,  and  then  the  cure  is  often  unattainable. 
Some  slight  benefit  may  be  derived  from  preparations  of  arsenic,  iodine,  and 
sulphur;  but  it  is  upon  topical  treatment  that  we  must  principally  rely. 
It  is  still  more  difficult  to  obtain  favorable  results  from  treatment,  when 
Ave  have  to  contend  against  the  scrofulous  diathesis ;  and  although  we  may 
to  some  extent  modify  the  state  of  the  system  by  placing  the  patient  under 
good  hygienic  conditions,  and  giving  him  certain  medicines  (the  triviality 
and  insufficiency  of  which  you  know),  it  is  necessary  to  trust  almost 
exclusively  to  remedies  which  can  be  applied  in  a  direct  manner  to  the 
diseased  mucous  membrane.  It  is,  therefore,  upon  the  topical  treatment, 
that  I  am  now  going  chiefly  to  insist :  it  is  the  kind  of  treatment  which 
will  render  you  the  most  signal  service. 

Powders  inspired  by  the  nose  (as  snuff  is  taken),  the  direct  application  of 
caustic  to  the  ulcerated  parts,  and  injections  of  various  kinds,  are  the  means 
generally  employed ;  and  as  they  are  those  which  have  proved  most  useful 
in  my  practice,  I  feel  that  I  am  entitled  to  recommend  them.  Do  what 
you  may,  it  is  not  easy  to  accomplish  a  cure,  nor  can  you  ever  obtain  a  cure 
within  a  short  period.  Still,  though  the  means  generally  employed  are 
imperfect,  and  not  so  efficacious  as  we  should  desire,  we  can  achieve  rela- 
tively good  results  upon  which  to  congratulate  ourselves. 

There  are  four  powders  which  I  chiefly  make  use  of:  I  shall  now  give 
you  the  formulae  by  which  to  prepare  them. 

No.      I.  Subnitrate  of  bismuth,  .         .         .  J"  of  each  15  grammes. 
Venetian  talc,         .         .         .         .  \  [232  grains.] 

No.     II.  Carbonate  of  potash,      ...       2  grammes.  [30  grains  ] 
Sugar  in  fine  powder,     .         .         .15         "  [232  grains.] 

No.  III.  White  precipitate,  .         .         .25  centigrammes.   [3|  grains  ] 

Sugar  in  fine  powder,     .         .         .15  grammes.   [232  grains.] 

No.  IV.  Bed  precipitate,     .         .         .         .25  centigrammes.   [3|  grains.] 
Sugar  in  fine  powder,     .         .         .     15  grammes.   [232  grains.] 

!So  topical  application  can  be  of  the  least  use  unless,  before  its  employ- 
ment, the  nasal  fossae  have  been  cleansed  by  the  patient,  causing  cold  or 
tepid  Avater  to  pass  through  them.  Before  the  topical  medication  is  pro- 
ceeded Avith,  the  mucous  accumulations  and  the  crusts  Avhich  cover  the 
pituitary  membrane  must  be  removed. 

I  at  once  begin  by  employing  the  mercurial  poAvders.  I  direct  the  patient 
to  draAV  up  vigorously  a  pinch  of  the  powder  through  each  nostril,  so  as  to 
cause  it  to  penetrate  into  most  of  the  turnings  and  hollows  of  the  nose.  This 
proceeding  ought  to  be  repeated  twice  or  thrice  a  clay,  the  frequency  being 
regulated  by  the  amount  of  irritation  produced.  Generally  speaking,  prac- 
titioners are  not  sufficiently  upon  their  guard  in  respect  of  the  powerfully 
irritant  action  of  white  and  red  precipitate.  Both  of  these  agents,  so  power- 
fully efficacious  in  the  treatment  of  chronic  ophthalmia,  and  diseases  of  the 
skin  and  mucous  membranes,  are  frequently  abandoned  just  because  their 


486  OZ.ENA. 

irritant  action  has  proved  greater  than  had  been  expected.  The  remedy 
is  charged  with  producing  a  bad  effect,  for  which  the  physician  alone  is  to 
blame.  You  must  remember,  therefore,  gentlemen,  when  you  prescribe 
these  mercurial  powders,  to  be  on  the  watch  for  the  irritation  which  they 
may  excite  in  the  nasal  fossae;  and  you  must  order  only  a  small  number  of 
inspirations  of  them  in  the  course  of  a  day,  likewise  directing  them  to  be 
continued  only  for  a  few  days. 

There  will  be  a  tendency  to  push  too  far  the  use  of  these  remedies  in 
ozsena,  from  the  beneficial  results  which  they  produce  being  as  rapid  as  they 
are  unlooked  for.  It  is  no  exaggeration  to  say  that  in  some  patients  the 
fetor  disappears  a  few  hours  after  the  powder  has  been  snuffed  up  for  the 
first  time  :  this  result  is  temporary,  I  admit,  but  it  is  positive,  however  in- 
explicable it  may  be.  The  effect  produced  at  least  proves  that  the  mercu- 
rial powders  possess  the  power  of  modifying  the  condition  of  the  diseased 
mucous  membrane ;  and,  at  the  same  time,  it  invites  us  to  give  the  prefer- 
ence to  the  topical  employment  of  mercury  in  the  treatment  of  ozsena,  in 
the  form  of  powder,  in  the  manner  I  have  just  described  ;  or  in  the  liquid 
form,  according  to  a  plan  which  I  shall  forthwith  mention. 

Though  it  is  necessary  to  be  guarded  in  the  use  of  the  mercurial  powders, 
no  such  caution  is  required  in  employing  the  mixture  of  bismuth  and  talc : 
patients  may  snuff  it  up  as  often,  and  in  as  large  quantities,  as  they  please. 
One  might  say  that  the  bismuth  and  talc  powder  was  inert,  were  an  opinion 
to  be  formed  by  the  slight  amount  of  irritation  produced  by  applying  it ; 
but  it  is  one  of  the  remedial  agents  on  which  I  place  most  reliance  in  the 
treatment  of  ozama,  and  to  which  I  revert  more  willingly  than  to  others, 
just  because  it  may  be  so  freely  applied  without  occasioning  auy  bad  con- 
sequences. 

The  chlorate  of  potash,  to  which  Dr.  Henri  Saint- Arnoult  has  given  a 
not  altogether  unmerited  reputation,  also  renders  real  service  :  like  the  mer- 
curial powders,  it  possesses  the  great  advantage  of  causing  the  smell  to  dis- 
appear whilst  it  is  being  used.  "Were  the  action  of  this  remedy  only  that 
of  a  disinfectant,  it  would  unquestionably  deserve  to  be  recommended  ;  but 
it  merits  recommendation  on  another  ground,  and  that  is,  that  like  mercury, 
it  modifies  the  state  of  the  mucous  membrane. 

You  have  seen,  gentlemen,  with  what  rapidity  topical  treatment  seems 
to  have  accomplished  a  cure  in  the  young  girl,  our  patient  in  St.  Bernard's 
Ward.  Looking  to  the  results,  it  might  appear  that  she  i-  already  cured, 
but  it  is  not  so;  and,  as  I  shall  tell  you  immediately,  there  are  few  affec- 
tions in  which  both  the  sufferer  and  his  physician  require  to  exercise  more 
patience  than  ozsena. 

In  adults,  as  their  obedience  to  instructions  may  be  counted  on,  the  in- 
spiration of  the  powder,  though  insufficient,  nevertheless  render  eminent 
service;  but  in  children,  this  method  IS  almost  useless,  and  in  them  we 
must  employ  injection-,  as  the  almost  only  available  treatment,  whereas, 
in  adults,  they  are  merely  the  complement  of  other  measures. 

The  following  are  the  injections  which  I  most  frequently  have  recourse  to: 

No.       I.  Eau  phagedenique,        .        .        .     200  grammes,  [jfvj  and  jjij.] 
[Shake  the  bottle  well  before  using  the  injection,  bo  that  the  precipitate  may  !>e 
thoroughly  mixed  with  the  fluid.]* 

No.     II.  Chlorate  of  potash, 2  grammes. 

illed  water, 200 

No.  III.  Nitrate pt silver, 6gramn 

I*  stilled  water, 100 


*  Eau  phag&lenique.  ill  of  this  volume. 


OZvENA.  487 

No.    IV.  Sulphate  of  copper  [or  zinc],         .        .        .       5  grammes. 
Distilled  water, 100  "     " 

There  is  a  very  important  practical  remark  which  I  have  to  make  in 
relation  to  these  injections.  The  pituitary  mucous  membrane  is  much 
more  sensitive  than  is  generally  supposed.  It  is  necessary,  therefore,  on 
beginning  injections,  to  use  very  weak  solutions.  It  often  happens  that  a 
solution  of  5  centigrammes  [f  of  a  grain]  of  nitrate  of  silver,  sulphate  of 
copper,  sulphate  of  zinc,  or  corrosive  sublimate,  in  100  grammes  [3  fl.  oz. 
and  1  drachm]  of  distilled  water,  is  not  well  borne.  Let  me  add,  that  this 
extreme  sensitiveness  quickly  disappears,  and  that  very  soon  a  tolerance 
for  a  stronger  solution  is  attained.  The  solution,  however,  ought  never  to 
be  very  strong,  and  should  always  be  proportionate  to  the  sensibility  of 
each  patient. 

The  injections  require  to  be  used  for  several  days  in  succession — twice, 
thrice,  or  four  times  a  day,  after  which  the  powders  ought  to  be  resumed  : 
then,  by  and  by,  the  injections  ought  to  be  resumed,  their  number  being 
diminished  or  increased  from  day  to  day,  in  accordance  with  the  amount 
of  irritation  which  they  excite  in  the  pituitary  membrane,  and  the  curative 
results  which  are  obtained. 

In  so  obstinate  an  affection  as  ozsena,  it  is  easy  to  see  that  remedial 
measures  must  be  continued  for  a  long  time  ;  and  if  the  physician,  pleased 
with  apparent  success,  abruptly  interrupt  the  treatment,  the  disease  will  at 
once  relapse.  Often,  we  may  exercise  the  greatest  patience,  and  modify 
our  plan  of  treatment  in  many  ways,  without  succeeding  in  obtaining  a 
radical  cure. 

The  proper  plan,  then,  is  at  once,  uninterruptedly,  and  repeatedly  in 
succession,  to  apply  the  remedies.  When  the  fetor  has  been  absent  for 
six  weeks  or  two  months,  the  severity  of  the  treatment  may  be  relaxed  by 
reducing  the  number  of  the  daily  nasal  inspirations  of  powder,  or  injec- 
tions. Should  the  improved  state  of  matters  continue,  the  remedies  may 
then  be  applied  only  once  in  two  days,  afterwards  once  in  three  days,  and 
finally,  for  some  months  longer,  at  intervals  of  four  days. 

There  is  another  very  important  practical  point  to  which  I  wish  to  direct 
your  attention.  At  the  menstrual  periods,  there  is  generally  a  great  in- 
crease in  the  severity  of  the  symptoms,  irrespective  of  treatment.  Even 
when  the  plan  of  medication  is  directed  in  the  best  possible  manner,  the 
fetor  generally  returns  somewhat  during  menstruation.  This  also  occurs 
under  the  influence  of  any  cause  which  excites  inflammation  of  the  pitui- 
tary membrane.  It  is  a  rule  which  never  ought  to  be  deviated  from,  to 
carry  out  the  treatment  in  all  its  rigor  when  the  patient  is  in  the  special 
conditions  I  have  mentioned.  Even  when  the  symptoms  of  ozrena  have 
been  absent,  for  a  long  time,  the  practical  precept  now  laid  down  must  not 
be  forgotten. 

However  beneficially  potent  the  inspirations  of  the  powders  and  the 
injections  may  be,  they  are  not  in  themselves  sufficient  even  as  topical 
remedies.  Dr.  Cazenave  of  Bordeaux  long  ago  insisted  on  the  necessity 
of  applying  modifying  agents  to  the  surface  of  the  nasal  fossa?  and  other 
accessible  situations,  by  means  of  elastic  bougies  or  rigid  sounds  adapted 
to  the  form  of  the  parts,  instruments  in  fact  analogous  to  those  employed 
in  treating  diseases  of  the  urethra,  bladder,  and  uterus. 

Although  topical  remedies  hold  the  chief  place  in  the  treatment  of  non- 
syphilitic  ozsena,  it  would  be  a  great  mistake  to  omit  general  treatment. 
Cod-liver  oil  taken  for  fifteen  consecutive  days  in  every  month,  and  con- 
tinued for  a  long  time,  is  sometimes  very  useful.  The  tincture  of  iodine 
administered  over  a  period  of  several  months,  twice  or  thrice  a  day,  at 


488  .STRIDULOUS    LARYNGITIS. 

meals,  in  a  dose  of  from  5  to  20  drops,  often  produces  exceedingly  benefi- 
cial results  in  constitutional  ozama.*  Arsenical  preparations,  perseveringly 
continued,  as  is  usual  in  treating  the  herpetic  diathesis,  are  still  more  pow- 
erful adjuvants  to  the  topical  medication. 

It  is  hardly  necessary  to  say,  that  in  syphilitic  ozrena,  mercurial  prepara- 
tions and  the  iodide  of  potassium  take  a  place  in  the  treatment  even  more 
important  than  local  applications. 

Necrosis,  polypi,  and  the  different  diseases  of  .the  antrum  of  the  maxilla, 
being  rather  within  the  sphere  of  the  surgeon  than  of  the  physician,  I  shall 
not  hei'e  discuss. 

Gentlemen,  I  must  not  conlude  without  repeating,  that  ozama  is  one  of 
the  most  difficult  diseases  to  cure  ;  but  that  it  is  also  one  of  those  which  it 
is  very  easy  to  palliate,  provided  reliance  can  be  placed  on  the  cleanliness, 
docility,  and  patience  of  the  sufferer,  and  provided  also,  that  there  is  a 
similar  exercise  of  patience  on  the  part  of  the  physician. 


LECTUEE  XXV. 

STRIDULOUS  LARYNGITIS,  OR  FALSE  CROUP. 

Long  confounded  with  Pseudo-membranous  Croup. — Differs  essential/;/  from 
that  disease  in  its  nature,  manner  of  invasion,  progress,  and  complica- 
tions.—  Croupy  [croupale]  Cough  presents  characters  very  different  from 
those  of  True  Croup. — False  Croup  is  not  a  dangerous  disease ;  but  still, 
in  some  very  rare  cases,  it  has  caused  death. — The  prognosis  is  serious 
when  the  laryngeal  affection  is  the  forerunner  of  peri-pneumonic  catarrh. 
— In  the  majority  of  cases,  the  Treatment  ought  to  be  Expectant. 

Gentlemen:  When  lecturing  on  diphtheria,  I  intentionally  omitted  the 
consideration  of  the  differential  diagnosis  of  true  and  false  croup, f  because 
it  seemed  more  in  place  to  speak  of  it  when  discussing  the  latter  affection. 
The  manner  of  establishing  the  differential  diagnosis  is  a  corollary  to  the 
remarks  which  I  propose  to  make  to-day  on  stridulous  laryngitis  [laryngite 
*tri(hdeuse~]. 

A  perusal  of  the  work  on  croup  by  Home  of  Edinburgh,!  leaves  a  con- 
viction on  the  mind  of  the  reader,  that  the  author  was  pretty  much  in  that 
deplorable  state  of  confusion  which,  at  the  lime  he  wrote,  had  been  intro- 
duced both  into  the  scientific  and  practical  discussion  of  the  subject.  It  is 
evident  that  he  describes  under  the  same  name  two  essentially  distinct  dis- 
eases; and  that  though  he  may  sometimes  have  had  to  do  with  pseudo- 
membranous  laryngitis,  the  majority  of  the  cases  he  reports  are  cases  of  false 
croup.  The  same  confusion  pervaded  all  the  writings  published  on  croup 
from  the  time  of  Home  to  the  appearance  of  Bretonneau's  treatise  on 
diphtheria.     '1  nis  confusion  even  pervaded  the   memoir.-  submitted  to  the 

The  tincture  of  iodii f  the  French  Codex  i-  Bimply  a  solution  of  about  one 

gramme  [  L5J  grains]  of  in. line  in  twelve  grammes  [four  fluid  drachms]  of  alcohol. 
— Translator 

f  For  the  lectures  mi  Diphtheria,  Bee  pp  ■•'■'>'>  484  of  tins  volume. 

:    1 1  •  - m  i. :   I  nquiry  into  the  Nature  and  Cure  of  the  Croup.     Edinburgh,  1766. 


STRIDULOUS    LARYNGITIS.  489 

Concours  in  1812 — even  the  memoirs  of  Vieusscux,  Jurine,  and  A I  hers  of 
Bremen,  which  were  honorably  mentioned  by  the  Academy.  Royer-Col- 
lard,  the  reporter  of  the  commission  appointed  to  examine  these  works,  did 
not  avoid  it;  and  his  report,  in  other  respects  remarkably  good, shows  that 

when  he  wrote,  the  notions  of  Home  were  still  in  the  ascendant.  Indeed, 
the  light  of  truth  did  not  shine  upon  this  chaos  of  opinion  till  Bretonneau 
established  with  marvellous  lucidity  the  characters  which  distinguish  from 
each  other  the  two  diseases,  showing  them  to  be  essentially  different  in 
their  nature,  lesions,  symptoms,  and  relative  gravity.  The  one,  true  croup, 
is  almost  always  fatal,  unless  the  treatment  be  prompt  and  proper  ;  but 
the  other,  false  croup,  is  not  a  dangerous  disease,  save  in  exceptional  cases. 

Stridulous  laryngitis,  or  false  croup,  is  a  very  common  affection.  Every 
physician,  in  the  course  even  of  a  very  short  practice,  has  often  been  sud- 
denly summoned  in  haste  to  children  said  to  be  suffering  from  "croup." 
Although  the  matter  has  now  been  pretty  generally  explained,  the  error  I 
mention  is  still  committed  every  day.  This  explains  how  it  is,  that  some 
practitioners  congratulate  themselves  upon  their  treatment  of  croup,  and 
boast  of  an  amount  of  success  which  would  astonish  us,  if  we  could  suppose 
that  the  cases  cured  were  undoubtedly  cases  of  pseudo-membranous  laryn- 
gitis. Persons  who  allege  that  they  have  cui*ed  a  great  many  cases  of  croup 
with  extraordinary  rapidity — in  a  few  hours  for  example — by  emetics,  blis- 
ters, and  leeches,  or  other  means,  fall  into  the  very  confusion  of  ideas  to 
which  I  have  now  been  directing  your  attention:  they  allow  themselves  to 
be  deceived  by  a  symptom,  to  which  they  have  attached  too  much  impor- 
tance, and  of  which  they  have  not  perceived  the  real  characters :  they,  in 
fact,  allow  themselves  to  be  misled  by  a  cough  very  improperly  called 
croupij.  So  exclusively  has  their  attention  been  occupied  with  this  cough, 
that  they  have  taken  no  account  of  the  antecedent  history,  or  at  least  have 
paid  insufficient  attention  to  the  progress  of  the  symptoms — they  have  not 
examined  the  pharynx  with  that  minuteness  which  was  necessary  to  ascer- 
tain whether  any  diphtheritic  exudation  existed. 

^Notwithstanding  the  frecpiency  of  stridulous  laryngitis,  it  is  a  disease 
which  is  rarely  met  with  in  our  hospitals,  and  I  have  only  had  one  case  in 
my  wards  since  I  occupied  the  chair  of  clinical  medicine.  The  reason  of 
this  you  can  quite  understand.  The  disease  is,  in  the  first  place,  peculiar 
to  infants  and  children  under  two  years  of  age ;  and,  save  in  a  few  excep- 
tional cases  received  into  the  nursery  ward,  children  so  young  are  not  ad- 
mitted into  the  Hotel-Dieu,  which  by  rights  is  exclusively  an  hospital  for 
adults.  In  the  second  place,  from  the  sudden  manner  in  which  false  croup 
declares  itself,  and  from  the  rapidity  with  which  it  yields,  it  is  very  unusual 
for  children  who  are  attacked  by  it  to  be  brought  to  the  hospitals.  I  shall 
therefore  only  recapitulate  the  particulars  of  the  one  case  which  we  have 
had  in  our  wards ;  but  I  should  be  leaving  the  subject  of  croup  in  an  un- 
finished state,  were  I  not  to  take  this  opportunity  of  speaking  to  you  of  the 
differential  diagnosis  of  croup  and  false  croup,  for  the  latter  affection, 
though  rare  in  hospitals,  is  very  common  in  private  practice. 

What  then  are  the  characteristic  symptoms  of  stridulous  laryngitis? 

A  child  between  two  and  five  years  of  age — the  age,  observe,  at  which 
true  croup  is  also  most  common — is  suddenly  seized  in  the  middle  of  the 
night — say  at  eleven  o'clock,  at  midnight,  or  at  one  in  the  morning — with 
a  paroxysm  of  difficult  breathing.  He  wakes  up  in  a  start,  in  a  state  of 
considerable  febrile  excitement:  he  has  a  cough,  which  is  hoarse  and  very 
frequent,  as  well  as  strong  and  noisy :  respiration  is  panting,  short,  and  ac- 
companied, during  inspiration,  by  a  sharp  sound — by  a  shrill,  jarring  laryn- 
geal whistle.     The  voice  is  altered  in  tone :    during  the  paroxysms,  it  is 


490  STRIDULOUS    LARYNGITIS. 

altogether  gone,  and  in  the  intervals,  is  harsh  and  hoarse.  In  true  croup, 
there  is  very  seldom  complete  loss  of  voice  :  this  is  an  important  point  to 
which  I  shall  return. 

The  symptoms  are  much  more  urgent  than  those  which  characterize  the 
commencement  of  an  attack  of  laryngeal  diphtheria.  Sometimes,  the 
dyspnoea  and  anxiety  are  as  great  as  in  the  last  stage  of  pseudo-membranous 
laryngeal  sore  throat ;  the  countenance  is  turgid,  and  the  eyes  express  pro- 
found terror  :  the  character  of  the  cough,  voice,  and  laryngeal  whistling  are 
such  as  to  strike  terror  in  families,  and  frighten  even  physicians  themselves. 
However,  in  half  an  hour,  an  hour,  or  in  two  or  three  hours,  the  frightful 
crisis  has  terminated:  the  child  becomes  calm,  sleep  returns,  his  pulse  is 
less  rapid,  and  his  skin  is  somewhat  moist:  when  he  wakes,  his  cough  is 
still  croupy,  but  it  is  more  moist,  and  in  the  morning,  it  is  still  more  catar- 
rhal ;  respiration  is  less  whistling,  and  the  voice  has  nearly  regained  its 
natural  tone.  The  symptoms  generally  recur  for  several  nights  in  succes- 
sion, but  with  diminished  severity  in  each  following  attack.  The  patient 
has  usually  good  days,  there  being  an  almost  total  absence  of  fever,  and 
general  discomfort :  the  cough  continues,  but  is  moist,  and  much  less  rough. 

Upon  questioning  the  relations  as  to  the  history  of  the  attack,  you  are 
told,  that  the  child  went  to  bed  in  perfect  health,  and  fell  into  a  tranquil 
sleep.  You  will  sometimes  be  informed  that  the  child  had  been  complain- 
ing a  little  for  some  days  prior  to  the  attack :  that  he  had  taken  cold,  but 
was  going  about,  eating,  and  playing  as  usual:  that  he  had  retained  his 
cheerfulness,  and  followed  his  accustomed  routine :  in  a  word,  that  there 
was  no  change  whatever  in  his  habits. 

If  you  inspect  the  throat  with  the  most  minute  care,  you  will  be  unable 
to  see  any  false  membrane.  The  mucous  membrane  is  sometimes  red  :  the 
tonsils  may  be  swollen  ;  but  on  examining  the  cervical  and  submaxillary 
regions,  you  will  find  that  there  is  no  swelling  of  the  glands. 

It  is  in  this  sudden  manner,  and  with  these  symptoms,  apparently  more 
alarming  than  those  of  croup,  that  false  croup  generally  declares  itself,  the 
disease  which  you  cure,  or  I  ought  rather  to  say  which  cures  itself:  fur  what- 
ever is  done,  however  inopportune  and  irrational  the  medical  intervention 
may  be,  it  is  seldom  capable  of  rendering  the  affection  dangerous,  so  little 
is  there  in  its  nature  of  a  serious  character. 

However,  gentlemen,  there  are  circumstances  which  limit  this  favorable 
prognosis.  Stridulous  laryngitis  supervenes  at  the  onset,  and  during  the 
ionise  of  certain  diseases;  so  that  it  is  obvious,  that  under  certain  circum- 
stances, you  may  have  to  do  with  a  peculiarly  modified  affection. 

When  speaking  of  eruptive  fevers,  I  called  your  attention  to  the  fact 
that  it  is  common,  during  the  invasion  period  of  measles,  when  the  nasal, 
ocular,  and  bronchial  mucous  membranes  become  affected,  to  see  the  larynx 
become  similarly  involved  ;  and  I  also  pointed  out  that  in  children,  during 
the  first  two,  three,  or  four  days,  before  the  eruption  has  come  out  on  the 
skin,  all  the  symptoms  of  stridulous  laryngitis  arc  sometimes  mel  with.  In 
small-pox,' which  is  also  generally  accompanied  bysore  throat  involving 
both  the  pharynx  and  the  larynx,  the  occurrence  of  false  croup  is  not  un- 
usual, though  it  is  not  BO  common  ;i>  in  niea.-les. 

Gentlemen,  false  croup  may  he  the  Btarting-poinl  of  one  of  the  most 
serious  diseases  of  childhood,  catarrhal  pneumonia,  capillary  catarrh,  which, 
according  to  my  experience,  is  more  formidable  than  croup  itself.  1  have 
long  ago  explained  to  you  my  views  on  this  subject,  and  I  shall  again  do 
so,  when  I  come  to  speak  of  the  pneumonia  of  children. 

Here,  gentlemen,  I  oughl  to  recapitulate  the  history  of  the  case  to  which 
I  alluded  at  the  beginning  of  this  lecture.     Prom  it  you  will  learn  a  fact, 


STRIDULOUS    LARYNGITIS.  491 

which  I  shall  afterwards  have  to  state,  thai  tracheotomy  may  be  useful  in 
false  croup;  and  it  will  likewise  show  you,  that  false  croup  may  he  the 
starting-point  of  fatal  pneumonia.  The  following  are  the  particulars  of 
the  case  to  which   I   refer. 

In  January,  1863,  a  female  infant  was  received  into  my  wards.  The 
interne  on  duty  observed  that  she  had  very  great  difficulty  in  breathing, 
but  no  suffocative  paroxysms.  According  to  the  statement  of  the  mother, 
the  dyspnoea  had  increased  rapidly  within  the  last  few  hours.  The  child 
had  liad  cough  for  some  days  :  upon  examining  the  chest,  however,  no 
sign  of  pleurisy  or  bronchitis  was  discovered.  Inspiration  was  very  labored, 
and  somewhat  whistling:  the  cry  was  hoarse  and  muffled  :  the  obstacle  to 
respiration  was  unquestionably  situated  in  the  larynx.  There  was  no  false 
membrane  in  the  back  part  of  the  mouth,  nor  had  the  child  thrown  off 
any:  still,  though  it  was  only  a  case  of  false  croup,  M.  Dumontpallier, 
without  hesitation,  immediately  performed  tracheotomy,  as  it  was  necessary 
to  prevent  suffocation.  The  operation  was  easily  accomplished  ;  and  the 
patient  breathed  freely  as  soon  as  the  tube  was  fixed.  The  infant  passed 
a  good  night ;  and  next  morning  I  found  that  there  were  no  morbid  sounds 
in  the  chest.  The  infant's  appearance  was  good ;  and  she  took  the  breast 
with  satisfaction. 

On  the  third  day  after  the  operation,  an  attempt  was  made  to  withdraw 
the  canula,  but  asphyxia  being  threatened,  it  was  instantly  abandoned. 
The  larynx,  therefore,  was  evidently  still  obstructed,  although  the  infant 
had  ejected  by  the  canula  nothing  more  than  pinkish  muco-puriform  sputa, 
such  as  are  seen  in  the  bronchitis  of  measles.  On  the  following  days,  we 
renewed  our  endeavors  to  remove  the  canula ;  but  each  time  we  took  it 
out,  it  was  necessary  to  replace  it  with  the  utmost  possible  haste,  as  no  air 
traversed  the  larynx. 

Ten  days  after  the  operation,  the  infant  still  had  a  favorable  appearance, 
and  continued  to  take  the  breast:  she  was  in  good  spirits,  her  flesh  had 
become  firm,  and  she  was  not  getting  thinner :  but  the  canula  had  been 
kept  constantly  in  the  trachea.  The  lips  of  the  wound  were  in  a  very  good 
state.  On  the  eleventh  day  after  the  operation,  I  was  told  that  the  patient 
had  been  very  restless  during  the  night.  The  pulse  was  quick,  and  the 
skin  burning.  The  infant  frequently  took  the  breast,  but  immediately  gave 
up  her  hold  of  it.  Fine  mucous  rales  were  heard  over  the  entire  thoracic 
region.  The  fever,  restlessness,  and  physical  signs  of  general  bronchitis 
caused  me  to  form  an  unfavorable  prognosis  :  very  probably,  small  masses 
of  pulmonary  hepatization  already  existed.  An  attempt  was  made  to  re- 
move the  canula,  but  it  wras  fruitless,  as  the  air  did  not  traverse  the  trachea 
in  sufficient  quantity. 

On  the  fourteenth  day,  the  little  patient,  at  the  morning  visit,  lay 
motionless  on  the  bed,  and  presented  the  signs  of  peripneumonic  asphyxia. 
The  pupils  were  very  much  dilated ;  sputa  no  longer  came  up  through  the 
canula:  the  pulse  was  too  rapid  to  be  counted :  death,  preceded  by  some 
convulsive  movements,  then  closed  the  scene. 

The  autopsy  showed  that  no  pseudo-membranous  deposit  existed  on  any 
part  of  the  respiratory  passages ;  but  the  glosso-epiglottidean  folds  were 
red,  and  the  aryteno-epiglottidean  folds  were  cedematous.  The  opening  of 
the  glottis  seemed  to  be  almost  entirely  closed  by  the  swollen,  injected 
mucous  membrane.  The  mucous  membrane  of  the  larynx,  which  was  also 
injected,  was  the  seat  of  an  inflammatory  vascularity.  Similar  indications 
of  inflammation  were  seen  on  the  mucous  membrane  of  the  trachea  and 
bronchi.  .Several  pulmonary  lobules,  particularly  on  the  left  side,  were 
inflamed  and  purulent:  wdien  cut,  they  yielded,  on  slight  pressure,  small 


492  STRIDULOUS    LARYNGITIS. 

drops  of  pus :  at  the  inflamed  points,  the  lung  had  the  appearance  of  a 
sponge  filled  with  purulent  matter.  There  was  likewise  empyema  on  the 
left  side,  which  perhaps  had  had  its  starting-point  in  the  nuclei  of  puru- 
lent hepatization  observed  on  the  surface  of  the  lung. 

In  this  case,  the  pneumonia  and  pleurisy  supervened  during  the  last  few- 
days  of  life,  the  morbid  changes  advancing  rapidly  to  the  formation  of  pus. 

With  out  any  of  the  complications  of  an  eruptive  fever  or  pulmonary 
inflammation,  false  croup  sometimes  causes  death  ;  although  generally,  I 
may  say  very  nearly  always,  it  is  not  a  dangerous  affection.  Fatal  cases 
are  cpiite  exceptional ;  but  you  must  recollect  that  they  sometimes  occur. 
Here  is  a  case  in  point. 

In  1834, 1  was  summoned  in  haste  to  see  a  pupil  at  the  College  of  Juilly, 
who,  I  was  told,  was  dying.  The  lad  was  thirteen  years  of  age.  On  the 
evening  hefore  his  attack,  he  was  quite  well.  In  the  morning,  on  awak- 
ing, he  was  suddenly  seized  with  a  frightful  attack  of  dyspnoea  :  he  got  up, 
however,  and  ran  to  the  room  of  the  prefect  of  the  studies.  Respiration 
was  exceedingly  embarrassed  :  there  was  a  hoarse  croupy  cough  ;  the  voice 
was  harsh  and  small :  inspiration  produced  a  noisy  whistling.  The  medi- 
cal attendant  of  the  college,  who  was  immediately  sent  for,  was  with  good 
cause  alarmed  at  the  state  of  the  patient,  and  at  once  sent  off  one  of  the 
masters  to  fetch  me.  I  started  forthwith  :  and  in  four  hours  reached  the 
jmtient,  who  had  just  expired.  The  circumstances  seemed  to  me  to  be  too 
extraordinary  to  allow  any  means  to  be  neglected  to  discover  the  cause  of 
the  sudden  catastrophe.  I  removed  with  the  greatest  care  the  larynx  and 
trachea  and  took  them  to  my  colleague's  house,  where  Ave  examined  them. 
We  found  that  it  was  only  a  case  of  false  croup.  There  was  a  good 
deal  of  swelling  of  the  vocal  cords,  redness  of  the  laryngeal  mucous  mem- 
brane, and  a  little  swelling  of  the  aryteno-epigottidean  folds:  on  one  of  the 
vocal  cords,  there  was  a  slight  membranous  concretion,  possesssing,  how- 
ever, none  of  the  characters  of  diphtheritic  false  membrane,  and  depending 
upon  a  very  intense  inflammatory  sore  throat. 

Patients,  therefore,  may  die  from  stridulous  laryngitis ;  but  let  me  again 
repeat  that  such  cases  are  exceedingly  rare.  During  my  long  practice,  I 
can  only  remember  to  have  met  with  three  fatal  cases.  Still,  gentlemen,  I 
say,  be  reserved  in  your  prognosis,  notwithstanding  the  extreme  benignity 
of  the  disease:  in  particular,  be  reserved,  not  so  much  because  in  a  few 
very  exceptional  cases,  the  issue  has  been  fatal,  but  because  false  croup 
may  be  the  forerunner  of  catarrhal  pneumonia,  a  disease  which  seldom 
spares  those  it  seizes.  I  may  say  that  I  have  had  some  experience  in 
croupy  affections,  and  though  I  am  perfectly  aware  of  the  immense  odds 
which  the  patient  has  in  his  favor,  I  cannot  exclude  from  my  mind  a  cer- 
tain amount  of  dread  that  I  may  by  and  by  have  to  do  with  that  terrible 
disease  of  which  false  croup  is  only  the  first  symptom. 

As  I  began  by  stating,  the  differential  diagnosis  of  true  and  false  croup 
is  a  logical  deduction  from  the  facts  which  1  have  laid  before  you.  Still, 
it  sometimes  happens,  that  to  form  a  diagnosis  is  embarrassing:  this  is  the 
<■;!-.•  when  stridulous  laryngitis  occurs  in  persons  affected  with  common 
membranous  sore  throat,  and  when  diphtheria  begins  by  simultaneously 

Seizing  larynx  ami  pharynx. 

You  we'll  know,  that  in  the  majority  of  cases,  tin'  membranous  affection 
commence-  'm  the  pharynx,  and  is  thence  propagated  to  the  larynx  :  some- 
times, however,  though  not   frequently,  the  attack  all  at  once  begins  with 

croup.      When  this  occurs,  it  is  Very  difficull  to  determine  whether  there  is 

pseudo-membranous  or  simple  laryngitis  :  bul  the  progress  of  the  symptoms 

may  furnish  presumptive  evidence  of  the  nature  of  the  disease  we  have  to 


STRIDULOUS    LARYNGITIS.  493 

deal  with.  Notwithstanding  what  has  been  alleged  to  the  contrary,  even 
in  cases  of  sudden  croup,  the  characteristic  symptoms  of  the  membranous 
affection  are  in  general  slowly  developed :  observe,  I  say,  generally  and  not 
always:  on  the  contrary,  the  characteristic  symptoms  of  false  croup  quickly 
declare  themselves.  False  croup  sets  in  abruptly,  and  from  the  very  first 
the  symptoms  are  alarming;  but  they  decrease  in  severity.  In  true  croup, 
the  invasion  is  less  abrupt,  but  the  symptoms  gradually  go  on  increasing  in 
severity.  Suppose,  for  example,  two  children,  one  of  whom  has  had  a  hoarse 
voire  tor  two  or  three  days,  and  a  suspicious  cough  for  forty-eight  hours; 
the  other,  a  sudden  attack  during  the  previous  night  of  difficult  breathing, 
accompanied  by  whistling  inspiration,  and  a  ringing  croupy  cough :  of  the 
two,  the  former  is  the  most  seriously  ill ;  for  he  has  true,  while  the  latter 
has  false  croup.  Diphtheritic  inflammation,  in  fact,  takes  a  certain  time  to 
evolve ;  two  or  three  days  elapse  before  it  attains  its  maximum  intensity. 
At  first,  the  irritation  which  it  causes  in  the  parts  about  to  be  covered  with 
false  membrane  is  very  slight,  and  only  excites  some  fits  of  coughing :  the 
discomfort  in  breathing,  which  in  the  first  instance  is  produced  by  the 
swelling  of  the  vocal  cords,  only  shows  itself  by  a  moderate  degree  of  op- 
pression. It  is  not  when  the  inflammation  of  the  mucous  membrane  of  the 
larynx  is  greatest,  but  when  the  thick  diphtheritic  membranous  deposit 
interposes  a  physical  obstacle  to  the  passage  of  air,  that  there  is  most  diffi- 
culty in  breathing.  Acute  simple  inflammation  of  the  larynx  proceeds 
otherwise  :  it  almost  at  once  produces  swelling  of  the  mucous  membrane  : 
in  from  half  an  hour  to  an  hour,  or  in  two  hours  at  the  most,  this  swelling 
is  at  its  maximum,  and  the  consequent  sudden  stricture  of  the  opening  of 
the  glottis  causes  the  suffocative  seizures  which  characterize  false  croup. 

It  is  a  remarkable  fact  that  the  suffocative  seizures  occur  during  the 
night,  and  very  seldom  in  the  daytime.  To  put  it  still  more  clearly,  they 
take  the  patient  by  surprise  when  he  is  asleep,  and  not  when  he  is  awake. 

Stridulous  laryngitis  not  only  differs  from  true  croup  in  mode  of  invasion 
and  progress  of  symptoms,  but  also,  and  even  more,  in  the  character  of  the 
cough  called  croupy,  the  semeiological  value  of  which  we  have  still  to  ex- 
amine. On  this  subject,  gentlemen,  let  me  give  you  the  result  of  my  long 
experience :  it  is  not  infallible— it  is  very  far  from  being  so — and  so  fre- 
quently does  it  deceive  me,  that  I  warn  you  not  to  be  astonished  should  you 
be  sometimes  similarly  misled ;  nevertheless,  my  experience  has  taught  me 
things  which  it  may  be  useful  for  you  to  know. 

In  very  young  children,  however  slightly  the  mucous  membrane  of  the 
larynx  is  inflamed — and  consequently  swollen — the  cough  has  a  hoarse 
character,  inspiration  is  whistling,  and  the  voice  is  greatly  altered.  This  is 
sometimes  observed  in  simple  catarrhal  affections.  The  vocal  cords  are 
exceedingly  sensitive  to  the  mucus  which  falls  on  them,  and  even  the  air 
which  traverses  the  glottis  ;  in  a  word,  the  mucous  membrane  of  the  larynx, 
naturally  of  an  irritable,  excitable  character,  is  in  a  state  of  exceedingly 
increased  irritability.  There  will  be  incessant  cough,  and  in  the  space  of 
one  minute  the  patient  will  have  from  fifteen  to  twenty  paroxysms.  The 
cough,  therefore,  which  has  received  the  name  of  croupy,  is  in  very  young 
children  the  consequence  of  acute  inflammation  of  the  mucous  membrane 
of  the  larynx ;  or,  to  be  more  precise,  it  is  the  expression  of  the  existence  of 
simple  acute  inflammation.  Diphtheritic  inflammation,  however,  is  not 
simple  and  acute :  at  first,  it  is  very  slight,  and  very  much  more  superficial 
than  simple  laryngitis.  If  you  will  allow  me  to  use  the  comparison,  it  is 
like  the  trifling  superficial  inflammation  which  accompanies  malignant 
pustule,  as  compared  with  the  severe  inflammation  which  accompanies  a 
common  boil.     Simple  laryngitis  makes  a  great  fracas,  but  diphtheritic  in- 


494  STRIDULOUS    LARYNGITIS. 

flammation  insidiously  instals  itself:  the  irritation  which  the  latter  causes 
in  the  parts  which  it  invades,  at  first  produces  scarcely  any  fits  of  coughing, 
as  I  have  just  been  remarking.  To  these  slight  symptoms  a  cough  soon 
succeeds,  which  by  its  hoarseness  and  frequency  recalls  to  one's  recollection 
those  which  I  have  just  been  pointing  out  under  the  name  of  angina  strkl- 
ulosa:  at  a  later  period,  a  pseudo-membranous  exudation  is  found  to  have 
covered  the  vocal  cords,  the  mucous  membrane  loses  its  sensibility,  pro- 
tected as  it  is  by  a  sort  of  coat  of  mail  from  the  action  of  air  and  mucus,  by 
which  otherwise  its  irritability  might  be  excited.  So  much  is  this  the 
case — and  observers  have  been  struck  by  the  phenomenon — that  in  con- 
firmed croup  [croup  confirme]  there  is  little  cough,  and  sometimes  none  at 
all ;  the  cough  is  at  least  as  often  silenced  as  the  voice. 

This  difference  between  the  cough  of  stridulous  laryngitis  and  of  pseudo- 
membranous laryngitis  is  chiefly  dependent  upon  entirely  mechanical 
causes.  If  there  be  any  notable  structural  alteration  in  the  vocal  cords,  or 
if  they  be  covered  with  a  substance  which  cannot  vibrate,  there  will  be  no 
vibration  of  the  air  as  it  passes  over  them.  This  can  be  shown  by  a  very 
simple  experiment.  The  larynx  may  be  regarded  as  a  wind  instrument  of 
the  nature  of  a  flute,  or  as  an  instrument  having  a  tubal  mouthpiece  with 
expanded  lips.  Now,  if  we  place  a  piece  of  moist  parchment  upon  the  lips 
of  the  mouthpiece,  or  on  the  openings  in  the  flute,  it  will  be  impossible  to 
obtain  any  vibration  of  air  by  blowing.  When  the  cough  remains  hoarse 
and  loud — cronpy  as  it  is  called — in  false  croup,  it  is  because  the  vocal 
cords  are  only  swollen;  and  when  it  is  muffled  or  extinct  in  true  croup,  it 
is  because  the  larynx  is  covered  with  false  membrane,  producing  an  influ- 
ence on  the  vocal  cords  similar  to  that  produced  on  the  metallic  lips  of  the 
clarionet  and  bassoon. 

Finally  then — and  that  is  the  point  I  have  been  making  for — croupxj 
cough  is  not  an  indication  of  croup.  Still,  we  can  understand  how  the  com- 
mencement of  pseudo-membranous  laryngitis  may  be  invested  with  all  the 
characters  of  false  croup,  and  we  can  likewise  perceive  how  it  is,  that  when 
false  membrane  which  covered  the  larynx  has  been  expelled,  the  croupy 
cough  should  again  be  heard.  Under  such  circumstances,  however,  it  is 
soon  again  enfeebled,  and  finally,  there  is  no  sound  :  whilst  this  change  is 
progressing,  the  severity  of  the  suffocative  symptoms  increases.  In  stridu- 
lous laryngitis,  on  the  contrary,  as  the  cough  loses  its  croupy  character  the 
difficulty  of  breathing  diminishes. 

Cases  are  recorded  in  which  stridulous  laryngitis  was  accompanied  by  a 
feeble  cough  resembling  the  cough  of  true  croup;  but  these  very  exceptional 
cases  do  not  diminish  the  value  of  the  differential  diagnostic  characters  to 
which  I  now  call  your  attention. 

The  remarks  I  have  made  on  croupy  cough  are  also  applicable  to 
changes  in  the  voice.  In  croup,  the  voice  is  first  of  all  very  much  altered 
in  tone:  it  then  becomes  very  much  weaker,  not  only  during  the  paroxysms, 
but  also  in  tin;  intervals  between  them.  In  false  croup,  if  it  become  feebler 
during  the  paroxysms,  the  feebleness  is  never  to  such  a  degree  as  in  true 
croup;   and  during  the  intervals  il  regains  its  strength  to  a  certain   extent, 

though  remaining  hoarse  and  broken. 

When  stridulous  laryngitis  is  coincident  with  coninion  membranous  BOM 
throat,  formed  by  thick  confluent  patches  of  membranous  deposit,  however 
well-marked  the  Laryngeal  symptoms  may  he,  hesitation  is  allowable:  it  is 

only  by  the  SUbsequenl   progress  of  the  case,  that  you  can  dearly  establish 

your  diagnosis,     xou  must  know,  therefore,  to  wait  before  forming  your 

opinion;   hut,  whilst  you  are  waiting,  treat  the  pharyngeal  affection  exactly 

as  il  it  were  diphtheritic. 


(EDEMA    OF    THE    LARYNX.  495 

An  experienced  practitioner  will  not  mistake  stridulous  laryngitis  for 
spasm  of  the  glottis  or  thymic  asthma;  but  as  some  authors  have  fallen 

into  confusion  on  the  subject,  1  shall  rapidly  point  out  the  signs  by  which 
the  differential  diagnosis  of  the  two  affections  may  he  established.  We 
have  jusl  Been  that  in  stridulous  laryngitis  there  are  suffocative  seizures, 
that  the  cough  ami  voice  are  croupy,  and  that  during  the  whole  course  of 
the  malady,  even  in  the  intervals  between  the  paroxysms,  the  patients  retain 
a  certain  amount  of  hoarseness  in  the  cry,  in  the  voice,  and  in  the  cough. 

In  spasm  of  the  glottis,  there  is  first  of  all  this  difference,  that  the 
paroxysms  are  equally  liable  to  occur  during  the  day  and  the  night:  then, 
again,  when  there  are  suffocative  seizures,  they  are  not  accompanied  by 
even  slight  hoarseness  of  cry,  voice,  or  cough.  Let  me  add,  that  the 
paroxysms  do  not  generally  recur  two,  three,  or  four  times  in  the  space  of 
a  few  minutes,  as  is  the  case  in  false  croup.  However  many  attacks  there 
may  be  in  the  twenty-four  hours,  there  is  always  a  long  interval  between 
them ;  and  as  soon  as  they  are  over,  the  patients  breathe  easily,  retaining 
apparently  no  recollection  of  what  they  have  suffered. 

The  treatment  of  false  croup  need  not  detain  us  long ;  for,  as  I  have 
already  told  you,  the  disease  cures  itself.  I  shall  only  recall  to  your  recol- 
lection the  treatment  adopted  by  Graves,  of  which  I  have  already  spoken 
in  my  clinical  lectures  on  measles,  and  which  consists  in  passing  along  the 
skin,  under  the  child's  chin  and  in  front  of  his  neck,  a  sponge  soaked  in 
very  hot  water.  This  operation  is  repeated  several  times  at  intervals  of 
ten  or  fifteen  minutes :  it  causes  a  sort  of  detei'mination  to  the  skin,  under 
the  influence  of  which  the  oppression  usually  ceases  in  a  remarkable 
manner,  while  the  cough  loses  its  hoarseness.  This  powerfully  efficacious 
treatment  has  the  advantage  of  being  marvellously  simple  ;  and  it  is  usually 
sufficient  without  any  other  means,  such  as  emetics,  being  employed  in 
connection  with  it.  But  even  when  there  is  no  false  membrane  in  the 
larynx,  the  swelling  of  the  mucous  membrane  may  be  so  great  as  to  place 
life  in  immediate  jeopardy,  and  to  impose  the  necessity  of  performing 
tracheotomy.  In  such  a  case  as  this,  my  excellent  friend  Dr.  Adolphe 
Richard  restored  to  its  mother,  a  poor  child  dying  from  suffocation,  the 
consequence  of  stridulous  laryngitis. 


LECTURE  XXVI. 

CEDEMA  OF  THE  LARYNX. 

(Edema  of  the  Larynx  is  not  in  itself  a  Disease :  it  is  a  Complication  of  Dis- 
eases of  the  Larynx. — Improperly  named  (Edema  of  the  Glottis. — Some- 
times, but  not  often,  Independent  of  Inflammation. — Predisposing  Cause*. 
— Exciting  Causes. — Frequently  supervenes  in  Chronic  Laryngitis. — 
Common  Termination  of  what  is  called  Laryngeal  Phthisis. —  Treatment : 
Topical3Iedicationis  Important. —  Often  necessary  to  resort  to  Tracheotomy. 

Gentlemen:  Some  of  you,  no  doubt,  recollect  a  young  woman  of  twenty- 
one,  who  was  brought  to  the  Hotel-Dieu,  on  the  24th  June,  where  she  occu- 
pied bed  No.  20  of  our  St.  Bernard's  Ward.  She  left  the  hospital  perfectly 
cured,  on  the  2d  July,  after  having  had  all  the  symptoms  of  oedema  of  the 


496  (EDEMA    OF    THE    LARYNX. 

larynx.  She  was,  on  a  former  occasion,  for  a  month  in  our  wards  under 
treatment  for  puerperal  peritonitis.  She  had  been  six  weeks  out  of  hos- 
pital, when  she  was  seized  with  violent  sore  throat,  difficulty  of  deglutition, 
and  a  good  deal  of  swelling  of  the  tonsils.  When  I  first  saw  the  patieut, 
the  affection  had  existed  ten  days,  and  had  already  made  rapid  progress. 
It  soon  produced  an  amount  of  difficulty  of  breathing,  which  gradually 
increased  till  it  became  so  serious  as  to  bring  on  suffocative  paroxysms. 
During  inspiration,  the  dyspnoea  was  accompanied  by  laryngotracheal 
whistling,  but  the  expiratory  sound  remained  normal,  and  the  voice  retained 
its  natural  tone.  I  found  the  patient  with  a  good  deal  of  oppression  :  the 
countenance  was  pale,  and  presented  that  peculiar  expression  observed  in 
persons  threatened  with  asphyxia.  The  pulse  was  small  and  miserable  ; 
the  submaxillary  region  was  swollen  and  painful.  On  examining  the 
throat,  I  saw  that  the  mucous  membrane  of  the  pharynx  had  a  bright  red 
color:  on  carrying  the  finger  towards  the  laryngeal  orifice,  I  found  that 
there  was  cedematous  swelling  of  the  epiglottis  and  aryteno-epiglottidean 
ligaments.  I  had  no  hesitation  as  to  the  diagnosis  :  it  was  a  case  of  what 
has  been  called  oedema  of  the  glottis. 

I  ordered  an  injection,  as  soon  as  possible,  into  the  back  part  of  the  throat, 
of  water-spray  strongly  charged  with  tannin.  Similar  injections  were  made 
every  hour  by  means  of  the  spray  apparatus  which  you  know,  and  which 
has  been  modified  by  Mathieu.  Under  the  influence  of  this  medication, 
the  severity  of  the  symptoms  moderated.  At  my  second  visit,  on  the  fol- 
lowing clay,  a  great  improvement  was  evident.  During  the  whole  day,  there 
had  been  only  one  suffocative  seizure,  and  it  was  of  a  much  less  violent 
character  than  those  of  the  previous  evening.  The  breathing  had  become 
free,  and  was  not  accompanied  by  any  abnormal  sound.  There  was  also  a 
great  diminution  in  the  swelling  of  the  epiglottis  and  aryteno-epiglottidean 
ligaments.  Notwithstanding  the  amendment,  I  ordered  the  treatment  to 
be  continued.  For  three  days,  she  had  one  suffocative  seizure  in  the  twenty- 
four  hours;  but  during  the  intervals  between  the  attacks,  respiration  was 
natural.  Although,  at  this  date,  the  cure  may  be  considered  to  have  been 
complete,  and  the  general  condition  very  satisfactory,  the  patient  did  not 
leave  the  hospital  till  four  days  later,  up  to  which  time  convalescence  had 
been  thoroughly  maintained. 

To-day,  a  new  case  of  oedema  of  the  larynx  has  been  presented  to  our 
notice.  The  patient,  a  woman  of  fifty-two  years  of  age,  occupies  bed  No. 
25  of  the  same  ward.  In  her,  oedema  of  the  glottis  is  a  sequel  of  chronic 
laryngitis.  The  recurrence  of  the  seizures,  their  severity,  and  the  immi- 
nence of  the  danger,  necessitated  surgical  interference;  and  tracheotomy, 
the  only  means  of  preventing  death,  was  resorted  to  with  complete  success. 

You  have  also  recently  had  an  opportunity  of  interrogating  a  patient 
who  occupied  bed  No.  2-'5  of  St.  Agnes's  Ward.  This  man,  aged  fifty- 
eight,  who  came  into  hospital  on  accounl  of  a  dcepscated  swelling  of  the 
lateral  region  of  the  neck,  had  on  the  anterior  part  of  that  region,  l  wo  cen- 
timetres above?  the  sternal  t'oiirchelte,  a  linear  cicatrix,  the  origin  of  which 
is  thus  accounted  for.  In  1858,  he  was  under  treatment,  in  the  wards  of 
my  lamented  colleague,  Dr.  Legroux,  for  chronic  laryngitis  of  syphilitic 
character.  During  fifteen  days,  he  had  been  subjected  to  specific  treat- 
ment, when  suddenly,  during  the  night,  after  a  chill,  he  experienced  great 
difficulty  of  breathing :  next  morning,  the  existence  of  oedema  of  the  larynx 

Was  ascertained ;  as  asphyxia  was  imminent,  tracheotomy  was  at  once  per- 
formed. The  danger  was  averted;  and  in  three  days  after  the  operation, 
it  was  found  practicable  to  remove  the  canula.     The  patient  was  soon  in  a 


(EDEMA    OF    THE    LARYNX.  497 

condition  to  resume  the  specific  treatment,  by  which,  in  a  few  weeks,  lie  was 
cured  of  the  syphilitic  laryngitis. 

Gentlemen,  I  must  not  omit  to  speak  to  yon  of  a  formidable  affection 
which  yon  have  had  several  opportunities  of  seeing  in  my  wards  during  the 
lasl  tew  vcars.  When  lecturing  upon  dothinenteria,  J  have  already  called 
your  attention  to  oedema  of  the  glottis,  in  connection  with  two  patients  who 
suffered  from  it,  and  in  whom  you  had  the  opportunity  to  see  the  gradual 
development  of  the  symptoms.  In  two  other  cases,  I  showed  you,  on  the 
dead  body,  the  larynx  of  persons  who  had  sunk  under  tubercular  phthisis, 
and  in  one  of  whom  tracheotomy  had  been  rendered  imperative  from  oedema 
of  the  glottis,  as  in  the  case  of  the  woman  occupying  bed  No.  25  of  St.  Ber- 
nard's Ward.  Finally,  when  speaking  to  you  of  scarlatina,  I  mentioned 
oedema  of  the  glottis  as  one  of  the  complications  liable  to  supervene  in  the 
decline  of  that  pyrexia. 

By  oedema  of  the  glottis  is  meant  a  serous,  purulent,  or  sero-purulent 
infiltration  of  the  submucous  cellular  tissue  of  the  epiglottis,  and  aryteno- 
epiglottidean  folds,  generally  extending  to  the  interior  of  the  larynx.  So 
accurate  is  this  description  of  the  affection  called  "  oedema  of  the  glottis," 
that  every  author  who  has  written  on  the  subject  states  that  the  diagnosis 
has  to  be  made  by  an  exploration  of  the  parts  by  the  finger.  Now,  how- 
ever deep  you  may  pass  the  finger  into  the  back  part  of  the  throat,  you 
cannot  by  any  possibility  get  the  finger  to  reach  beyond  the  epiglottis  and 
the  aryteno-epiglottidean  ligaments.  (Edema  of  the  glottis  is,  therefore,  an 
incorrect  name  to  apply  to  this  affection,  because  in  the  majority  of  cases, 
its  seat  is  not  the  glottis  but  the  margin  of  its  superior  orifice.  Again,  the 
swelling  of  the  aryteno-epiglottidean  folds  is  itself  a  cause  of  symptoms 
which  are  otherwise  very  much  more  serious  than  those  to  which  it  gives 
rise  when  it  only  occupies  the  vocal  cords.  If  you  reflect  upon  the  ana- 
tomical arrangement  of  the  aryteno-epiglottidean  folds,  you  will  under- 
stand that,  when  they  swell  in  so  remarkable  a  manner  as  to  form  large 
cushions,  trembling  at  each  inspiration,  as  the  air  enters  the  larynx,  they 
become  glued  to  one  another,  closing  by  a  sort  of  valve  the  upper  part  of 
the  air-passage,  while  the  vocal  cords,  being  formed  of  a  more  compact 
tissue,  and  therefore  not  easily  infiltrated,  do  not  swell  out  in  the  same 
proportion.  Those  who  have  witnessed  Czermak's  experiments  with  the 
laryngoscope  have  had  an  opportunity  of  convincing  themselves,  that  during 
forced  inspiration,  the  vocal  cords  diverge  in  such  a  manner  as  to  form  a 
very  large  opening.* 

Although  the  name  "  oedema  of  the  glottis  "  [cedeme  de  la  glotte]  was,  and 
still  is,  in  constant  use,  "laryngeal  ©edematous  sore  throat"  [angine  laryngee 
cedemateme]  is  preferable.  Besides  possessing  the  advantage  of  not  falsely 
describing  the  seat  of  the  affection,  the  name  last  mentioned  expresses  the 
peculiar  character,  without  in  any  way  asserting  its  pathological  nature, 
an  objection  which  applies  to  the  term  "  submucous  laryngitis  "  [laryngite 
sous-muqueuse],  which  has  also  been  given  to  it,  and  which  conveys  the  idea 
of  an  inflammatory  malady.  OEdema  of  the  aryteno-epiglottidean  folds  is 
nearly  always  the  result  of  inflammation,  but  it  cannot  be  denied  that,  in 
some  rare  cases,  inflammation  has  either  had  no  part  or  only  a  very  secon- 
dary part  in  causing  the  oedema. 

Some  of  you  may  recollect  my  stating,  on  a  former  occasion,  that  scarlati- 
nous anasarca  may  invade  deepseated  parts,  causing  effusions  in  the  serous 
cavities — pleurisy  and  pericarditis — also,  oedematous  infiltration  of  the  veil 
of  the  palate,  uvula,  and  aryteno-epiglottidean  folds.     In  the  lecture  to 

*  Czermak:   Du  Laryngoscope.     8vo.,  Paris  :  1860. 
vol.  i.— 32 


498  (EDEMA    OF    THE    LARYNX. 

which  I  refer,*  I  related  the  history  of  a  child  seen  by  me  in  consultation 
with  my  colleague,  Dr.  Henry.  This  patient  having  been  suddenly  seized, 
during  the  course  of  an  attack  of  scarlatina,  with  considerable  anasarca, 
would  have  been  lost  from  oedema  of  the  aryteno-epiglottidean  folds,  had 
it  not  yielded  to  cauterizations  with  the  nitrate  of  silver,  and  insufflations 
of  alum  into  the  back  of  the  throat.  I  also  laid  before  you  the  history  of 
another  case  communicated  to  me  by  my  colleague,  M.  Richet.  The  patient, 
a  child,  was  similarly  affected,  and  was  rescued  from  impending  death  by 
tracheotomy.  To  these  cases  may  be  added  others  published  by  Baudelocque 
and  Barrier. f 

These  examples  are  more  than  sufficient  to  prove  that  there  exists  a  non- 
inflammatory form  of  oedema  of  the  glottis.  In  these  cases  the  infiltration 
takes  place  into  the  cellular  tissue  of  the  aryteno-epiglottidean  ligaments, 
from  causes  similar  to  those  which  produce  effusions  in  other  parts  of  the 
body,  without  there  having  been  preceding  inflammation. 

I  am  aware  that  as  an  objection  to  illustrations  derived  from  scarlatinous 
patients  it  may  be  said  that  in  scarlatina  there  is  always  a  pharyngeal  in- 
flammation, and  that  this  inflammation  being  the  cause  of  the  oedematous 
congestion  of  the  aryteno-epiglottidean  ligaments,  the  cedema  is  consequently 
inflammatory  in  its  nature :  but  to  argue  thus  would  be  to  exaggerate  the 
bearing  of  the  facts.  Might  it  not  be  said,  with  equal  justice,  that  the  in- 
filtration of  the  subcutaneous  cellular  tissue  is  produced  under  the  influence 
of  the  inflammation  of  which  the  skin  has  been  the  seat  during  the  eruptive 
period  ?  Scarlatinous  anasarca,  however,  does  not  occur  during  the  erup- 
tive period,  but  in  the  decline  of  the  fever :  moreover,  it  is  by  no  means 
those  who  have  had  the  eruption  in  the  most  violent  manner  who  are  most 
frequently  the  subjects  of  anasarca  ;  and,  again,  the  anasarca  supervenes  in 
patients  who  have  not  had  the  exanthematous  eruption  at  all.  In  respect 
of  oedema  of  the  glottis,  it  is  possible  that  the  sore  throat  by  which  it  has 
been  precedefl  favors  its  production,  but  if  so,  the  pharyngeal  inflammation 
is  only  the  immediately  exciting  cause,  the  predisposing  being  here  the 
principal  cause. 

It  is  reasonable  to  believe  (although  I  cannot  adduce  examples  in  sup- 
port  of  the  view),  that  this  non-inflammatory  oedema  of  the  larynx  may 
take  place  in  connection  with  every  disease  during  the  course  of  which  \\>' 
see  anasarca  supervene — in  albuminuria  lor  instance;  but,  apart  from  these 
cases,  idiopathic  cedema  of  the  glottis  is  far  from  occurring  so  frequently  as 
some  authors  have  alleged:  and  I  repeat,  that  you  will  almost  constantly 
see  cedema  of  the  larynx  depending  on  inflammation,  a  fact  which  Bayle 
established,  and  was  the  first  to  describe. 

CEdema  of  the  larynx  may  be  either  primary  or  consecutive :  it  is  primary 
when  it  is  the  result  of  an  inflammatory  action  advancing  towards  the  larynx 
or  pharynx,  and  simultaneously  to  the  aryteno-epiglottidean  ligaments;  and 
it  i-  consecutive  when  it  depends  upon  an  organic  alteration  of  the  larynx. 
In  the  lir.-t  case  the  inflammation  is  propagated  to  the  scat  of  Lesion,  the 
aryteno-epiglottidean  ligaments:  in  the  second  case  the  serous  infiltration 
is  due  to  engorgement  of  the  vessels  connected  with  the  diseased  part.-:  but 
in  neither  can  the  osdema  of  the  larynx,  as  it  has  for  its  starting-point  an 
ulcerated  and  consequently  an  inflamed  tissue,  be  regarded  as  independent 
of  inflammation. 

What  then  are  the  differenl  circumstances  in  which  this  oedema  Buper- 

■  p.  168  of  this  volume. 
f  Battdblocqub  :  Gazette  des  Hdpitaux,  1884.     Barribb:  Train'"  Pratique  dee 
Maladies  do  L'Enfance,  t.  ler,  p.  166. 


(EDEMA    OF    THE    LARYNX.  499 

venes?  Before  answering  this  question,  let  me  say  a  word  upon  the  con- 
ditions which  favor  the  production  of  oedema  of  the  larynx. 

These  conditions  exist  in  the  texture  itself  of  the  affected  parts.  You 
know,  gentlemen,  that  an  inflammation  of  the  skin,  a  common  boil  for  ex- 
ample, causes  swelling  of  the  surrounding  parts,  which,  within  certain 
Limits,  retains  the  mark  of  the  finger  when  pressure  has  been  made  upon 
them  with  it.  (Edematous  swelling,  resulting  from  an  afflux  and  effusion 
of  fluids  into  the  cellular  tissue,  will  proportionately  have  the  more  tendency 
to  be  produced,  the  less  the  degree  in  which  the  tissue  is  compact.  We 
therefore  see  it  in  the  most  marked  degree  in  the  eyelids  and  prepuce,  when 
there  is  an  inflammatory  afflux  to  these  parts ;  the  presence  of  variolous 
pustules,  for  example,  ujjon  the  eyelids,  will  determine  a  great  amount  of 
swelling  in  these  membranous  curtains,  and,  in  the  same  way,  a  Variolous 
pustule  on  the  prepuce  may  occasion  swelling  sufficient  to  impede  the  pas- 
sage of  urine.  Well  then,  the  uvula,  epiglottis,  and  aryteno-epiglottidean 
ligaments  present  identical  conditions  of  structure,  and  as  these  organs  are 
composed  of  a  still  looser  cellular  tissue,  you  can  understand  how  it  is  that 
they  have  a  tendency  to  become  cedematous,  not  only  under  the  influence 
of  a  direct  attack  of  inflammation,  but  likewise  from  inflammation  of 
neighboring  parts  causing  a  stasis  and  consequent  effusion  of  fluids. 

Let  us  now  review  the  different  circumstances  in  which  oedema  of  the 
larynx  may  supervene. 

One  morning  fifteen  years  ago,  when  the  physicians  of  the  Xecker  Hos- 
pital were  arriving  for  their  visit,  my  honorable  colleague  Bricheteau  and 
I  were  together  in  the  vestry,  when  we  were  summoned  in  haste  to  a  person 
just  brought  in,  who  was  dying  in  frightful  paroxysms  of  suffocation.  He 
was  a  vigorous  man  of  thirty-five  or  forty  years  of  age,  who  had  been  picked 
up  on  the  Boulevard  des  Invalides.  Horrible  anxiety  was  depicted  in  his 
countenance:  his  respiration  was  embarrassed  to  the  very  last  degree;  and 
during  inspiration,  he  emitted  a  whistling  sound  from  the  larynx,  while 
expiration  was  a  little  less  difficult  than  inspiration.  I  at  once  introduced 
my  finger  deep  down  into  the  throat,  and  detected  great  tumefaction  of  the 
epiglottis  and  aryteno-epiglottidean  ligaments.  Interrogating  the  patient, 
who — though  speaking  with  great  difficulty,  gave  a  good  account  of  his 
state — wTe  learned  that  on  the  previous  evening,  having  drunk  too  freely  at 
a  wine  shop,  he  had  been  turned  out  into  the  street,  where  he  fell  asleep. 
The  night  was  cold ;  and  towards  morning,  he  awoke  with  a  violent  sore 
throat,  which  was  almost  immediately  accompanied  by  great  difficulty  in 
breathing :  in  an  hour  or  two,  it  had  attained  the  point  at  which  we  saw 
it.  The  pharynx  was  of  a  bright  red  color,  and  the  veil  of  the  palate  was 
much  swollen  :  the  enlarged  uvula,  more  than  three  centimetres  in  length, 
trailing  on  the  tongue,  was  infiltrated  with  serosity,  and  looked  like  a  large 
yellow  grape.  This  oedeniatous  condition  of  the  uvula  led  us  to  conclude 
that  the  epiglottis  and  aryteno-epiglottidean  ligaments  were  in  a  somewhat 
similar  state,  and  in  fact  showed  us  the  nature  of  the  case.  We  saw  that 
we  had  to  do  with  oedema  of  the  larynx.  Under  the  influence  of  a  chill, 
the  man  had  contracted  a  catarrhal  sore  throat,  a  violent  inflammation, 
which  invading  the  whole  of  the  throat,  and  extending  to  the  entrance  of 
the  larynx,  had  attacked  the  epiglottis  and  aryteno-epiglottidean  ligaments, 
in  the  same  manner  in  which  it  had  laid  hold  of  the  uvula  and  veil  of  the 
palate.  Tracheotomy  was  performed  :  and  in  a  few  days  the  patient  was 
cured. 

In  the  young  woman  of  bed  No.  20,  St.  Bernard's  Ward,  of  whom  I 
spoke  at  the  beginning  of  this  lecture,  the  laryngeal  affection,  which 
presented  characters  almost  more  alarming  than  those  seen  in  the  patient 


500  (EDEMA    OF    THE    LARYNX. 

of  the  Necker  Hospital,  was  also  dependent  on  a  catarrhal  inflammation 
of  the  pharynx. 

Thus,  gentlemen,  you  see  that  catarrhal  pharyngitis  may  be  one  of  the 
causes  of  oedema  of  the  larynx.  With  that  cause  may  be  grouped  eri/sipe/a* 
of  the  pharynx;  whether  the  erysipelas  be  originally  developed  in  that 
region,  or  in  the  face,  it  will  extend  to  the  pharynx.  You  will  find  two 
cases  illustrating  this  point  in  the  thesis  of  Dr.  Laillier,  to  whom  they  were 
communicated  by  Dr.  Gubler.* 

Speaking  in  more  general  terms,  I  may  say,  that  any  inflammatory 
affection  of  the  pharynx  or  back  part  of  the  mouth,  irrespective  of  its  par- 
ticular nature  and  seat,  may  originate  the  affection  now  under  considera- 
tion. A  simple  inflammatory  sore  throat,  inflammation  at  the  root  of  the 
tongue,  or  inflammation  excited  by  the  presence  of  a  cancerous  tumor  of 
that  organ,  will  sometimes  lead  to  oedema  of  the  glottis,  when  the  inflam- 
matory afflux  extends  to  the  epiglottis  and  aryteno-epiglottidean  ligaments. 

The  circumstances,  however,  in  which  oedema  of  the  larynx  is  the  conse- 
cjiience  of  inflammation  descending  from  the  parts  above,  or  directly  attack- 
ing the  aryteno-epiglottidean  ligaments,  are  much  less  common  than  those 
in  which  ft  is  the  direct  result  of  acute  or  chronic  inflammation  of  the  larynx 
itself. 

We  can  understand  the  facility  with  which  the  fluxionary  movement 
which  accompanies  acute  inflammation  of  the  larynx  may  extend  to  the 
ligaments  of  the  epiglottis,  and  even  to  the  epiglottis,  and  determine  in  the 
cellular  tissue  which  enters  into  their  composition,  a  more  or  less  consider- 
able accumulation  of  serosity.  This  is  chiefly  observed  in  laryngismus 
stridulus,  a  form  of  laryngitis  which  is  rare  in  adults  and  frequent  in  chil- 
dren. In  that  disease,  it  is  not  uncommon  to  see  oedema  of  the  mucous 
membranes  not  only  originate  in  the  larynx  itself,  but  extend  likewise  to 
the  aryteno-epiglottidean  ligaments:  the  paroxysms  of  false  croup  also 
present  the  characteristic  symptom  of  oedema  of  the  larynx, — whistling  in- 
spiration, and  inspiration  more  labored  than  expiration. 

In  describing  to  you  the  history  of,  small-pox,  I  noticed  the  laryngeal 
complications  met  with  in  the  eruptive  stage  of  that  disease :  I  mentioned 
three  patients  who  were  carried  off  by  frightful  suffocative  paroxysms,  and 
I  stated  that  at  the  autopsy  of  one  of  them,  appearances  of  inflammation 
were  found  in  the  larynx,  and  variolous  pustules  below  the  glottis.  I  am 
not  aware  of  any  cases  having  been  recorded  of  oedema  of  the  glottis  de- 
pendent on  small-pox ;  but  looking  to  the  cases  to  which  I  have  now  referred, 
one  can  quite  well  conceive  that  the  affection  may  supervene  in  the  course 
of  small-pox,  in  consequence  of  pustules  being  developed  upon,  and  in  the 
neighborhood  of  the  aryteno-epiglottidean  ligaments. 

But  the  most  frequent  causes  of  oedema  of  the  larynx,  are  the  more  deeply- 
seated  affections  of  that  organ.  I  refer  to  laryngeal  ulceration,  acute  <>r 
chronic,  embracing  several  species,  which  have  been  long  known  under  the 
generic  term  hiri/iK/rn/  jihthisU — 1<>  nonspecific  laryngeal  ulceration — ami  to 
syji/ii/itlc,  cmicrroii*,  ami  hihrrrn/ar  ulceration  of  the  larynx. 

Exclusive  of  the  cases  in  which  non-specific  or  what  may  be  called  idio- 
pathic ulceration  of  the  larynx  supervenes  after  severe  fevers  (as  in  the  two 
patients  of  whose  cases  I  spoke  when  lecturing  on  dothinenteria),  this 
specieE  is  rare.  Generally,  ulceration  of  the  larynx  is  of  one  of  the  other 
specie.-  now  enumerated,  of  which  the  tubercular  is  the  mosl  common,  and 
to  which  alone  the  name — the  objectionable  name — of  laryngeal  phthieU  is 
at  all  applicable.    Were  this  term  to  he  rigorously  and  literally  interpreted, 

*  La i i.i.i  kk:  Sot  L'OBddme  de  hi  Glotte.     [These]  :   Paris,  1848. 


(EDEMA    OF    THE    LARYNX.  501 

we  should  say  that  it  signified  a  chronic  disease  of  the  larynx  capable  in 
itself  of  giving  rise  to  consumption.  But  it  results  from  the  anatomy  of 
the  parts,  that  patients  sink  most  frequently  under  the  (Edematous  affection 
before  the  disease  has  reached  the  last  stage  of  marasmus. 

Nevertheless,  there  are  cases — very  exceptional  cases — in  which  death 
may  be  the  consequence  of  consumption.  At  first  it  seems  difficult  to  under- 
stand how  an  inflammation  of  the  larynx  can  of  itself  lead  to  consumption. 
We  can  conceive  chronic  inflammation,  ulceration,  or  suppuration  of  the 
kidneys,  intestines,  bladder,  or  large  extent  of  cellular  tissue,  having  the 
power  of  contaminating,  day  by  day,  the  mass  of  the  blood,  exciting  fever, 
and  causing  the  patient  to  waste  away ;  but  we  cannot  so  readily  conceive 
such  consequences  being  the  result  of  similar  conditions  of  the  larynx,  the 
morbid  surfaces  of  which  are  so  small  in  extent,  the  products  of  their  sup- 
puration so  moderate  in  quantity,  and  their  sympathetic  relations  so  unim- 
portant. But  there  is  another  point  which  here  requires  to  be  taken  into 
consideration.  The  ulcerations  burrow  deeply,  and  extend  into  the  larynx: 
the  epiglottis  and  the  aryteno-epiglottidean  ligaments  participate  in  the 
inflammation  :  for  a  long  time  these  parts  are  turgid,  but  not  to  a  degree  suf- 
ficient to  cause  complete  obstruction  to  the  passage  of  air :  they  have  acquired 
excessive  irritability :  the  larynx,  of  which  the  muscles  and  nerves  have 
become  pathologically  modified,  can  no  longer  act  in  a  normal  manner. 
The  patient  breathes  with  difficulty  :  he  is  prevented  from  having  a  minute's 
sleep,  and  coughs  incessantly  from  the  irritating  action  of  the  air  on  the 
affected  parts:  cough  is  likewise  brought  on  in  fits,  by  the  contact  of  alimen- 
tary substances  and  drinks,  which,  from  difficulty  of  deglutition,  are  con- 
stantly getting  entangled  in  the  air-passages,  and  so  exciting  fears  of  suffo- 
cation. Under  these  conditions,  the  wretched  sufferer  refuses  to  take  food, 
except  when  forced  to  do  so  by  the  imperious  demands  of  hunger.  His 
nutriment,  therefore,  is  insufficient,  and  he  falls  into  a  state  of  emaciation 
which  leads  him  to  his  grave. 

Laryngeal  phthisis,  I  repeat,  is  quite  an  exceptional  termination  of 
laryngeal  ulceration.  The  most  frequent  cause  of  death  is  oedema  of  the 
larynx,  resulting  from  previous  disease  of  the  larynx. 

Whether  the  inflammation  of  the  larynx  be  simple  or  syphilitic,  tuber- 
cular or  cancerous,  cedema  may  supervene,  when  there  are  more  or  less 
extensive  and  more  or  less  numerous  ulcerations. 

Thus  it  happens,  gentlemen,  that  we  frequently  meet  with  individuals, 
who,  having  to  a  certain  extent  lost  their  voice  from  syphilitic  disease,  con- 
tinue to  speak  with  more  and  more  difficulty,  and  increasingly  to  suffer 
from  difficult  breathing.  The  dyspnoea,  which  at  first  existed  only  when 
they  exerted  themselves  in  some  unusual  manner,  such  as  walking  more 
quickly  than  usual,  or  ascending  a  stair,  at  last  becomes  permanent,  being 
present  even  when  they  remain  in  complete  repose.  Inspiration,  which  is 
more  embarrassed  than  expiration,  is  accompanied  by  a  characteristic 
laryngeal  whistling  ;  and  the  symptoms  go  on  increasing  in  severity  from 
day  to  day,  till  real  suffocative  attacks  supervene.  By  introducing  the 
finger  behind  the  tongue,  the  condition  of  the  epiglottis  and  aryteno-epi- 
glottidean ligaments  can  be  ascertained  :  by  this  proceeding  it  will  be 
found,  that  they  are  swollen,  and  in  a  state  of  cedematous  puffiness.  This 
oedema  of  the  glottis  is  dependent  upon  an  inflammation  of  the  larynx, 
characterized  by  primary  or  secondary  syphilitic  ulcerations,  whether  the 
disease  has  begun  in  the  larynx  or  pharynx. 

The  same  phenomena  are  observed  in  persons  affected  with  tubercular 
laryngitis,  of  which  the  most  common  lesions  are  erosions,  involving  only 
the  mucous  chorion,  or  ulcerations,  presenting  great  variety  in  number, 


502  (EDEMA    OF    THE    LARYNX. 

form,  extent,  and  depth.  The  number  of  the  ulcerations  is  generally  in 
an  inverse  ratio  to  their  size,  although  it  is  by  no  means  unusual  to  find  a 
single  very  small  ulcer  on  the  margin  of  the  vocal  cords,  or  at  the  bottom 
of  one  of  the  ventricles.  Ulcers  may  invade  the  entire  larynx,  vocal  cords, 
aryteno-epiglottidean  ligaments,  and  mucous  membrane  of  the  epiglottis :  of 
the  latter,  Dr.  Belloc  and  I,  in  our  treatise  on  laryngeal  phthisis,  have 
given  an  account  of  a  remarkable  example,  and  illustrated  it  by  a  draw- 
ing. With  regard  to  form,  the  ulcez*ations  are  sometimes  rounded  and  are 
sometimes  irregularly  circumscribed  :  their  edges  are  at  times  jagged,  and 
at  other  times  flattened  :  their  depth  also  is  variable.  In  the  majority  of 
cases,  the  ulceration  evidently  begins  in  the  mucous  membrane,  but  in 
others,  we  meet  with  submucous  abscess,  when  it  is  clear  that  the  ulcera- 
tion is  produced  in  the  same  way  in  which  some  cutaneous  fistula?  are 
formed.  Under  the  influence  of  an  unobserved  cause,  or  in  consequence 
of  irritation  excited  by  exposure  to  cold,  a  more  acute  inflammation  super- 
venes around  the  ulcerations  ;  the  fluxionary  movement  is  propagated  to 
the  aryteno-epiglottidean  ligaments,  and  serous  infiltration  into  their  cel- 
lular tissue  takes  place,  the  symptoms  of  oedema  of  the  larynx  being 
thereby  produced. 

When  the  laryngitis — whatever  may  have  been  its  cause — has  led  to 
necrosis  or  caries  of  the  cartilages,  oedema  of  the  glottis  is  inevitable  : 
under  such  circumstances,  it  is,  so  to  speak,  a  necessity. 

These  structural  changes  of  the  cartilages  of  the  larynx  occur  in  simple 
ulcerous  laryngitis,  as,  for  example,  in  those  which  follow  aggravated 
fevers.  In  relation  to  this  point,  I  ask  you  to  recall  to  your  recollection 
cases  which  we  observed  together,  and  on  which  I  dwelt  too  long,  when 
reviewing  the  sequelae  of  dothinenteria,  for  it  to  be  necessary  now  to 
repeat  what  I  then  said.  These  changes  are  met  with  in  syphilitic  ulcer- 
ous laryngitis.  They  are  most  common,  however,  in  tubercular  ulcerous 
laryngitis. 

The  ulcerative  process,  burrowing  deeply,  reaches  the  cartilages,  which 
it  denudes  ;  then,  according  to  the  greater  or  less  rapidity  of  the  ulcerative 
inflammation,  there  is  found,  either  necrosis  without  previous  ulceration  of 
the  cartilages,  or  caries  of  the  cartilages  ;  or,  in  other  cases,  there  is  ossifi- 
cation along  with  necrosis.  Necrosis  without  ossification  is  observed  in 
acute  ulcerous  laryngitis  following  aggravated  fevers  :  caries,  which  I  have 
never  seen  coincident  with  tubercular  laryngitis,  is  almost  invariably  ob- 
served in  very  young  subjects;  while  in  persons  of  more  advanced  years, 
when  the  laryngitis  has  been  of  long  standing,  it  is  necrosis  that  we  find, 
and  it  is  always  accompanied  by  ossification,  the  latter,  in  fact,  lias  even 
preceded  the  necrosis,  the  ulceration  which  is  the  cause  of  the  necrosis  hav- 
ing commenced  by  determining  inflammation  of  the  perichondrium,  and  a 
subsequent  exudation  of  osseous  matter  into  the  subjacent  cartilage:  then. 
ulceration  reaching  the  ossified  cartilage,  it  becomes  the  more  readily  ne- 
crosed, that  ossification  has  deprived  it  of  a  great  pari  of  its  vitality.  In 
old  people,  in  whom  ossification  of  these  cartilages  has  pretty  generally 
taken  place,  simple  chronic  laryngitis,  irrespective  of  any  special  diathesis, 

leads  to  the  Structural  changes   01   the  larynx  of  which    i   have  been  speak- 
ing ;  consecutively  also  to  oedema  of  the  glottis,  as  occurred  in  the  patient 
occupying  bed  No.  25,  St.  Bernard's  Ward. 
Gentlemen, you  can  understand  that  when  once  necrosis  of  the  cartilages 

has  begun,  Oedema    of  the  larynx   inevitably  follows.      Here,  as  in    necrosis 
of  the  hones,  where  the  Bequestra  must  he   extruded,  as  also  in   all  tissues, 

in  the  cellular  tissue,  for  instance,  where  the  dead  portions  musl  be  Bepa- 


(EDEMA    OF    THE    LARYNX.  503 

rated  from  the  living — the  rapidity  with  which  the  separation  and  elimina- 
tion take  place  is  proportionate  to  the  vitality  of  the  tissues. 

In  respect  of  hones,  what  takes  place?  The  irritation  caused  hy  the 
sequestrum  induces  suppurative  inflammation  ;  and  if  the  necrosis  he  sub- 
cutaneous, the  pus,  sooner  or  later,  makes  its  way  to  the  surface.  Some- 
times, the  opening  becomes  cicatrized,  hut  if  this  occur,  it  soon  reopens, 
unless  other  openings  form  in  the  neighborhood  to  afford  an  exit  to  the  pus 
which  is  being  constantly  secreted:  finally,  a  fistula  is  formed,  which  con- 
tinues to  exist  till  the  whole  of  the  dead  portions  of  bone  have  been  elimi- 
nated. The  inflammation  extends  to  the  soft  parts,  which  swell,  and  be- 
come the  seat  of  oedematous  engorgement. 

In  necrosis  of  the  cartilages  of  the  larynx,  the  course  of  events  is  simi- 
lar. As  soon  as  there  is  necrosis,  whether  of  the  cricoid  cartilage,  which 
is  most  common,  or  of  the  thyroid  cartilage,  which  is  less  usual,  an  abso- 
lute necessity  exists  that  the  necrosed  part  be  eliminated.  During  the 
whole  of  the  period  of  elimination,  suppuration  is  going  on  :  abscesses  form 
under  the  laryngeal  mucous  membrane,  which  they  detach,  and  from  the 
inflammatory  afflux  extending  at  the  same  time  to  the  neighboring  cellular 
tissue,  that  becomes  the  seat  of  more  or  less  pasty  induration. 

To  pursue  still  further  our  comparative  study  of  the  manner  in  which 
bone  and  cartilage  is  affected,  let  us  suppose  an  individual  with  necrosis  of 
the  tibia  suddenly  taking  erysipelas  of  the  leg,  under  the  influence  of  one 
of  those  epidemics  so  common  in  our  hospitals.  This  attack  will  have  as 
its  starting-point  the  existing  fistula ;  and  the  erysipelas,  acquiring  great 
intensity,  will  occasion  an  engorgement  extending  to  a  greater  or  less  dis- 
tance around  the  primarily  affected  parts. 

Suppose,  again,  that  an  individual  suffering  from  ulcerous  laryngitis  and 
necrosis  of  the  cartilages,  take  acute  inflammation  of  the  larynx,  from 
exposure  to  cold,  undue  exertion  of  the  voice,  or  other  cause,  that  inflamma- 
tion, being  greatly  aggravated  by  that  already  existing,  will  extend  to  dis- 
tant parts,  will  reach  not  only  the  vocal  cords,  but  likewise  the  aryteno- 
epiglottidean  ligaments ;  and  the  patient  will  have  all  the  symptoms  of 
oedema  of  the  larynx. 

I  ought  also  to  notice  a  frequent  cause  of  oedema  of  the  glottis  in  very 
young  children  in  England,  ISTorth  America,  and  Russia,  where  tea  is  an 
ordinary  beverage.  In  every  family  there  is  almost  constantly  a  kettle  on 
the  fire :  and  the  children  going  to  drink  from  the  beak  of  the  kettle  or 
tea-pot  when  the  boiling  water  is  about  to  be  poured  out,  terrible  burns  of 
the  mouth  and  throat  are  the  result  ISo  doubt  the  child  immediately  re- 
jects the  water  which  he  has  taken  into  his  mouth ;  but  it  has  had  time  to 
come  in  contact  with  the  epiglottis,  the  aryteno-epiglottidean  ligaments,  the 
veil  of  the  palate,  and  the  interior  of  the  mouth.  In  general,  for  some 
hours  after  the  occurrence  of  accidents  of  this  description,  they  do  not 
seem  to  be  at  all  serious ;  but  ere  long,  respiration  becomes  disti'essed,  and 
all  the  phenomena  of  oedema  of  the  glottis  make  their  appearance. 

Mr.  Jameson,  surgeon  to  one  of  the  Dublin  Hospitals,  has  published  a 
very  interesting  paper  on  this  subject.  He  shows  the  necessity  of  resorting 
to  tracheotomy  as  soon  as  the  suffocative  attacks  occur ;  and  he  details 
several  cases  in  which  a  cure  was  obtained  by  that  proceeding.  The 
canula  ought  to  be  removed  as  soon  as  the  local  effects  of  the  burn  have 
disappeared.* 

You  know,  gentlemen,  the  symptoms  of  oedema  of  the  glottis.  In  a  few 
rare  cases,  the  disease  declares  itself  suddenly,  as  occurred  in  my  patient 

*  Jamesox  :  Dublin  Quarterly  Journal  for  February,  1848. 


504  (EDEMA    OF    THE    LARYNX. 

of  the  Necker  Hospital.  More  frequently,  according  as  it  is  dependent  on 
an  acute  or  chronic  inflammation,  the  phenomena  by  which  it  is  character- 
ized have  been  preceded  by  the  symptoms  which  belong  to  these  diseases, 
that  is  to  say,  by  the  symptoms  of  pharyngitis,  tonsillitis,  acute  laryngitis, 
or  chronic  laryngitis. 

In  the  latter,  the  most  frequent  case,  changes  in  the  voice  will  have  ex- 
isted for  some  time :  the  individual  will  have  had  for  some  time  roughness 
of  voice,  which  will  at  last  pass  into  aphonia :  his  hoarse,  dry  cough  will 
become  less  and  less  heard,  till  it  ultimately  becomes  inaudible.  At  this 
stage,  the  disease  of  the  larynx  having  made  progress,  respiration  will  have 
become  more  painful.  At  first,  the  oppression  is  greatest  during  inspiration, 
which  is  accomplished  with  great  effort,  and  is  accompanied  by  a  guttural 
snoring  noise,  which  is  sometimes  very  loud  :  at  first,  this  noise  is  only  heard 
during  sleep.  Expiration,  hitherto  easy,  now,  in  its  turn,  becomes  difficult. 
The  malady  advances,  and  the  dyspnoea  increases.  The  dyspnoea,  which 
in  the  beginning  of  the  attack  was  most  severe  at  night,  is  now  great  both 
by  day  and  by  night ;  but  during  the  night  it  is  so  urgent,  that  the  patients 
are  obliged  at  last  to  retain  constantly  the  sitting  posture.  Orthopncea  be- 
comes incessant ;  and  it  has  exacerbations  which  are  suffocative  seizures, 
and  constitute  the  symptom  characteristic  of  cedematous  sore  throat. 

These  suffocative  seizures  have  a  very  frightful  aspect.  The  patient — 
with  livid  face,  open  mouth,  distended  nostrils,  moist  and  protruding  eye, 
the  skin  streaming  with  sweat — rises  abruptly,  and  walks  about  the  room, 
from  time  to  time  holding  the  articles  of  furniture,  the  jams  of  the  mantel- 
piece, or  the  ratteens  of  the  casements,  seeking  everywhere  something  to 
rest  on  that  he  may  breathe  more  easily :  sometimes,  he  will  hold  his  head 
low  and  look  down;  but  more  frequently, he  will,  with  stretched  neck,  turn 
his  head  backwards :  at  last,  he  will  sit  down  exhausted,  but  he  will  soon 
rise  again  and  repeat  the  same  postures.  You  see  him  in  extreme  excite- 
ment, throwing  off  the  garments  which  cover  his  head,  neck,  and  chest, 
opening  the  windows  in  a  sort  of  frenzy,  that  he  may  inhale  the  fresh  an- 
trum without,  and  grasping  his  neck,  as  if  for  the  purpose  of  wrenching 
from  it  some  foreign  body  by  which  he  was  being  straugled. 

Persons  sometimes  die  in  the  first  paroxysm  of  cedematous  sore  throat  ; 
but  in  general,  the  symptoms  abate,  and  the  suffocative  attack  ceases:  the 
breathing,  however,  continues  embarrassed,  particularly  during  inspiration  : 
the  voice  is  scarcely  audible :  the  state  of  excitement  is  succeeded  by  col- 
lapse. 

When  we  proceed  to  examine  into  the  state  of  the  affected  parts,  we  find 
that  our  means  of  investigation  arc  unfortunately  very  insufficient.  If  in 
certain  cases,  inspection  of  the  hack  part  of  the  throat  is  of  -nine  use  :  if  tin- 
existence  of  a  catarrhal  or  inflammatory  sore  throat  had  us  to  believe  that 
the  oedema  of  the  glottis  is  dependent  upon  pharyngitis,  this  inspection  too 
often  fails  to  aid  our  diagnosis  when  the  sore  throat  which  preceded  the 
laryngeal  affection  has  entirely  disappeared,  or  when  the  affection  of  the 
aryteno-epiglottidean  folds  is  dependent  upon  disease  of  the  larynx.  In 
the  latter  cas< — which  is  the  most  usual — auscultation  docs  not  afford 
information  as  to  the  state  of  the  parts  nearly  bo  good  as  thai  obtained  by 
observing  the  manner  in  which  respiration  is  performed,  and  attentively 
studying  the  modifications  of  the  voice.  It  is  only  the  /"(/(//which  can 
give  us  Borne  positive  indications ;  but  to  whatever  degree  of  perfection  this 

mode   of  exploration    is  carried,  it    does  not    do   more   than    enable    US    to 

reco-ni/r  the  (edematous  swelling  of  the  epiglottis  and  aryteno-epiglottidean 
ligaments.  Exploration  by  the  finger  must  be  practiced  in  a  very  careful 
manner.      You  recollect  that  w  hilsl  1  was  examining  the  throat  of  a  woman 


(EDEMA    OF    THE    LARYNX.  505 

with  my  finger  in  the  most  guarded  possible  way,  I  induced  a  suffocative 
seizure  which  very  nearly  proved  fatal.  To  ascertain  the  existence  of  lesions 
is  unquestionably  of  great  importance  in  the  diagnosis  of  oedema  of  the 
larynx,  but  it  throws  no  light  upon  the  nature  of  the  affection  whence  the 
oedema  arises.  Examination  of  the  larynx  by  a  suitable  speculum  was  felt 
to  be  a  likely  means  of  attaining  this  end.  Long  prior  to  1837,  when  Dr. 
Belloc  and  I  published  our  treatise  on  laryngeal  phthisis,  this  idea  had 
engaged  the  attention  of  practitioners  ;  and  at  the  date  of  our  publication 
we  were  occupied  with  the  construction  of  a  speculum  ktryngis.  At  that 
time  likewise  M.  .Selligue,  an  ingenious  mechanician,  who  was  also  a  sufferer 
from  laryngeal  phthisis,  made  for  his  physician,  an  apparatus  consisting  of 
two  tubes,  one  for  throwing  light  on  the  glottis,  and  the  other  for  affording 
a  view  of  the  image  of  the  glottis,  as  reflected  in  a  mirror  placed  at  the 
guttural  extremity  of  the  instrument.  There  were,  however,  serious  defects 
in  this  instrument;  and  the  difficulties  in  applying  it  were  so  great,  that  I 
long  since  ceased  to  use  it.  Laryngoscopy  has  been  carefully  studied  in 
England  and  Germany  ;  and  you  can  read  in  the  Archives  Generales  de 
Medecine  for  February,  1860,  an  account  by  my  friend  Dr.  Lasegue  of  the 
results  arrived  at  by  our  colleagues  on  the  other  side  of  the  Channel  and 
beyond  the  Rhine.  When  laryngoscopy  shall  have  attained  a  greater 
degree  of  perfection,  it  will  no  doubt  render  service  not  only  in  the  diag- 
nosis but  also  in  the  treatment  of  laryngeal  affections — particularly  in  the 
treatment  of  oedema  of  the  glottis,  for  sight  ought  certainly  to  assist  the 
hand  in  the  application  of  the  topical  remedies  which  are  of  such  essential 
importance  in  treating  that  affection.*  I  must  not,  however,  exaggerate 
the  practical  utility  of  the  laryngoscope  in  the  class  of  cases  we  are  now- 
considering.  The  application  of  instruments  is  not  well  borne  by  the 
larynx,  particularly  when  there  is  a  liability  to  suffocative  seizures ;  and 
you  have  observed  that  M.  Czermak,  notwithstanding  the  great  experience 
which  he  had  in  the  use  of  the  laryngoscope,  was  only  able  to  get  a  good 
view  of  the  larynx  in  patients  with  very  tolerant  throats,  and  in  whom 
respiration  was  not  much  embarrassed.  When  there  is  suffocation,  the 
introduction  of  the  laryngoscope  increases  the  anxiety,  and  it  is  only  by 
stealth,  if  I  may  use  such  an  expression,  that  one  can  get  a  view  of  the 
vocal  cords  and  upper  part  of  the  larynx. 

I  now  propose  to  consider  the  symptoms  and  progress  of  oedema  of  the 
larynx. 

I  stated,  gentlemen,  that  patients  are  occasionally  carried  off  in  the  first 
suffocative  seizure ;  but  that  usually  this  attack  passes  off,  leaving,  how- 
ever, embarrassed  breathing.  I  also  stated,  that  there  is  a  variety  in 
the  early  symptoms,  according  to  the  oedema  of  the  larynx  being  depen- 
dent upon  acute  or  chronic  inflammation.  In  the  former  case,  the  attack 
comes  on  abruptly,  and  the  symptoms  are  of  a  violent,  irregular  character, 
recurring  several  times  within  the  twenty-four  hours  ;  in  the  second  case, 
the  seizures  supervene  at  distant  intervals,  at  intervals  of  from  eight  to  fifteen 
days,  or  longer ;  but  after  a  time,  the  duration  of  the  intervals  diminishes, 
so  that  in  the  course  of  the  twenty-four  hours,  there  are  several  attacks,  those 
which  occur  during  the  night  being  the  most  violent. 

When  oedema  of  the  larynx  is  a  primary  affection,  or  is  connected  with 
acute  inflammation  of  the  pharynx  or  larynx,  its  progress  is  more  rapid, 
and  the  chances  of  a  favorable  termination  are  also  greater,  which  arises 
from  the  affection  being  transient  in  its  nature  like  the  pathological  state 

*  See  the  work  of  Czekmak  :  "  D\i  Laryngoscope  et  de  son  eraploi  en  Physiologie 
et  en  Medecine.''     Paris,  1860. 


506  (EDEMA    OF    THE    LARYNX. 

on  which  it  depends.  Spontaneously,  therefore,  or  under  the  influence  of 
appropriate  treatment,  resolution  of  this  inflammation  takes  place,  the  cure 
being  certain  and  complete.  I  am  not  speaking  to  you,  gentlemen,  of  very 
exceptional  cases  in  which  recovery  is  the  result  of  another  mechanism 
which  you  will  find  pointed  out  in  some  works, — the  opening  of  an  abscess 
formed  in  the  substance  of  the  aryteno-epiglottidean  ligaments. 

When  oedema  of  the  larynx  is  connected  with  chronic  inflammation  of 
the  larynx,  or  structural  alteration  of  the  cartilages,  the  progress  of  the 
symptoms  is  very  different;  and  from  what  I  have  already  said,  you  can 
understand  that  they  then  have  a  disposition  to  repeat  themselves.  There 
is  in  fact  an  inevitable  necessity  for  the  elimination  of  the  necrosed  parts  : 
the  eliminative  process  gives  rise  to  suppuration,  and  to  the  formation  of 
abscesses,  which  by  raising  up  the  mucous  membrane,  diminishes  the  calibre 
of  the  glottis,  already  narrowed  by  the  thickening  of  the  vocal  cords 
caused  by  their  inflammatory  engorgement ;  and  which  engorgement,  by 
extending  to  the  aryteno-epiglottidean  ligaments,  causes  them  to  become 
infiltrated. 

If  the  pus  make  an  exit  for  itself  into  the  interior  of  the  larynx,  or 
externally  by  the  skin  (examples  of  which  I  have  seen),  if  the  inflamma- 
tory action  is  at  first  very  circumscribed,  and  quite  passes  away,  the  suffo- 
cative symptoms  will  decrease  more  or  less  completely,  in  proportion  to  the 
greater  or  less  size  of  the  opening  in  the  abscess,  the  patient,  however, 
retaining  hoarseness  of  voice,  some  amount  of  aphonia,  and  difficulty  of 
breathing,  which  latter  depends  on  the  vocal  cords  and  laryngeal  mucous 
membrane  remaining  in  a  thickened  state.  But  this  amendment  is  only 
temporary :  the  causes  continue,  and  will,  sooner  or  later,  induce  a  repeti- 
tion of  the  consecmences.  The  organic  lesion  advancing  and  the  edema- 
tous infiltration  becoming  permanent,  the  symptoms  recur  with  increasing 
intensity ;  and  unless  art  interpose,  the  patient  will  probably  be  carried  off 
in  a  suffocative  paroxysm.  Death  also  frequently  occurs  in  the  intervals 
between  the  attacks.  The  patients  becoming  weaker  and  weaker,  more 
and  more  prostrated  by  each  attack,  fall  into  a  state  of  drowsy  HstlessnesSj 
and  sometimes  expire  in  perfect  possession  of  consciousness.  In  such  cases, 
tracheotomy  often  gives  no  fresh  life,  the  victims  sinking,  in  the  same  man- 
ner as  certain  asphyxiated  persons  sink,  after  the  causes  of  asphyxia  have 
been  removed. 

Although  the  principal  obstacle  to  respiration  in  oedema  of  the  larynx  is 
generally  seated  in  the  aryteno-epiglottidean  folds,  this  inflammatory 
oedema  may  also  become  developed  in  the  cellular  tissue  of  the  laryngeal 
mucous  membrane  it-elf:  thus,  in  the  cases  in  which  there  is  none  of  that 
shrill  whistling  inspiration  which  particularly  belongs  to  (edema  of  the 
aryteno-epiglottidean  folds,  it  i>  probable  that  the  chief  obstacle  exist-  in 
the  situation  of  the  vocal  cords.  Then  the  patient,  who  generally  bas  seri- 
ous lesions  of  the  cartilages  of  the  larynx  ami  particularly  of  the  cricoid 
cartilage,  has  no  whistling  inspiration:  there  is  puffiness  of  the  mucous 
membrane  and  oedema  of  the  submucous  cellular  tissue  covering  the 
affected  cartilage:  there  is  only  very  greatly  embarrassed  breathing,  the 
in-piled  air  traversing  the  larynx,  and  producing  there  a  more  or  Less 
barsb  hut  not  shrill  sound,  while  the  expiratory  murmur  is  still  percepti- 
ble: there  exists  in  fact  a  variety  of  wheezing  without  any  shrill  whistling 
sound.  You  may  have  observed  this  slate  of  matters  in  a  patient  occupy- 
ing bed  No.  .".  in  Si.  Agnes's  Ward.  The  man  to  whom  I  refer  is  sixty- 
three  years  of  age:  for  a  long  period  he  had  been  the  subjeel  of  chronic 
laryngitis.  Examination  by  the  laryngoscope  enabled  us  to  ascertain  that 
there  was  do  oedema  of  the  aryteno-epiglottidean  folds,  while  we  saw  diffuse 


(EDEMA    OF    THE    LARYNX.  507 

redness  of  the  upper  part  of  the  larynx  and  vocal  cords,  and  below  them,  a 
serious  structural  change.  We  were  ignorant  of  the  cause  of  the  chronic 
laryngitis:  no  benefit  had  resulted  from  treatment, and  the  embarrassraenl 
in  respiration  was  rapidly  increasing.  Suffocative  seizures  frequently 
occurred  during  the  night,  the  extremities  at  the  same  time  becoming  cold. 
Fearing  that  the  patient  might  die  in  one  of  these  attacks,  I  requested  M. 
Dumontpallier  to  perform  tracheotomy.  The  operation  is,  as  you  know, 
difficult  in  old  people.  In  them,  the  trachea  is  nearly  always  very  deeply 
seated.  The  large  veins  must  be  avoided  with  care,  lest  hemorrhage  com- 
plicate the  proceedings.  When  the  trachea  has  been  properly  isolated,  the 
most  difficult  part  of  the  operation  remains  to  be  encountered — the  opening 
of  the  canal,  which  is  generally  ossified.  The  upper  rings  of  the  trachea 
ought  to  be  included  between  the  blades  of  the  scissors,  care  being  taken  to 
avoid  cutting  the  mucous  membrane.  Before  penetrating  the  mucous 
membrane  of  the  trachea,  it  is  necessary  to  remove  a  portion  of  the  rings, 
a  precaution  without  which  it  is  impossible  to  introduce  the  canula.  In 
the  aged,  therefore,  there  is  a  particular  time  for  opening  the  mucous  mem- 
brane of  the  windpipe,  and  that  time  is  the  last  stage  of  the  operation. 
In  our  patient,  tracheotomy  was  performed  in  accordance  with  these  rules, 
and  the  canula  was  easily  introduced.  The  patient  at  once  breathed 
freely  :  and  no  untoward  event  occurred  after  the  operation.  I  said  to  you 
at  the  time,  that  it  would  probably  be  right  to  leave  the  canula  in  the 
trachea,  because,  whether  the  affection  was  cured  or  not,  such  an  amount 
of  stricture  would  remain  as  to  leave  an  insufficient  passage  for  the  entrance 
of  the  air  required  in  hsematosis.  Well  then,  the  man,  after  remaining  six 
months  in  our  wards,  was  received  as  an  incurable  into  the  Bicetre.  He 
could  not  remain  more  than  a  minute  without  the  canula,  and  when  it  was 
being  cleaned,  it  was  necessary  to  keep  the  tracheal  opening  in  a  patent 
state  by  means  of  the  dilator,  for  otherwise  a  risk  of  suffocation  would  be 
incurred.  From  time  to  time,  small  sequestra  from  the  cricoid  cartilage 
were  eliminated. 

I  now  come  to  the  subject  of  treatment. 

When  the  inflammation  is  simple  and  very  acute — when,  as  in  our 
patient  of  the  Hospital  Xecker,  it  is  connected  with  violent  inflammation 
of  the  pharynx  or  larynx — when  the  febrile  reaction  is  intense — antiphlo- 
gistic remedies  are  at  once  indicated.  One  or  two  large  general  bleedings, 
and  the  abstraction  of  blood  from  the  cervical  region  by  leeches  or  cupping, 
will  give  great  relief  and  moderate  the  severity  of  the  symptoms.  Recourse 
will  afterwards  be  had  to  cauterization  with  nitrate  of  silver,  to  insufflation  of 
alum  or  tannin  into  the  back  part  of  the  throat,  and  as  far  clown  as  the  aryt- 
eno-epiglottidean  ligaments.  When  it  is  practicable,  scarification  of  these 
ligaments  has  been  recommended.  I  have  not  had  the  courage  to  practice 
this  operation  ;  but  Mr.  Gordon  Buck,  surgeon  to  the  hospital  of  New  York, 
has  published  numerous  cases  of  recovery  from  oedema  of  the  larynx  in 
which  repeated  scarifications  of  the  epiglottis  and  aryteno-epiglottidean 
ligaments  were  performed.  The  instrument  employed,  a  sort  of  blunt- 
pointed  bistoury  with  a  short  curved  blade,  is  carried  to  the  back  of  the 
throat,  the  index  finger  being  used  as  a  conductor.  Mr.  Gordon  Buck  has, 
however,  exaggerated  both  the  utility  and  the  facility  of  this  operation.  In 
reading  over  the  cases  reported  by  this  honorable  practitioner,  it  may  be 
asked,  whether  the  majority  of  the  patients  would  not  have  recovered  under 
simpler  treatment.  The  cases,  gentlemen,  were  acute,  non-symptomatic 
cases  of  oedema  of  the  glottis,  an  affection  which  as  you  know  corresponds 
in  the  adult  to  false  croup  in  the  child,  and  which  gets  well  of  itself,  not- 
withstanding the  very  alarming  aspect  of  the  symptoms. 


508  (EDEMA    OF    THE    LARYNX. 

Topical  treatment  is  exceedingly  useful.  You  saw  me  ernplov  it  success- 
fully, ami  to  the  exclusion  of  other  remedial  means,  in  the  case  of  the 
patient  of  bed  No.  20,  St.  Bernard's  Ward :  in  that  case,  there  was  laryngeal 
cedematous  sore  throat  dependent  on  catarrhal  inflammation,  unattended 
by  much  general  febrile  disturbance  of  the  system.  Let  me  call  your 
attention  to  the  manner  in  which  I  applied  the  treatment.  It  consisted  in 
injecting  I  by  means  of  a  spray-apparatus  )  water-spray  strongly  charged 
with  tannin.  This  excellent  method  of  application,  which  is  easy  in  adults, 
is  in  my  opinion  even  more  serviceable  in  chronic  affections  of  the  larynx, 
than  in  cedema  of  the  glottis. 

Whatever  may  be  the  nature  of  the  disease,  whatever  may  be  the  laryn- 
geal lesion  which  has  induced  the  oedema  of  the  glottis,  the  first  thing  to 
do  is  to  apply  topical  treatment.  Under  its  influence,  the  local  affection 
of  the  aryteno-epiglottidean  folds  may  become  modified  to  such  a  degree  as 
to  cause  a  cessation  of  the  symptoms,  and  gain  time  sufficient  for  the  inflam- 
mation which  originated  the  cedematous  infiltration  to  pass  through  its  stages, 
and  come  to  an  end.  Eecollect,  gentlemen,  that  a  definitive  cure  cannot 
take  place,  unless  the  pharyngeal  or  laryngeal  inflammation  upon  which 
the  cedematous  laryngeal  sore  throat  depends  is  of  the  kind  which  spon- 
taneously terminates  in  recovery — unless  the  inflammation  be  either  simple 
in  its  nature,  or  dependent  upon  a  diathesis  the  manifestations  of  which  we 
can  prevent. 

Let  me  explain  this  point.  We  are  justified  in  hoping  for  a  radical  and 
final  cure  when  oedema  of  the  glottis  supervenes  in  the  course  of  a  simple 
ulcerous  or  syphilitic  laryngitis,  because  in  these  cases  we  possess  the  means 
of  effectively  combating  the  pathological  condition  of  which  the  oedematous 
affection  is  the  result :  but  we  cannot  entertain  such  hopes  when  the  oedema- 
tous affection  comes  on  in  the  course  of  a  tuberculo-ulcerous,  or  a  cancerous 
laryngitis,  for  then  the  disease  of  the  larynx  is  developed  under  the  influ- 
ence of  a  diathesis  beyond  the  resources  of  art.  Supposing  that  we  are  for- 
tunate enough  to  master  the  symptoms  of  oedema  of  the  glottis,  we  must 
be  prepared  for  their  return. 

These  considerations  are  still  more  applicable  to  cases  in  which  oedema- 
tous laryngeal  sore  throat  depends  upon  serious  lesions  of  the  cartilages  of 
the  larynx.  "When  lecturing  on  dothinenteria,  I  mentioned  the  case  of  a 
young  woman  who  became  affected  with  oedema  of  the  glottis  after  an  attack 
of  typhoid  fever,  and  was  entirely  relieved  after  getting  rid  of  some  small 
osseous  sequestra.  This  is  certainly  the  most  fortunate  termination  which 
can  be  met  with  ;  but  it  occurs  too  seldom  to  be  counted  on.  The  pi 
of  eliminating  the  necrosed  parts  is  accomplished  too  slowly — in  the  case 
to  which  I  alluded,  the  laryngeal  malady  was  of  nine  months'  standing — 
to  prevent  fear  of  the  patient  being  carried  off  by  a  suffocative  attack. 
When  the  oedema  of  the  larynx  depends  on  formidable  Lesions  of  the  laryn- 
geal cartilages,  it  is  necessary  to  wait  to  sec  whether  there  be  a  recurrence 
of  the  symptoms.  Here  the  employment  of  topical  treatment  is  explicitly 
indicated,  because  it  will,  by  gaining  time,  afford  the  slighl  chance  which 
there  is  of  the  fortunate  resull  occurring  which  I  have  ju.-t  mentioned. 
Sooner  or  later,  however,  it  will  be  necessary  to  resort  t<>  tracheotomy. 

[n  conclusion,  ]  shall  now  repeat  what  I  said  on  a  previous  occasion  when 
speaking  on  this  subject.  When  we  have  to  deal  with  patients  affected  with 
oedematous  laryngeal  sore  throat,  after  we  have  tried  the  therapeutic  means 

at  our  disposal,  insufflation  of  tannin   and  alum,  cauterization  with    nitrate 

of  silver,  and  'when  practicable)  scarification  of  the  aryteno-epiglottidean 
folds,  we  rnusl  hold  ourselves  in  readiness  to  perform  tracheotomy.  Earlier 
or  later,  recourse  to  the  operation  will  be  determined  by  the  severity  of  the 


apiionia:    cauterization  of  the  larynx.  509 

suffocative  seizures,  the  rapidity  with  which  they  follow  one  another,  and 
the  urgency  of  the  dyspnoea  in  the  intervals  between  the  paroxysms. 
Finally,  increased  debility  of  the  patient  demands  earlier  recourse  to  the 
operation. 


LECTURE  XXVII. 

APHONIA— CAUTERIZATION   OF   THE   LARYNX. 

Different  Causes  of  Aphonia. — From  Lesion,  or  without  Lesion  of  the  Larynx. 
— Nervous  Aphonia. —  Good  Effects  resulting  from  Cauterization,  and 
sometimes  even  from  the  mere  Introduction  of  the  Laryngoscope. 

Gentlemen  :  A  long  period  has  now  elapsed  since  I  called  the  attention 
of  practitioners  to  a  mode  of  treatment  which  I  had  found  wonderfully  suc- 
cessful in  certain  cases  of  chronic  aphonia.  During  the  present  year  you 
have  had  an  opportunity  of  judging  of  its  efficacy,  having  seen  me  apply  it 
in  the  cases  of  several  young  women  who  remained  in  our  wards  for  some 
days. 

By  the  term  aphonia,  we  mean  a  more  or  less  complete  loss  of  voice,  the 
power  of  speaking  remaining.  The  patient  has  not  lost  the  power  of  utter- 
ing articulate  sounds,  as  in  dumbness,  with  which  aphonia  must  not  be  con- 
founded ;  the  sound  of  the  voice  is  only  greatly  enfeebled. 

The  causes  of  aphonia  are  numerous,  and  also  various  in  character. 
Chronic  aphonia  is  generally  a  symptom  of  disease  of  the  larynx,  and  is 
most  frequently  dependent  on  ulcerous  laryngitis,  of  which  I  incidentally 
spoke  in  my  last  lecture.  You  will  often  meet  with  it  in  persons  who  have 
formerly  had  venereal  symptoms,  and  it  almost  always  occurs  in  tubercular 
laryngitis. 

According  to  one  of  my  good  pupils,  Dr.  Krishaber,  whose  researches 
have  rendered  him  a  very  competent  authority  on  the  subject,  syphilitic 
leads  less  frequently  than  tubercular  laryngitis  to  complete  aphonia,  and 
the  explanation  of  this  is  to  be  found  in  the  nature  of  the  lesions.  In 
syphilitic  laryngitis  the  lesions  generally  occupy  in  order  of  invasion :  1st, 
the  epiglottis  ;  2d,  the  superior  thyro-arytenoid  ligaments  (or  superior  vocal 
cords) ;  3d,  the  aryteno-epiglotticlean  ligaments  (the  seat  of  suffusion,  oedema, 
and  even  of  suppuration) ;  4th,  the  mucous  membrane  of  the  vestibule  of 
the  larynx ;  5th,  the  mucous  membrane  of  the  trachea ;  and  6th  (quite  as 
an  exceptional  occurrence),  the  inferior  thyro-arytenoid  ligaments  (or  in- 
ferior vocal  cords).  You  will  immediately  perceive,  gentlemen,  that  this 
last  peculiarity  explains  the  rarity  of  complete  aphonia  in  syphilitic  laryn- 
gitis. Dr.  Krishaber  adds,  that  when  the  aphonia  is  complete,  it  is  almost 
never  dependent  on  a  lesion  of  the  vocal  cords  properly  so  called,  but  is 
generally  the  result  of  the  swollen,  puffy  superior  vocal  cords  covering,  and 
preventing  vibration  of,  the  inferior  vocal  cords. 

With  the  aid  of  a  strong  light — sunlight  or  electric  light — we  can  see  the 
color  of  the  mucous  membrane,  and  from  that  determine  whether  the  lesion 
be  due  to  syphilis  or  tuberculosis :  if  the  mucous  membrane  have  a  dusky 
shade,  the  affection  is  syphilitic. 

It  is  more  difficult  to  recognize  the  specific  character  of  the  lesion  by  the 
form  of  the  ulcerations,  as  in  both  lesions  it  is  very  similar.     The  syphilitic 


510  aphonia:   cauterization  of  the  larynx. 

ulcerations  are  deeper,  and  more  frequently  attack  the  cartilages,  while  in 
phthisis,  the  fibrocartilaginous  tissue  alone  is  implicated.  QEdema  of  the 
larynx  is  more  common  in  ulcerous  laryngitis  depending  upon  syphilis,  than 
in  laryngitis  arising  from  the  tubercular  diathesis. 

Tubercular  laryngitis  invades  in  succession:  1st,  the  mucous  membrane 
of  the  superior  thyro-arytenoid  ligaments ;  2d,  the  epiglottis ;  3d,  the  in- 
ferior vocal  cords ;  4th,  the  aryteno-epiglotticlean  ligaments ;  5th,  the  ves- 
tibule ;  6th,  and  exceptionally,  the  mucous  membrane  of  the  trachea. 

Syphilitic  laryngitis  shows  a  tendency  to  the  formation  of  polypiform 
vegetations,  which  are  met  with  throughout  the  whole  extent  of  the  larynx 
and  trachea.  In  tubercular  laryngitis,  on  the  contrary,  there  are  no  vege- 
tations, but  a  peculiar  appearance  resembling  a  polypus  is  produced  by 
puckering  of  the  edges  of  the  ulcerated  mucous  membrane. 

Cases  of  purely  nervous  aphonia,  it  is  important  to  remember,  are  some- 
times met  with  in  both  diatheses.  I  shall  have  forthwith  to  speak  of  this 
class  of  cases. 

Dr.  Krishaber  has  stated,  in  an  oral  communication,  that  there  is  most 
destruction  of  j>arts  in  simple,  that  is  to  say,  in  non-diathetic  ulceration  of 
the  larynx,  as,  for  example,  in  that  which  originates  in  chronic  laryngitis, 
or  occurs  as  the  sequel  of  a  severe  attack  of  fever.  When  speaking  to  you 
of  oedema  of  the  larynx,  I  stated  that  it  is  in  simple  chronic  laryngitis,  in 
the  ulcerous  laryngitis  consecutive  to  dothinenteria,  that,  nearly  always, 
necrosis  of  the  cartilages,  and  subsequent  symptoms  of  the  most  formidable 
character,  occur. 

Lesion  of  the  recurrent  nerves,  accidental  deformity  of  the  larynx,  the 
compression  of  that  organ  by  a  cervical  tumor,  or  abscess,  or  the  existence 
in  its  interior  of  vegetations,  fungous  growths,  and  polypi,  may  occasion 
aphonia ;  but  it  is  not  unusual  to  meet  with  it  when  there  is  no  serious 
anatomical  lesion  ;  and  in  such  cases,  the  affection  is  not  less  obstinate,  last- 
ing as  it  sometimes  does  for  years. 

The  method  of  treatment  of  which  I  wish  to  speak  to  you  to-day,  and 
which  is  not  applicable  to,  or  at  least  is  of  very  little  service  in  aphonia 
dependent  on  a  serious  affection  of  the  phonetic  apparatus,  is  exceedingly 
useful  when  the  aphonia  is  independent  of  serious  material  lesions,  and  still 
more  beneficial  in  those  cases  in  which  no  lesions  at  all  can  be  observed. 

There  are  two  species  of  aphonia,  distinguishable  from  one  another  by 
the  manner  in  which  the  symptoms  are  developed.  The  one  comes  on 
gradually:  from  time  to  time,  the  voice  is  observed  to  be  muffled,  soon  after 
which,  it  becomes  increasingly  hoarse.  The  tone  of  the  voice  is  very  deep 
when  the  patient  rises  in  the  morning,  and  in  the  evening,  it  is  much  more 
shrill.  At  this  stage,  it  is  only  by  making  great  efforts  that  clear  sounds 
can  be  produced  ;  subsequently,  there  arc  days,  when,  after  too  much  speak- 
ing, no  eflbrl  avails,  and  the  larynx  absolutely  refuses  to  produce  any  BOUnds. 
At  first,  (his  species  of  aphonia,  which    is  intermittent,  comes  on  chiefly  in 

the  evening:  it  afterwards  becomes  complete  and  continuous.    It  affects  both 

sexes;  but  men  are  mosl  subject  to  it.  It  is  chiefly  met  with  in  person- 
who  have   lo  cry  aloud,  to  sing  or  speak    in  a  high  pilch  in    the  open  air  or 

in  a  large  expanse.  Consequently,  singers,  advocates,  clergymen,  naval 
officers,  and  itinerant  hucksters  are  frequently  subjeel  to  serious  alterations 

in  the  tone  of  the  voice,  and  at  last   to  aphonia.      This  species  of  aphonia  is 

often  coincident  with  chronic  follicular  inflammation  of  the  pharynx  :  the 

probability  IS  that  the  inflammation  extend-  from  the  pharynx  to  the 
mUCOUS  membrane  of  the  larynx.      Though  in  such  cases,  the  lesion  may  be 

superficial,  it  has  not  less  the  power  to  alter  very  much  the  tone  of  the  voice; 
ami  as  it  generally  is  a  symptom  of  the  existence  of  the  herpetic  diathesis, 


aphonia:    cauterization  of  the  larynx.  511 

it  is  particularly  obstinate.  Nevertheless,  arsenical  fumigations,  followed, 
at  a  later  stage,  by  cauterizations  of  the  upper  part  of  the  larynx,  are 
generally  sufficient  to  bring  about  permanent  recovery. 

An  engineer  on  the  Spanish  railways  consulted  me  regarding  an  affec- 
tion of  this  kind.  He  did  not  derive  much  benefit  from  the  iodide  of  po- 
tassium; but  his  condition  rapidly  ameliorated  from  the  use  of  arsenical 
cigarettes,  made  according  to  a  formula  which  you  know,  and  which  is  as 
follows  : 

Take  of  Arseniate  of  Potash,  ...       1  gramme  [15  grains]. 

"  Distilled  Water,        .         .     15  grammes  [15  fl.  drachms]. 

Evaporate  this  solution  upon  a  sheet  of  white  paper  which  does  not  con- 
tain any  glue.     Having  dried  the  paper  make  it  into  twenty  cigarettes. 

Every  morning,  the  patient  ought  slowly  to  inhale  into  the  bronchi  from 
eight  to  ten  whiffs  of  the  smoke  of  one  of  these  cigarettes. 

Along  with  that  treatment,  I  applied,  every  second  day,  to  the  upper 
pant  of  the  larynx,  a  very  small  sponge,  fixed  to  the  end  of  a  piece  of  bent 
whalebone,  slightly  soaked  in  a  saturated  solution  of  sulphate  of  copper. 
From  time  to  time,  I  substitute  tincture  of  iodine  for  the  sulphate  of  copper. 
Eight  days  of  this  treatment  produced  a  remarkable  improvement  in  the 
state  of  the  patient.  By  the  end  of  the  month,  the  voice  was  quite  restored. 
I  then  directed  the  patient  to  have  recourse  to  the  cigarettes  on  eight  con- 
tinuous days,  once  a  month,  with  a  view  to  prevent  a  relapse. 

There  is  another  species  of  aphonia,  which  begins  abruptly,  and  without 
having  been  preceded  by  any  other  laryngeal  affection.  It  is  caused  by  a 
great  shock  to  the  nervous  system :  it  is  liable  to  occur  in  very  irritable 
subjects,  and  particularly  in  hysterical  women,  in  consequence  of  some 
violent  moral  emotion,  such  as  fear,  anger,  bad  news,  or  great  joy.  All  of 
you  know  the  classical  story  of  the  woman  who,  from  finding  her  husband 
in  the  very  act  of  adultery,  suddenly  lost  her  voice. 

Classical  authors  have  hitherto  taught  that  nervous  aphonia  is  solely  de- 
pendent on  lesion  of  the  recurrent  nerves.  Dr.  Krishaber  remarks  that  they 
seem  all  to  have  forgotten  that  the  superior  laryngeal  nerves  only  supply 
the  erico-thyroid  muscles — the  chief  phonetic  muscles.  These  muscles  render 
the  vocal  cords  tense  by  causing  the  thyroid  to  swing  upon  the  cricoid  car- 
tilage. They  impart  to  the  inferior  vocal  cords  the  oscillatory  movements 
observed,  by  the  aid  of  the  laryngoscope,  when  the  voice  is  normal. 

Aphonia,  therefore,  may  either  be  dependent  on  a  lesion  of  the  superior 
laryngeal  nerve  or  of  the  inferior  laryngeal  nerve,  or  on  a  simultaneous 
lesion  of  both  nerves. 

When  the  superior  laryngeal  nerve  only  is  affected,  the  aphonia  is  never 
complete:  the  patient  can  generally  articulate  the  deep  tones,  and  his  voice 
is  hoarse,  but  he  cannot  utter  the  higher  notes.  This  statement  is  both 
supported  and  explained  by  the  experiments  of  Charles  Bernard.  In  fact, 
the  section  of  the  superior  laryngeal  nerves  causes  the  voice  to  become 
hoarse,  but  does  not  produce  its  complete  extinction  :  the  hoarseness  de- 
pends on  paralysis  of  the  crico-thyroid  muscles,  and  an  inadequate  tension 
of  the  vocal  cords.  In  patients  thus  affected,  laryngoscopic  examination 
demonstrates  this  fact  in  the  most  unquestionable  manner.  Thus  it  is,  that 
although  we  can  see  the  vocal  cords  approach  and  separate  in  a  normal 
manner,  the  emission  of  sound  is  accomplished  with  difficulty.  One  is 
struck  with  the  absence  of  oscillation  of  the  vocal  cords,  which  is  indis- 
pensable to  the  production  of  normal  voice,  and  which  is  dependent  on  the 
action  of  the  crico-thyroid  muscles. 

When  the  inferior  laryngeal  nerve  is  affected  the  aphonia  is  complete  ; 


512     aphonia:  cauterization  of  the  larynx. 

and  the  experiments  of  Ch.  Bernard  have  shown  that  this  is  the  ease 
whether  the  affection  be  with  or  without  lesion.  By  the  aid  of  the  laryn- 
goscope, we  can  see  that  the  vocal  cords  are  motionless  and  far  apart ;  if 
there  be  any  movement,  it  is  very  slight,  and  connected  with  respiration.* 
The  following  is  a  case  of  nervous  aphonia,  due  to  lesion  or  functional  dis- 
turbance of  the  superior  laryngeal  nerve. 

A  young  woman,  aged  twenty-seven,  a  shoe  merchant,  presented  herself 
as  an  out-patient  in  the  consultation-room,  during  May,  1863.  She  com- 
plained of  an  alteration  in  her  voice,  which  was  very  hoarse  ;  and  when 
she  attempted  to  utter  the  higher  sounds,  she  suddenly  lost  her  voice  alto- 
gether. Dr.  Krishaber  examined  her  with  a  laryngoscope  in  the  presence 
of  myself  and  my  clinical  class.  He  found  that  the  appearance  of  the 
larynx  was  healthy.  The  formation  of  the  epiglottis  was  normal,  the  vocal 
cords  were  of  their  natural  whiteness  :  the  other  parts  of  the  larynx  were 
slightly  discolored,  but  with  this  exception  presented  no  lesion  of  any  kind. 
When  the  patient  emitted  sounds,  the  vocal  cords  were  distinctly  seen 
during  deep  inspiration,  normally  to  approach  or  retire  from  each  other, 
performing  their  functions  in  the  natural  physiological  manner.  It  was 
observed,  however,  that  during  the  emission  of  sounds,  the  vocal  cords  did 
not  oscillate  and  vibrate  upon  the  glottis,  in  so  distinctly  visible  a  manner 
as  when  the  organ  emits  natural  sounds.  The  patient  was  quite  unable  to 
utter  the  higher  sounds. 

This  patient  was  pale,  and  not  quite  regular  in  her  periods ;  but  she  had 
no  symptoms  of  hysteria  or  chlorosis.  Auscultation  revealed  nothing  ab- 
normal in  the  state  of  the  lungs:  the  heart  presented  no  morbid  sign,  except 
a  slight  clatter  of  the  valves.  All  the  functions  were  naturally  performed, 
and  hoarseness  was  the  only  symptom  of  which  the  patient  complained. 
She  positively  denied  having  ever  had  any  specific  diseases.  Examination 
of  the  external  and  internal  genital  organs  disclosed  no  trace  of  antecedent 
lesion,  except  a  perineal  cicatrix,  the  consequence  of  a  laceration  during 
labor. 

In  this  case,  I  adopted  the  treatment  which  for  so  long  a  period  I  have 
been  in  the  habit  of  employing.  By  means  of  a  sponge  attached  to  the 
end  of  a  piece  of  whalebone,  I  applied  a  solution  of  sulphate  of  copper 
around  the  laryngeal  opening.  Soon  after  this  cauterization,  the  voice 
returned. 

This  was  evidently  a  case  of  purely  nervous  aphonia  :  during  phonation, 
the  vocal  cords  perfectly  approached  each  other,  and  normally  retired  during 
respiration,  which  proved  that  there  was  neither  complete  nor  incomplete 
paralysis  of  the  inferior  laryngeal  nerve.  Although  there  was  no  oscilla- 
tory movements  of  the  vocal  cords,  or  if  any,  very  slight,  this  was  evidently 
the  result  of  diminished  tension  of  the  vocal  cords  :  there  was  an  absence 
of  the  degree  of  tension  indispensable  to  the  emission  of  normal  voice,  and 
particularly  to  the  articulation  of  the  higher  sounds.  It  appears,  therefore, 
that  in  the  case  now  under  consideration  there  existed  a  functional  change 
in  the  superior  laryngeal  nerve. 

I  ought  to  ;i<hl  thai  besides  aphonia  due  to  material  lesions  resulting 

from  syphilis  and  tuberculosis,  both  morbid  states  produce  a  purely  oervoUS 

aphonia. 

Pulmonary  phthisis,  for  example,  may,  in  it<  lasl  stage,  produce  nervous 
aphonia,  the  consequence  of  general  exhaustion  of  the  system.   The  aphonia 

*  Lagarde  (L.  Charles):  De  I'Aphonie  Nerveuse.  [Thhse  Inaugurate,  1866.] 
Thia  tbfj-is  was  suggested  by  the  researches  of  Dr.  Krishaber,  to  which  the  author 
constantly  appeals 


aphonia:   cauterization  of  the  larynx.  513 

then  shows  itself  with  characters  similar  to  that  which  is  met  with  at  the 
close  of  severe  attacks  of  disease  ;  and  there  is  an  extinction  of  voice,  just 
as  there  is  an  extinction  of  all  the  other  functions.  But  likewise,  and  with- 
out any  material  lesion,  as  is  shown  by  examination  with  the  laryngoscope, 
pulmonary  tuberculization  sometimes  produces  nervous  aphonia.  Dr.  La- 
garde  gives  an  example  of  this,  which  was  communicated  to  him  by  Dr. 
Krishaber.* 

In  a  phthisical  young  woman  who  had  had  aphonia  for  two  months,  the 
vestibule  of  the  glottis,  the  aryteno-epiglottidean  ligaments,  the  inferior 
vocal  cords,  and  the  margin  of  the  ventricles  of  Morgagni  were  perfectly 
healthy.  The  vocal  cords  could  approach  each  other,  and  yet  there  was  no 
voice.  There  was,  as  I  told  yon  is  the  case  when  paralysis  of  the  superior 
laryngeal  nerves  exists,  neither  vibration  nor  oscillation  of  the  vocal  cords. 
In  eight  days,  however,  the  patient  recovered  her  voice,  without  any  special 
treatment  having  been  adopted.  She  died  two  months  later  from  the 
progress  of  the  pulmonary  phthisis.  She  retained  her  voice  in  its  integrity 
to  the  very  last,  which  is  a  proof  that  her  aphonia  was  purely  nervous. 
The  laryngoscopic  examination  probably  had  some  beneficial  influence  in 
re-establishing  the  voice  in  this  case. 

Syphilis  also,  without  there  being  any  lesion,  may  cause  aphonia.  To 
this  variety  of  syphilitic  aphonia,  Diday  gives  the  name  of  secondary  aphon  ia, 
to  distinguish  it  from  that  which  is  met  with  in  inveterate  syphilis.f  This 
kind  of  aphonia  supervenes  between  the  third  and  sixth  month  from  the 
appearance  of  the  first  symptoms.  It  commences  without  pain  or  precur- 
sory symptoms.  There  is  at  first  less  fulness  of  voice,  and  the  alteration 
afterwards  proceeds  gradually  till  there  is  complete  aphonia.  Nevertheless, 
there  is  neither  cough,  dyspnoea,  nor  any  general  febrile  state.  Diday  has 
observed  these  symptoms  both  in  male  and  female  singers  affected  with 
syphilis.     In  such  cases,  fatigue  of  the  organ  is  probably  the  exciting  cause. 

Under  specific  treatment,  recovery  sometimes  takes  place  in  less  than 
eight  days.  Hence,  with  Diday,  we  may  ask,  whether  the  affection  is  not 
simply  a  nervous  disturbance  of  the  functions  of  the  larynx.  In  an  abso- 
lutely similar  case  observed  at  the  Hotel  Dieu  by  Dr.  Krishaber,  and  in 
which  the  voice  returned  at  the  end  of  eight  days  of  mercurial  treatment, 
there  was  no  lesion  discoverable  by  means  of  the  laryngoscope.  The  case, 
therefore,  was  one  of  syphilitic  nervous  aphonia. 

Nervous  aphonia  is  not  uncommon  in  women  suffering  from  disorder  of 
the  menstrual  function.  Such  a  case  you  had  an  opportunity  of  observing 
in  a  young  woman  who  occupied  bed  No.  31  of  St.  Bernard's  Ward — a  case 
the  history  of  which  I  shall  by  and  by  narrate. 

In  relation  to  the  subject  of  purely  nervous  aphonia  let  me  recall  to  your 
recollection  a  girl  of  eighteen  who  came  into  St.  Bernard's  Ward  in  Decem- 
ber, 1859.  Some  months  before  admission,  consequent  upon  a  great  fright, 
she  suddenly  lost  her  voice,  and  at  the  end  of  six  weeks  regained  it,  with- 
out having  had  any  treatment.  She  had  been  ill  for  fifteen  days,  when  she 
entered  the  hospital.  She  was  working  in  a  shop  in  the  basement  story,  on 
a  level  with  the  street,  when  all  at  once  a  cart,  with  tremendous  noise, 
smashed  in  the  shop-front.  The  girl,  struck  with  terror,  fainted,  and  had 
a  nervous  attack :  on  regaining  consciousness,  she  was  voiceless.  On  the 
day  after  hei>  admission,  in  presence  of  all  the  students,  I  cauterized  the 
lpper  part  of  the  larynx,  with  a  saturated  solution  of  the  sulphate  of  copper  : 
;he  voice  immediately  returned.  Next  morning,  however,  as  there  was 
1 '. 

*  Lagarde  :  Op.  cit.      f  Diday:  Gazette  Medicate  de  Lyon.     T.  xii,  p.  35. 
vol.  i.— 33 


514  APHONIA:     CAUTERIZATION    OF    THE    LARYNX. 

still  some  hoarseness,  I  repeated  the  cauterization,  and  the  result  was  a 
radical  cure. 

During  1862,  you  saw  three  young  women  enter  our  clinical  wards,  suffer- 
ing from  aphonia  ;  one  of  them  had  been  thus  affected  for  two  months.  In 
all  three,  cauterization,  practiced  in  your  presence  at  the  visit,  almost  com- 
pletely re-established  the  voice  within  a  few  minutes ;  and  after  four  or  five 
cauterizations,  the  functions  of  the  larynx  were  restored  to  a  perfectly 
satisfactory  state. 

In  June,  1863,  you  saw  a  girl  of  sixteen  occupying  bed  No.  16  of  St. 
Bernard's  Ward.  She  is  the  patient  to  whom  I  have  just  alluded  when 
speaking  of  the  relation  of  aphonia  to  disorder  of  the  menstrual  function. 
When  admitted,  she  had  menorrhagic  fever,  accompanied  by  very  acute 
uterine  pains.  Menstruation  was  easily  re-established,  but  aphonia  super- 
vened and  lasted  ten  days,  without  being  in  any  degree  modified  by  the 
different  therapeutic  measures  which  I  employed.  In  your  presence,  I 
cauterized  the  upper  part  of  the  larynx  with  a  saturated  solution  of  sulphate 
of  copper,  applied  by  means  of  a  sponge  attached  to  the  end  of  a  long  piece 
of  bent  whalebone.  The  voice  at  once  regained  somewhat  of  its  natural 
tone,  and  after  the  third  cauterization  was  quite  restored. 

In  this  case,  laryngoscopic  examination  did  not  disclose  the  existence  of 
any  local  lesion.  However,  in  some  cases,  though  the  vocal  cords  do  not 
in  their  whole  extent  approach  one  another  during  the  emission  of  high 
sounds,  there  is  apparently  paralysis  of  their  tensor  muscles  ;  and  in  that 
condition,  cauterization  would  seem  to  act  as  an  excitant  of  muscular  ac- 
tion. In  this  class  of  cases,  Dr.  Krishaber  has  sometimes  been  able  to  re- 
establish the  voice  by  the  introduction  of  the  laryngoscope,  as  if  a  merely 
mechanical  excitant  sufficed  to  induce  reflex  action. 

When  the  laryngoscope  discloses  signs  of  acute  inflammation  of  one  or 
both  vocal  cords,  or  still  more,  when  it  shows  that  there  is  ulceration, 
the  treatment  which  I  have  just  been  recommending,  though  efficacious,  is 
not  so  marvellously  powerful  as  you  have  often  seen  it  in  my  hands :  and 
frequently,  when  two  cases  have  been  seemingly  identical,  the  revelations 
of  the  laryngoscope  have  explained  why  the  result  was  not  so  satisfactory 
in  one  as*  in  the  other.  Gentlemen,  I  cannot  too  earnestly  recommend 
you  to  learn  how  to  use  the  laryngoscope.  But  I  must  now  return  to  my 
subject. 

It  sometimes  happens  that  individuals  suddenly  lose  their  voice  after 
taking  a  cold  bath,  or  after  passing  abruptly  from  one  temperature  to 
another.  Sudden  aphonia  may  also  show  itself  consecutively  to  the  sup- 
pression of  a  customary  sanguineous  flux  ;  and  one  of  the  most  common  of 
this  class  of  causes  is  suppression  of  the  menses. 

The  remarkable  sympathy  which  exists  between  the  genital  and  vocal 
organs  is  sometimes  exhibited  by  the  occurrence  of  aphonia  during  preg- 
nancy, after  delivery,  and  in  a  still  more  general  manner  in  the  course  of 
diseases  of  the  organs  of  generation,  especially  in  women,  though  the  same 
remark  is  to  a  certain  extent  applicable  to  the  male  sex,  li  is  in  these 
different  kinds  of  aphonia  that  cauterization  at  the  lower  part  of  the 
pharynx  and  upper  part  of  the  larynx  has  rendered  me  Buch  unquestion- 
able services,  after  the  total  failure  of  all  previous  treatment.  The  prepa- 
rations which  1  employ  are  a  saturated  solution  of  the  Bulphate  of  copper 

or  a  solution  of  nitrate  of  Bilver  in  the  proportion  of  one    part    of  the  sal 

to  five  of  water  (by  weighl  >.  The  apparatus  which  I  use  for  applying  th< 
solution  is  a  piece  of  whalebone  armed  with  a  Bponge,  such  as  all  of  yoi 
have  seen  me  employ  in  cauterizing  the  throat  in  diphtheria.  I  oeed not, 
therefore,  now  describe  this  little  apparatus  to  you,  which,  moreover,  as 


aphonia:  cauterization  of  the  larynx.  515 

you  all  know,  is  exceedingly  simple;  neither  is  it  necessary  for  me  to-day 
to  repeat  remarks  which  I  Formerly  made  on  the  harmlessness  of  the  ope- 
ration, seeing  that  it  is  now  an  operation  within  the  ordinary  domain  of 
medical  practice. 

The  efficacy  of  this  method  of  treatment  may  lead  one  to  think  that  in 
these  cases  of  aphonia,  the  mucous  membrane  of  the  larynx  was  the  seat 
of  slight  inflammatory  action,  even  though  evidences  of  no  such  inflam- 
mation could  be  shown  to  exist;  for  in  the  cases  which  I  have  observed, 
there  was  neither  pain,  swelling,  nor  difficulty  of  breathing.  But  the  bene- 
ficial effects  of  cauterization  of  the  upper  part  of  the  larynx  may  be  ex- 
plained by  supposing  that  it  produces  a  peculiar  modality  on  the  entire 
nervous  system,  and  in  particular  on  the  nerves  of  the  vocal  apparatus. 
It  causes  a  cessation  of  the  spasm  upon  which  the  aphonia  depends. 

However  it  may  be  explained,  this  sort  of  cauterization  is  still  more 
useful  in  some  cases  in  which  the  existence  of  inflammation  is  very  obvious, 
and  particularly  in  syphilitic  laryngitis,  in  which  there  is  no  ulceration. 
The  inflammation  is  characterized  by  pain  in  swallowing,  in  inhaling  cold 
air,  or  in  making  an  effort  to  speak. 

The  efficacy  of  the  treatment  I  am  now  recommending,  and  the  rapid 
manner  in  which  recovery  takes  place  under  it,  seem  to  occur  exactly  in 
proportion  to  the  superficiality  of  the  inflammation,  if  one  may  be  allowed 
to  employ  so  incorrect  an  expression.  In  aphonia  supervening  as  the 
sequel  of  a  moral  emotion,  or  as  the  result  of  abrupt  stoppage  of  the  menses, 
as  well  as  in  aphonia  occurring  during  pregnancy  or  after  delivery,  one  or 
two  cauterizations  generally  suffice :  and  you  have  witnessed  with  what 
rapidity  recovery  took  place  after  the  first  operation,  in  our  two  young 
women  of  St.  Bernard's  Ward. 

I  have  elsewhere  pointed  out  to  you  that  Mr.  Green  of  ISTew  York  not 
only  applies  the  caustic  to  the  entrance  of  the  larynx,  but  even  introduces 
into  the  cavity  of  the  organ  the  little  apparatus,  consisting  of  a  sponge 
attached  to  the  extremity  of  a  piece  of  whalebone  suitably  bent. 

As  for  myself,  I  often  employ,  for  the  same  purpose,  the  instrument  for 
applying  caustic  invented  by  Dr.  Loiseau,  which  I  described  when  lectur- 
ing on  the  topical  treatment  of  diphtheria  :  it  is  much  more  reliable  than 
Mr.  Green's  apparatus.*  Prior  to  the  discovery  of  the  laryngoscope,  be- 
fore the  numerous  useful  applications  of  this  instrument  to  the  diagnosis 
and  treatment  of  diseases  of  the  larynx,f  there  was  no  way  of  reaching 
beyond  the  vocal  cords  and  to  attain  even  so  far  was  attended  by  uncer- 
tainty and  many  difficulties.  Now,  however,  it  has  become  easy  to  see  the 
lesions,  and  by  practice  one  can  very  soon  acquire  the  art  of  introducing 
surgical  instruments  and  medicinal  appliances  into  the  larynx. 

Recovery  is  slower  in  the  cases  in  which  aphonia  comes  on  gradually  as 
a  consequence  of  compulsory  or  excessive  exercise  of  the  voice.  But  aphonia 
associated  with  palpable  inflammation  of  the  larynx  yields  still  more  slowly. 

One  remark  more  before  I  conclude !  It  might  be  supposed  a  priori, 
that  inasmuch  as  aphonia  can  be  easily  cured  by  cauterization,  it  would  be 
much  more  easy  to  cure  a  mere  alteration  of  the  voice  characterized  by  im- 
possibility of  producing  certain  sounds  :  but  experience  has  taught  us  that, 
on  the  contrary,  it  is  more  easy  and  more  satisfactory  to  treat  complete  than 
incomplete  aphonia. 

*  Loiseau:  Bulletin  del'Academielmperialede  Medecine,  t.  xxii,  p.  1138.  Paris, 
1857. 

f  Czeruak  :  Du  Laryngoscope  et  de  son  Emploi  en  Physiologie  et  en  Medecine. 
Paris,  1860. 


516  DILATATION    OF    THE    BRONCHI:     BRONCHORRH03 A. 


LECTUEE   XXVIII. 

DILATATION  OF  THE  BRONCHI  AND  BRONCHORRHCEA. 

Extreme  Difficulty  of  Diagnosis. — Dilatation  of  the  Bronchi  may  be  mistaken 
for  Pulmonary  Phthisis,  or  for  Pleurisy  with  Perforation,  of  the  Lung. — 
Differential  Diagnosis. — Important  Signification  of  abundant  and  Fetid 
Expectoration. —  Causes  of  the  Fetor. — Dilatation  of  the  Bronchi,  unless 
it  be  to  a  very  great  degree,  is  not  a  Serious  Affection. — Treatment  of 
Bronchorrhoza,  or  Pxdmonary  Blenorrhagia. — Balsams. — Arsenical  In- 
halation. 

Gentlemen  :  The  facts  observed  in  early  life  are  those  which  are  the 
most  permanently  engraven  on  the  memory :  and  very  often,  now  that  I  am 
approaching  old  age,  I  recollect  the  most  minute  circumstances  connected 
with  cases  of  which  I  took  down  notes  when  on  the  threshold  of  my  profes- 
sional career. 

In  1823,  when  I  was  still  an  hospital  pupil,  my  excellent  master  Bre- 
tonneau  had  under  his  care  a  Parisian  architect,  who  had  long  been  an  in- 
valid, and  had  been  recommended  to  go  to  the  Eaux-Bonnes  by  his  medical 
attendant.  At  that  period,  there  were  no  railways :  the  patient  conse- 
quently posted,  travelling  by  short  daily  journeys.  The  first  halt  was  at 
Orleans,  and  the  second  at  Tours.  On  arriving  at  Tours,  he  was  so  exceed- 
ingly fatigued  as  to  be  unable  to  proceed.  Under  these  circumstances,  he 
sent  for  Bretonneau. 

The  appearance  of  the  patient  seemed  to  tell  pretty  plainly  the  nature  of 
the  disease  under  which  he  was  laboring.  Frightful  emaciation,  a  yellow 
clayey  complexion,  continued  fever,  night  sweats,  and  very  copious  muco- 
puriform  expectoration,  were  the  symptoms  which  he  presented.  Breton- 
neau felt  almost  certain  that  the  disease  was  tubercular  phthisis.  Auscul- 
tation, however — then  a  recent  art,  which  Bretonneau  had  studied  with 
great  enthusiasm — did  not  furnish  the  signs  usually  met  witli  in  phthisical 
persons.  He  neither  found  a  dull  sound  on  percussing  the  upper  pari  of 
either  lung,  nor  did  he  hear,  as  he  expected,  gurgling  in  one  of  the  superior 
lobes.  The  patient  died  within  a  few  days  ;  and  at  the  autopsy,  made  with 
the  greatest  possible  care,  no  trace  of  tubercle  was  discovered:  Bretonneau 
recognized  chronic  inflammation  of  the  bronchial  mucous  membrane;  but 
he  did  not  examine  the  tubes  with  a  view  to  ascertain  whether  they  were 
dilated  in  some  places,  or  whether  they  were  throughout  of  normal  calibre. 
It  must  be  stated  that  in  those  days,  attention  had  not  as  yet  been  so  much 
directed  to  the  symptoms  of  dilatation  of  the  bronchi,  as  it  was  in  L825, 
when  Laennec  published  (he  second  edition  of  his  immortal  treatise  on  aus- 
cultation. 

Laennec's  description  of  dilatation  of  the  bronchi  is  complete,  although 
it  was  probably  tin-own  off  at  the  first  dash.  New  facts  have  been  added  by 
the  researches  of  Dr.  Barth ;  hut  he  confirms,  in  almosl  every  particular, 
the  previous  statements  of  the  illustrious  physician  of  the  Necker  Hospital. 

If  you  read  the  cases  narrated  by  Laennec — especially  his  fourth  case, 
to  which  beseems  to  attach  most  importance — you  will  become   convinced 


DILATATION    OF    THE    BRONCHI:     BRONCHORRH(E A.  517 

that  it  is  exceedingly  difficult  to  diagnose  between  phthisis  and  bronchial 
dilatation,  by  observing  that  the  illustrious  founder  of  the  art  of  ausculta- 
tion hesitated,  and,  up  to  the  autopsy  even,  remained  in  doubt :  then,  too, 
will  you  be  better  able  to  understand  how  Bretonneau's  diagnosis  was  at 
fault  in  the  case  which  I  have  just  related  to  you. 

The  first  case  in  the  excellent  monograph  of  Dr.  Barth  affords  testimony 
to  the  same  effect.  In  1835,  Drs.  Louis  and  Barth  saw  a  woman  die  in  their 
wards,  whom  both  supposed  to  have  had  tubercular  phthisis  in  the  third 
stage,  and  yet  at  the  autopsy,  it  was  seen,  that  the  tubercular  lesions  were 
quite  unimportant,  and  had  no  possible  relation  to  the  very  formidable 
symptoms  which  had  terminated  in  death  :  but  they  found  enormous  bron- 
chial dilatations.  Most  probably,  the  morbid  condition  of  the  Parisian 
architect  would  have  been  proved  to  have  been  similar,  had  the  attention 
of  Bretonneau  been  directed  to  the  subject  now  before  us  when  the  case 
came  under  his  notice. 

First  of  all,  then,  gentlemen,  it  appears  that  certain  attacks  of  bronchial 
catarrh  may  give  rise  to  all  the  symptoms  of  tubercular  phthisis :  and  I  am 
only  speaking  of  symptoms,  for  stethoscopic  signs  are  generally  absent,  at  least 
in  cases  in  which  the  bronchial  dilatations  are  not  confined,  as  is  sometimes 
observed,  to  the  summits,  or  in  others,  in  which  dilatations  exist  both  in  the 
upper  and  central  parts  of  the  lungs :  in  such  cases  diagnosis  is  nearly  im- 
possible. 

There  is  still  another  source  of  error,  which  has  to  be  added  to  those  I 
have  mentioned.  It  sometimes  happens  that  patients  during  the  course  of 
the  catarrhal  affection  are  seized  with  haemoptysis  :  and  in  place  of  quoting 
numerous  examples,  let  me  refer  to  Laennec's  well-known  case  (Case  4th), 
in  which  upon  tw7o  occasions  the  patient  had  spit  blood  within  six  weeks  of 
his  admission  to  the  Hopital  de  la  Charite,  and  to  the  seven  similar  cases 
which  constitute  the  basis  of  Dr.  Barth's  memoir.  A  perfectly  similar  case, 
which  has  recently  occurred  in  my  own  practice,  I  shall  immediately  bring 
under  your  notice. 

If  you  consider,  that  according  to  the  testimony  of  Dr.  Barth,  bronchial 
dilatation  exists  on  one  side  only  in  th,e  majority  of  cases,  that  it  as  fre- 
quently occupies  the  summit  as  the  base  of  the  lung,  and  that  the  disease, 
when  extensive,  is  very  often  accompanied  by  hectic  fever,  muco-purulent 
expectoration,  and  nearly  all  the  symptoms  of  consumption,  you  will  be  a 
little  more  indulgent  to  those  who  make  an  erroneous  diagnosis  in  such 
cases. 

It  is  true,  gentlemen,  that  errors  of  this  kind  are  not  of  very  great  im- 
portance ;  for  although  we  may  sometimes  be  able  to  intervene  usefully  in 
cases  of  bronchial  dilatation,  the  treatment  does  not  materially  differ  from 
that  usually  instituted  in  tubercular  phthisis.  In  fact  the  therapeutic  indi- 
cations are  the  same  ;  such  as  moderating,  as  far  as  is  practicable,  the  catar- 
rhal flux,  the  sweating,  and  the  fever,  sustaining  the  flagging  vital  powers, 
and,  in  a  word,  contending  against  the  conditions  more  immediately  dan- 
gerous to  life  which  arise,  leaving  alone,  as  of  secondary  importance,  the 
lesions  against  which  our  resources  are  impotent. 

Gentlemen,  the  remarks  now  made  are  not  offered  as  the  preamble  of  a 
bill  of  indemnity  which  I  ask  from  you  in  respect  of  the  young  woman  we 
have  just  lost  in  St.  Bernard's  Ward,  whose  case  was  one  of  the  most  re- 
markable examples  of  bronchial  dilatation  which  I  have  had  an  opportunity 
of  observing.  The  diagnosis,  established  with  precision  on  the  day  of  ad- 
mission, has  been  confirmed  at  the  autopsy.  I  will  admit,  however,  that 
sometimes  my  confidence  in  my  diagnosis  was  shaken ;  and  when  the  symp- 
toms of  a  hectic  condition  became  more  decided,  and  when  the  fetor  of  the 


518  DILATATION    OF    THE    BRONCHI:     BROXCHORRHCE  A. 

sputa  increased,  I  became  afraid  that  I  had  committed  a  mistake:  several 
times  I  hesitated  in  my  diagnosis  between  bronchial  dilatation  and  pleural 
effusion  communicating  with  the  bronchi  by  a  pulmonary  perforation ;  but 
I  reverted  to  my  original  opinion,  thus  giving  you  a  specimen  of  uncer- 
taintv  which  would  have  been  much  greater  had  the  principal  lesion  occu- 
pied the  apex  in  place  of  the  central  and  inferior  portion  of  the  lung.  I 
shall  now  give  you  a  summary  of  the  history  of  this  case. 

The  patient  was  a  woman  of  thirty  years  of  age,  little,  thin,  and  puny,  who, 
on  2d  June,  1863,  came  to  occupy  bed  No.  6  iu  St.  Bernard's  Ward.  She  had 
had  a  cough  from  her  earliest  infancy;  and  although  she  bad  never  had  an 
attack  of  asthma,  was  habitually  out  of  breath.  The  menstrual  function 
was  normal,  she  had  never  had  haemoptysis,  and  no  member  of  her  family 
had  had  tubercular  disease.  She  had  had  frequent  attacks  of  inflamma- 
tion of  the  chest,  accompanied  by  severe  stitches  in  the  side.  She  had  been 
confined  twenty-one  months  before  admission  to  hospital,  and,  till  within  a 
month,  had  nursed  her  infant.  From  that  time,  her  cough  increased  :  she 
had  had  constant  fever  for  a  fortnight,  but  till  then,  was  able  to  attend  to 
her  household  duties. 

This  woman,  as  I  have  said,  was  thin  :  she  had  curving  in  of  the  nails — 
Hippocratic  nails,  as  they  are  called — and  yet  her  countenance  was  not  that 
of  a  phthisical  subject. 

Percussion  below  the  spine  of  the  scapula  was  very  resonant :  and  the 
resonance  was  excessive  at  the  middle  and  posterior  part  of  the  right 
lung,  which  was  evidently  dilated  in  that  situation.  Over  the  middle  and 
inferior  part  of  the  left  lung  there  existed,  on  the  contrary,  flattening  of 
the  thoracic  walls,  and  well-marked  dulness.  No  vesicular  expansion,  no 
expiratory  murmur,  nor  blowing  sound  could  be  perceived  on  auscultating 
the  supra-spinal  and  infra-spinal  fossa?.  In  the  right  subclavicular  region, 
and  there  only,  the  expiratory  murmur  was  slightly  prolonged.  But  in 
the  middle  and  inferior  regions,  along  the  left  vertebral  hollow,  there  were 
heard  mucous  rales  combined  with  coarse  gurgling  and  mucous  blowing: 
the  voice  of  the  patient  was  bo  weak  as  not  to  be  in  the  slightest  d  g 
resonant  in  that  situation.  "Within  twenty-four  hours,  the  patient  filled 
two  or  three  spittoons  with  expectoration,  which  was  purulent,  semi- 
opaque,  semi-salivary,  somewhat  frothy,  and  of  a  sickly,  almost  fetid  odor. 
This  fluid  was  brought  up  by  an  effort  to  vomit  rather  than  by  expectora- 
tion, after  two  or  three  fits  of  cough  ;  and  at  each  time  two  or  three  Bpoon- 
i'uls  were  discharged. 

My  diagnosis  was — the  existence  of  chronic  bronchitis,  and  considerable 
bronchial  dilatation  at  the  middle  and  lower  part  of  the  left  lung,  and  the 
(il,sr„cf  of  tubercles.  I  prescribed  eight  turpentine  capsules,  and  fumiga- 
tions with  arsenical  paper. 

By  the  7th  June,  the  oppression  in  the  breathing  had  increased,  and  on 
that dav  the  fever  was  higher  than  on  the  previous  evening.  Very  exten- 
sive fine  subcrepitant  rales — the  rales  of  acute  bronchitis — were  beard. 
An  emetic  dose  of  ipecacuan  was  administered  with  the  effeel  of  produc- 
ing decided  relief. 

Five  dav.-  later,  remarkable  fetor  of  the  breath  was  perceived,  although 
there  was  "not  a  corresponding  fetor  oi*  the  sputa.  The  pulse  was  1-1.  and 
the  respiration  48  in  the  minute.  There  was  orthopnoea.  Over  the  right 
side  generally,  hue  mucous  rales  were  heard.  An  attack  of  acute  bron- 
chitis had  evidently  become  chronic. 

On  the  12th  dune,  at  the  evening  visit,  the  pulse  was  128:  the  respira- 
tion, which  was  verv  anxious,  remained  at  48:  the  skin  was  dry. and  burn- 
ing.   There  was  pain  on  both  Bides  of  the  chest    On  auscultation,  fine 


DILATATION    OF    THE    BRONCHI:     BRONCHORRIKE  A.  519 

mucous  rales  were  heard  posteriorly  throughout  the  whole  of  the  right  side: 
the  rales  were  nearly  crepitant,  and  dry  at  the  base.  On  the  left  side, 
down  to  the  middle  third  of  the  lung,  there  was  gurgling  along  with  blow- 
ing, and  a  somewhat  amphoric  sound  of  the  voice,  while  fine  mucous  rales 
were  audible  at  the  base.  Dry  cupping  with  eight  glasses,  and  an  ipecacuan 
emetic  afforded  remarkable  and  almost  immediate  relief. 

Next  morning,  the  fine  rales,  so  distinctly  heard  on  the  previous  even- 
ing, were  no  longer  audible.  There  were  no  longer  any  vibrating  rales. 
But  in  the  evening,  the  fine  mucous  rales  returned,  and  the  respiration  again 
became  anxious.  The  ipecacuan  was  repeated,  but  not  with  the  same  suc- 
cess as  on  the  former  occasion. 

On  the  15th,  there  was  no  increase  in  the  frequency  of  the  respirations, 
but  the  pulse  was  140,  at  which  it  afterwards  remained. 

On  the  17th,  rales,  almost  cavernous,  were  perceived  at  the  external 
angle  of  the  left  scapula  in  the  subspinal  fossa  :  some  of  them  almost  had  an 
imperfect  sound  of  metallic  tinkling.  No  change  had  taken  place  in  the 
patient's  general  state,  which  was  very  bad.  Slight  perspiration  was  visi- 
ble on  the  forehead  and  front  of  the  chest. 

On  the  19th,  there  was  slight  sweating.  The  countenance  was  greatly 
changed,  and  had  a  pale  bistre  color.  The  voice  was  plaintive  and  feeble, 
but  not  extinct.  The  sputa,  which  had  become  as  fetid  as  the  breath, 
surged  up  in  large  quantities,  filling  four  or  five  spittoons  daily. 

On  the  20th,  the  pulse  was  148 ;  and  the  respiration  only  44. 

On  the  22d,  the  face  changed,  the  features  becoming  expressionless,  the 
naso-labial  groove  deepening,  and  everything  announcing  that  the  end  was 
near. 

On  the  24th,  death  occurred. 

It  is  worthy  of  remark  that  this  woman,  who  in  the  Grecian  meaning 
of  the  term  was  phthisical,  had  never  had  the  aspect  of  a  person  affected 
with  tuberculosis,  arid  had  had  neither  colliquative  sweats  nor  colliquative 
diarrhoea.  TVe  have  just  seen  that  the  progressive  wasting  of  the  body  and 
death  necessarily  resulted  from  the  progressive  and  continuous  diminution 
of  the  sources  of  hamiatosis,  and  the  enormous  extent  of  the  daily  loss  by 
bronchial  suppuration.  It  may  be  asked  whether  pregnancy  and  prolonged 
lactation  did  not  produce  in  this  case  of  chronic  bronchitis  the  same  bane- 
ful influence  which  they  cause  in  phthisis. 

The  following  is  an  account  of  the  anatomical  lesions  met  with  in  this 
case.  The  lungs  were  voluminous  and  very  heavy ;  they  did  not  collapse 
when  the  chest  was  opened.  They  were  closely  bound,  particularly  on  the 
left  side,  where  the  pleura  had  nearly  disappeared,  to  the  parietal  pleura, 
by  very  numerous  adhesions.  Similar  adhesions  united  both  pleura  at  the 
part  corresponding  to  the  pericardium.  There  was  no  effusion  into  the 
pleural  cavities.  The  adhesions  were  evidently  the  remains  of  the  numer- 
ous attacks  of  pleurisy  described  by  the  patient  when  giving  the  historical 
details  of  her  malady.  The  right  lung,  emphysematous  throughout  nearly 
the  whole  of  its  extent,  was  solidified  in  many  places  to  such  an  extent  that, 
notwithstanding  the  emphysema  of  which  it  was  the  seat,  the  pulmonary 
tissue  presented  a  remarkable  consistence.  At  the  lateral  surface  of  the 
inferior  lobe  of  the  right  lung,  a  cavity  was  found  capable  of  holding  a 
small  hazel-nut;  its  walls  were  soft,  pultaceous,  of  a  yellowish-gray,  and 
yielded  a  gangrenous  odor. 

Perhaps  this  explains  why  the  breath  was  more  fetid  than  the  sputa. 
Around  the  excavation  there  was  no  tubercular  deposit,  but  the  surround- 
ing parenchyma,  which  presented  a  blackish-red  color  for  about  five  mil- 


520  DILATATION    OF    THE    BRONCHI:     BRONCHORRHCEA. 

linietres,  had  a  density  nearly  equal  to  that  of  hepatization.  Upon  one  of 
its  walls,  there  opened  the  orifice  of  a  small  dilated  bronchial  tube.  This 
small  cavity  was  evidently  not  of  tubercular  origin,  but  the  result  of  a  pro- 
cess simultaneously  inflammatory  and  gangrenous.  There  was  no  tuber- 
cular deposit  at  the  apex,  where  the  lung  was  exceedingly  emphysematous  ; 
it  was  slightly  vascular,  and  immediately  collapsed  when  cut  into,  as  is  the 
case  in  vesicular  emphysema.  When  an  incision  was  made  into  the  pul- 
monary tissue,  a  liquid  exuded  similar  to  that  which  the  patient  ejected 
during  life.  The  lower  portion  of  the  superior  lobe  presented  incipient 
hepatization.  The  second  and  third  divisions  of  the  bronchi  were  much 
dilated  ;  their  mucous  lining  was  injected,  and  of  a  somewhat  slaty  color. 

The  left  lung  had  a  solidified  appearance,  especially  its  posterior  aspect, 
which  was  red  and  marbled ;  on  moving  the  finger,  however,  over  the 
middle  part  of  the  surface  of  this  lung,  places  were  met  with  which  were 
very  easily  depressed,  and  were  really  caverns  corresponding  to  the  situ- 
ations in  which  gurgling  had  been  heard  during  life.  There  were  about 
twelve  of  these  cavities,  varying  in  capacity  from  the  size  of  an  almond  to 
that  of  a  walnut,  filled  with  a  whitish,  cheesy  substance,  apparently  con- 
crete pus.  The  membrane  lining  these  cavities,  so  far  from  having  the 
thickness  and  hardness  belonging  to  tubercular  cavities,  was  exceedingly 
thin.  There  opened  into  one  of  them  a  small  bronchial  tube,  which  was 
dilated  throughout  its  whole  extent.  The  pulmonary  tissue  intervening 
between  the  cavities  presented  the  appearance  of  mere  plates  of  conjunctival 
tissue,  bloodless,  almost  transparent,  and  seemingly  devoid  of  contractility. 
On  making  a  section  of  the  lung,  through  the  assemblage  of  cavities,  the 
appearance  presented  was  that  of  a  cut  sponge,  or  to  employ  a  still  better 
comparison,  of  the  lung  of  a  batrachian  reptile.  Some  of  the  cavities  com- 
municated with  each  other,  and  were  only  separated  by  small  imperfect 
partitions,  resembling  the  valves  of  veins  both  in  form  and  slightness. 

This  alteration  of  texture  has  been  specially  described  by  Laennec.  The 
presence  of  these  cavities  near  the  surface  of  the  middle  of  the  lung  ex- 
plained the  gurgling  heard  during  life,  on  auscultation;  and  the  large 
quantity  of  dense  cheesy  matter  which  they  contained  accounted  for  the 
dulness  on  percussion. 

Nearly  all  the  bronchial  tubes  were  dilated  ;  but  one,  of  the  second  order 
iu  respect  of  calibre,  going  to  the  inferior  lobe,  was  specially  remarkable, 
from  exhibiting  about  its  middle  an  ampullary  dilatation  in  diameter  equal 
to  that  of  the  great  bronchus:  in  the  situation  of  this  protuberance,  the 
mucous  membrane  had  a  violet-red  color.  Most  of  the  tubes  which  opened 
into  the  cavities  already  described  as  containing  semi-concrete  purulent 
matter  were  divisions  of  this  enlarged  tube. 

The  superior  lobe  of  this  lung  was  a  typical  illustration  of  vesicular  em- 
physema :  it  had  a  grayish-white  color,  gave  to  the  touch  the  sensation  com- 
municated by  a  down  pillow,  and  collapsed  when  cut.  Like  the  superior 
lobe  of  the  right  lung,  it  contained  no  tubercle.  At  the  lower  part  of  this 
lobe,  there  were  seven  or  eight  cavities  similar  to  those  so  numerous  at  the 
middle  and  lower  part  of  the  inferior  lobe  of  the  same  lung. 

The  bronchial  glands  were  very  Large  ;  when  cut,  they  showed  a  blackish- 
gray  appearance  ;  and  there  was  no  trace  of  tubercle. 

To  sum  up  the  description  :  there  was  vesicular  emphysema  of  the  upper 
part  of  both  Lungs;  bronchial  dilatation,  and  numerous  cavities  particularly 
in  the  middle  and  lower  portions  of  the  I  ( ■  1 1  Lung;  here  and  there,  hepatiza- 
tion ;  and  nowhere,  any  tubercle.      Such  were  tin'  structural  changes  in  the 

organs  of  bsematosis  in  this  patient,  who  scarcely  breathed,  except  with  the 

Upper  pails  of  her  lungs — and  these  parts  were  emphysematous! 


DILATATION    OF    THE    BRONCHI:     BRONCHORRHCti A.  521 

You  have  all  been  struck  with  the  extreme  fetor*  of  the  breath  in  this 
case,  which  was  almost  intolerable  when  the  patient  coughed,  and  constituted 
a  great  source  of  annoyance  to  those  who  occupied  adjoining  beds;  and  yet 
it  did  not  taint  the  expectoration.   The  sputa  were  diffluent,  rauco-puriform, 

and  exceedingly  copious,  the  quantity  brought  up  in  a  day  being  at  least  a 
litre  (rather  more  than  an  Imperial  British  quart) ;  but  their  sickly  and 
somewhat  nauseous  odor  fell  far  short  of  the  breath  in  disgusting  fetor. 

There  are  two  points  of  importance  to  consider  in  reference  to  the  expec- 
toration— its  great  quantity  and  its  fetor.  I  wish  to  discuss  with  you  the 
great  diagnostic  value  of  both. 

Extreme  fetor  of  the  breath  is  observed  in  gangrene  of  the  lung,  and 
occasionally  in  tubercular  phthisis,  but  in  phthisis  it  is  generally  tran- 
sient, seldom  lasting  more  than  three  or  four  days :  in  gangrene  of  the  lung 
it  certainly  continues  longer,  particularly  in  that  strange  kind  which  attacks 
many  lobules  in  succession ;  but  in  such  cases,  it  is  very  powerful  for  some 
days,  when  it  moderates  and  then  returns  as  it  was  before,  and  again  ceases 
to  be  powerful :  these  alternations,  without  the  aid  of  any  other  signs,  are 
quite  sufficient  to  guide  the  practitioner  to  a  correct  diagnosis.  There  is 
something  distinctive  in  the  odor  of  gangrene :  and  in  bronchorrhcea  con- 
nected with  dilated  tubes,  the  smell  is  quite  different,  being  suggestive  of 
the  presence  of  putrescent  animal  matter. 

I  am  aware  that  in  successive  lobular  gangrene  of  the  lung,  the  duration 
of  the  fetor  may  be  considerable ;  and  I  recollect  its  continuing  for  nearly 
three  months  in  a  lady  wTho  was  under  the  care  of  my  accomplished  friend 
Dr.  Lasegue  and  me.  But  in  bronchorrhoea  connected  with  bronchial  dila- 
tation the  offensive  smell  continues  for  a  very  much  longer  period. 

In  1848,  I  saw  in  the  Rue  St.  Honore,  Paris,  along  with  my  honorable 
friend  Dr.  Louis,  a  man  between  sixty-two  and  sixty-three  years  of  age,  who 
had  bronchial  catarrh  and  dilatation  of  the  bronchi.  At  the  time  when  Ave 
were  sent  for  to  this  patient,  he  had  been  seriously  ill  for  several  months, 
and  after  we  had  attended  him  for  two  months  without  his  being  benefited, 
he  sought  other  advice.  During  the  entire  course  of  the  disease,  the  smell 
of  the  breath  was  such  as  to  render  pestiferous  the  whole  of  his  suit  of  rooms ; 
and  even  the  staircase  leading  to  them  was  redolent  of  the  same  stench.  I 
did  not  know  what  had  become  of  the  patient,  I  believed  him  to  be  dead, 
when,  in  May,  1863,  that  is,  fifteen  years  later,  I  was  sent  for  to  see  one  of 
his  daughters,  from  whom  I  learned  that  he  was  still  alive,  and  still  had 
a  bronchial  cough,  which,  however,  except  obstinacy,  had  no  peculiar 
character. 

The  persistence  of  fetor,  when  there  is  nothing  else  to  lead  to  the  belief 
that  lobular  gangrene  of  the  lung  exists,  is  in  itself  an  important  diagnostic 
sign  of  dilatation  of  the  bronchi. 

Nevertheless,  gentlemen,  it  may  happen  that  for  several  months  the 
expectoration  is  copious  and  fetid,  although  there  is  only  a  simple  pul- 
monary catarrh  :  in  some  persons  a  common  bronchial  flux  leads  to  conse- 
quences similar  to  those  induced  by  certain  fluxes  connected  with  inflam- 
mation of  a  mucous  membrane.  It  was  the  other  day  only,  when  speaking 
to  you  of  ozsena,  that  I  mentioned  that  in  both  sexes  the  gonorrhoea!  dis- 
charge sometimes  assumes  an  extreme  degree  of  fetor,  and  also  the  flux  in 
acute  and  subacute  coryza,  in  circumstances  in  which  it  is  impossible  to 
assign  the  cause  of  this ;  and  moreover,  this  stench  is  not  always  met  with 
in  the  same  individuals  although  placed  under  apparently  identical  con- 
ditions. In  certain  epidemics  of  influenza,  or  under  the  influence  of  the 
herpetic  diathesis,  for  example,  the  bronchial  flux  in  some  persons  acquires 
an  extraordinary  stench,  which  will  continue  during  the  continuance  of  the 


522  DILATATION    OF    THE    BRONCHI:     BRONCHORRHCE  A. 

special  phlegmasia  on  which  the  flux  depends.  This  is  perhaps  the  very 
thing  which  occurred  in  the  patient  mentioned  to  you  in  whom  Dr.  Louis 
and  I  suspected  dilatation  of  the  bronchial  tubes,  and  who  fifteen  years  sub- 
sequent to  our  forming  this  diagnosis  was  enjoying  such  good  health  as  to 
lead  us  to  suppose  that  we  had  erred  in  diagnosis ;  for  it  rarely  occurs  that 
bronchial  dilatation  diminishes  as  age  increases. 

Gentlemen,  if  for  several  months,  the  expired  air  is  continuously  fetid, 
it  is  a  diagnostic  sign  of  great  value  in  bronchial  dilatation:  copious  expec- 
toration is  not  a  less  valuable  sign.  You  have  seen  how  much  importance 
I  attached  to  this  sign,  and  how  it  has  imparted  confidence  to  my  diagnosis. 
The  diffluence  and  extreme  copiousness  of  the  sputa  are  hardly  ever  found 
except  in  cases  of  pleural  vomica,  unless  we  have  to  do  with  bronchial 
dilatation.  Sometimes  in  the  case  before  us,  you  have  seen  me  hesitate, 
particularly  when,  during  the  patient's  efforts  to  cough,  the  gurgling  assumed 
the  sound  of  metallic  tinkling  :  nevertheless,  I  was  brought  back,  in  spite 
of  myself,  to  my  original  diagnosis  by  the  following  special  consideration. 
Undoubtedly,  when  a  collection  of  fluid  in  the  pleura  makes  a  way  for 
itself  into  the  bronchial  tubes,  a  diffluent  and  very  copious  expectoration 
supervenes :  but  in  such  a  case,  the  copiousness  is  sudden,  on  the  day  after 
its  occurrence,  it  decreases,  and  although  the  quantity  of  matter  brought 
up  continues  to  be  considerable  for  some  days,  after  the  lapse  of  that  time, 
the  copiousness  is  never  so  great  as  when  the  perforation  took  place,  unless 
indeed  there  be  hydro-pneumothorax,  in  which  case  enormous  quantities  of 
matter  may  for  weeks  continue  to  be  discharged. 

Here,  however,  gentlemen,  there  is  not  much  danger  of  confusion.  The 
signs  of  hydro-pneumothorax,  when  the  cavity  is  of  considerable  size,  are 
unmistakable  even  by  a  somewhat  careless  physician ;  and  when  the  mor- 
bid cavity  is  much  circumscribed,  the  quantity  of  the  flux  is  also  much 
limited.  You  will  recollect  that  when  I  was  hesitating  between  belief  in 
a  pleuro-pulmouic  perforation  and  a  dilatation  of  the  bronchi,  I  was  always 
brought  back  to  the  latter  view  by  the  fact  that  I  could  never  hear  metallic 
tinkling,  Hippocratic  gurgling,  nor  tympanitic  resonance  in  any  part  of  the 
chest. 

I  am  well  aware  that  a  sign  existed  which  greatly  shook  your  confidence; 
I  refer  to  the  presence  of  dulness  posteriorly  of  the  affected  side  of  the 
chest.  This  dulness  which  has  been  explained  to  you,  not  by  condensation 
of  the  lung  as  pointed  out  by  Laennec  fand  as  is  the  general  cause  of  dul- 
ness"), but  by  the  presence  of  an  enormous  quantity  of  semi-concrete  matter 
in  the  ampul  lary  cavities — this  dulness  I  say,  was  not  so  complete  in  our 
case,  and  indeed  never  is  so  complete,  as  in  pleurisy.  But  I  quite  under- 
stand that  it  may  lead  to  an  error  in  diagnosis,  that  it  may  lead  to  the  be- 
lief that  pleurisy  exists,  and  so  to  the  conclusion  that  there  is  a  communi- 
cation between  the  cavity  of  the  pleura  and  the  bronchial  tubes. 

Gentlemen,  I  have  no  intention  of  giving  you  in  this  lecture  a  complete 
account  of  dilatation  of  the  bronchial  tubes,  a  subject  which  you  will  find 
so  well  explained  by  Laennec,  and  by  the  later  researches  of  Dr.  Barth ; 
but  I  was  unwilling  to  allow  the  ease  which  has  been  engaging  our  atten- 
tion to-day  to  pass  without  pointing  out  all  its  clinical  importance,  and 
without  making  you  aware  oi'  the  magnitude  of  the  difficulties  with  which 
the  diagnosis  of  bronchial  dilatation  is  surrounded. 

The  lung  which   I  showed  you  on  the  anatomical  table  is  an  example  of 

bronchial  dilatation  in  its  extreme  degree ;  and  I  do  not  believe  that  any 
case  is  on  record  in  which  this  lesion  has  been  found  more  extensive.  (  'in- 
patient was  actually  disfigured,  SO  to  speak,  by  the  great  extent  of  the 
Structural  alterations;  and  you  would   form   a  very  erroneous   idea    of  the 


DILATATION    OF    THE    BRONCHI:     BRONCHORRHCH  A.  523 

affection  were  you  to  regard  the  lung  of  which  I  am  speaking,  as  a  typical 
specimen  of  bronchial  dilatation. 

Chronic  bronchitis  usually,  and  to  a  certain  extent  necessarily,  causes 
vesicular  emphysema.  The  vesicles  and  bronchial  tubes,  however,  give 
way  more  easily  in  some  subjects  than  in  others  :  in  the  majority  of  cases, 
the  vesicles  become  dilated,  and  the  intervesicular  tissue  becomes  con- 
densed :  the  dilatation  of  the  vesicles  may  proceed  to  such  a  degree  as  to 
cause  their  rupture,  whence  originate  the  large  vesicles  which  sometimes 
give  to  the  human  lung  the  appearance  of  the  lung  of  a  batrachian  reptile, 
as  was  seen  in  so  remarkable  a  degree  in  the  case  of  our  patient.  In  com- 
paring the  lungs  of  patients  presenting  a  very  great  degree  of  vesicular 
emphysema  with  lungs  which  are  quite  free  from  disease,  a  certain  amount 
of  attention  only  is  required  to  perceive  a  fact  which  at  a  first  glance  might 
escape  notice,  viz.,  that  besides  the  vesicular  expansion,  there  is  dilatation 
of  the  trachea  and  bronchial  tubes:  from  the  uniformity  of  the  dilatation, 
it  is  the  more  apt  to  escape  notice.  The  same  remark  is  applicable  to  vesic- 
ular dilatation,  when  it  is  everywhere  in  the  same  degree :  a  certain  amount 
of  attention  is  then  necessaiy  to  detect  it,  although  the  general  enlargement 
of  the  lung,  and  its  not  collapsing,  testify  to  the  existence  of  the  lesion. 
Bronchial  dilatation  may  be,  and  in  fact  ought  to  be,  regarded  as  an  em- 
physema of  the  bronchial  tubes.  In  most  cases,  it  is  equally  distributed, 
and  associated  with  vesicular  emphysema :  in  other  cases,  it  is  unequally 
distributed,  and  then  constitutes  the  affection  known  as  bronchial  dilatation, 
in  which  the  dilated  bronchi  bulge  out  either  into  moniliform  protuberances, 
having  exactly  the  appearance  of  a  string  of  beads,  or,  as  is  more  usual, 
expand  into  elongated,  fusiform,  or  ampullary  shapes,  as  in  the  case  now 
before  us.  Many  of  the  bronchial  cavities  may  communicate  with  one 
another,  so  as  to  give  the  lung  the  appearance  of  collections  of  united  ab- 
scesses, or  still  more  the  appearance  of  certain  multilocular  ovarian  cysts 
after  they  have  been  cut  open  and  had  their  fluid  contents  evacuated.  At 
the  same  time  it  can  be  seen,  that  the  pulmonary  tissue  between  the  large 
cavities  is  condensed,  a  condition  which  explains  the  frequency  of  dulness 
on  percussion,  a  common  sign  of  extreme  bronchial  dilatation. 

I  have  often  asked  myself  when  looking  at  this  induration  of  the  lung, 
and  at  the  evidences  of  chronic  pleurisy,  so  commonly  found  at  the  autopsy, 
whether  the  large  cavities  in  the  pulmonary  tissue  were  not  real  vomica? 
formed  by  the  softening  of  the  inflamed,  suppurating  lobules.  When  we 
come  to  study  the  lobular  pneumonia  of  children,  we  shall  see  that  it  is  very 
usual  in  that  disease  to  find  purulent  collections  of  the  size  of  a  millet-seed  or 
a  lentil,  or,  exceptionally,  as  large  as  a  small  cherry.  It  is  usual  to  admit 
in  these  cases — and  as  for  myself  I  give  my  formal  adhesion  to  the  doctrine 
— that  there  has  been  an  inflammatory  melting  down  of  a  union  of  lobules, 
and  the  opening  into  the  bronchial  tubes  of  the  little  abscesses  so  formed. 
It  is  believed  that  the  inflamed  pulmonary  lobule  passes  through  all  the 
degrees  of  hepatization  to  the  third  stage,  to  the  stage  of  purulent  soften- 
ing; and  it  is  asked  whether  something  analogous  may  not  take  place  in 
the  adult,  in  some  cases  of  bronchial  catarrh.  The  case  now  under  review 
seems  to  indicate  an  affirmative  answer  to  this  inquiry :  indeed,  in  some 
places,  the  lung  has  a  greenish-black  appearance,  and  is  evidently  sphace- 
lated. In  bronchial  dilatation,  therefore,  there  are  several  degrees:  there 
is  that  degree  in  which  the  air-tubes  are  dilated,  and  to  which  the  term 
bronchial  dilatation  is  properly  applied  ;  while  there  is  another  degree  in 
which  lobules  or  parts  of  lobules  are  destroyed  by  compression  or  by  the 
mere  inflammatory  process  itself,  which  may  produce  ampullary  cavities, 


524  DILATATION    OF    THE    BRONCHI:     BKONCHORRHCE  A. 

hardly  resembling  bronchial  dilatations,  it  is  true,  and  being  more  like 
purulent  cavities  than  dilatations. 

Whatever  there  may  be  in  this  opinion,  an  opinion  which  I  would  not  ven- 
ture to  maintain  positively,  and  which  rests  on  an  examination  of  the  path- 
ological anatomy  of  the  parts,  there  still  remains  one  peculiarity  in  this 
disease  which  I  wish  to  point  out  and  briefly  illustrate.  On  reading  the 
different  cases  which  have  been  published,  one  is  struck  with  the  apparent 
harmlessness  of  the  disease  until  it  has  nearly  reached  its  last  stage.  The 
young  woman  with  whose  autopsy  we  are  now  engaged  was  not  really  ill  till 
within  a  month  of  her  death,  for  up  to  that  period,  though  in  precarious 
health,  she  went  about  her  usual  occupations.  There  was  nothing  in  her 
condition  to  justify  the  belief  that  her  end  was  so  near.  The  aggravation 
of  the  symptoms  came  on  rather  suddenly,  as  also  occurred  in  many  of  the 
patients  whose  histories  have  been  related  by  Laennec  and  Barth.  The 
celebrated  subject  of  Laennec's  fourth  case  did  not  discontinue  work'  till 
within  a  few  days  of  admission  to  hospital.  Bronchial  dilatation  in  itself, 
then,  is  only  of  secondary  importance  in  respect  of  danger.  Indeed,  if  you 
reflect  upon  the  circumstance,  that  the  local  lesion  is  often  so  slight  as  to  be 
limited  to  only  one  bronchial  ramification,  and  extends  sometimes  only  to 
as  many  tubes  as  in  the  aggregate  do  not  constitute  the  hundredth  part  of 
the  respiratory  area,  you  will  admit  that  occasionally  it  must  be  very  diffi- 
cult during  life  to  detect  bronchial  dilatation,  particularly  when  there  is  a 
total  absence  of  general  symptoms. 

On  July  2d,  1863,  I  received  a  patient,  about  sixty  years  of  age,  in  my 
consulting-room.  He  came  to  consult  me  about  a  catarrh  accompanied  by 
oppression  of  breathing,  from  which  he  had  suffered  for  more  than  two  years. 
During  the  hour  which  he  had  to  wait  his  turn  for  consultation,  he  filled  a 
pocket  handkerchief  with  copious  diffluent  sputa.  He  stated  that  he  had 
often  had  slight  haemoptysis,  and  that  occasionally  the  expectoration  became 
very  fetid.  He  said  that  he  had  not  had  fever,  and  that  his  general  state  of 
health  was  not  bad.  I  suspected  that  there  was  bronchial  dilatation  ;  and 
on  examining  the  chest,  I  obtained  results  which  I  shall  now  state.  On 
the  right  side,  there  were  signs  of  vesicular  emphysema ;  on  the  left  side, 
the  lower  half  of  the  chest  was  to  some  extent  flattened,  and  there  was  much 
less  than  the  normal  amount  of  resonance.  On  auscultation,  I  heard  coarse 
gurgling,  with  suction-sound  and  vocal  resonance,  similar  to  that  which  is 
so  often  observed  at  the  summit  of  the  lung  in  tuberculous  subjects. 

,  The  point  in  this  case,  gentlemen,  to  which  I  wish  to  direct  your  atten- 
tion, is  the  following:  The  patient  walked,  followed  his  usual  occupations, 
and  had  no  fever:  although  he  had  considerable  bronchial  dilatation,  he 
did  not  suffer  much,  and  Ins  state  was  endurable,  though  he  always  had 
oppressed  breathing  and  copious  expectoration. 

When  the  dilatation  is  slight,  it  can  hardly  be  called  a  complication,  as 

it  does  not  increase  the  danger  of  the  br shitis:  hut  if  it  extend  in  an 

entire  Inn--,  and  still  more,  if  it  extend  to  both,  there  is  real  danger,  the 
causes  of  which  are  easily  understood.  First  of  nil,  the  patient  has  availa- 
ble for  the  requirements  of  hseinatosis,  only  three-fourths,  the  half,  or  two- 
fifths  of  the  pulmonary  parenchyma.  If,  under  such  circumstances,  an 
attack  of  bronchitis  or  pneumonia  supervene,  and  respiration  is  without 
an  apparatus,  the  patient  necessarily  dies.  On  the  other  band,  when  we 
observe  that  a  lune  is  in  a  very  advanced  Btate  of  bronchial  dilatation,  we 
have  reason  to  believe  thai  the  pulmonary  parenchyma  surrounding  the 
dilated  tuhes  is  the  seat  of  chronic  inflammation,  which,  under  the  influence 
of  even  slightly  irritating  causes,  will  become  subacute. 

There  is  -till  another  cause  of  danger  \\  Inch  I  cannot  pass  over  in  silence : 


DILATATION    OF    THE    BRONCHI:     BRONCHORRIIGBA.  525 

it  is  one  which  was  apparent  in  the  young  woman  whose  case  we  are  now 
considering.  You  saw  the  enormous  pouches  containing  accumulations  of 
semi-concrete  pus,  in  appearance  very  like  putty,  and  exhaling  a  frightful 
stench.  I  do  not  wish  to  affirm  positively  that  the  putrid  discharge  in 
contact  with  the  diseased  surfaces,  and  floating  in  the  bronchi,  carried  by 
successive  inspirations  into  the  air-passages  leading  to  healthy  portions  of 
the  lungs,  may  not  become  a  source  of  infection  to  the  whole  economy,  a 
source  all  the  more  prolific,  that  the  respiratory  surfaces  are  of  all  parts  of 
the  body  those  which  absorb  with  the  greatest  ease  and  rapidity,  as  is 
shown  by  the  phenomena  of  respiration,  by  the  sudden  overwhelming  effects 
produced  by  the  inhalation  of  ether,  chloroform,  and  some  deleterious 
gases. 

Upon  the  whole,  gentlemen,  dilatation  of  the  bronchial  tubes  is  only  a 
consequence,  and  one  of  the  forms,  of  chronic  bronchitis.  I  bring  it  promi- 
nently under  your  notice,  because  it  presents  symptoms  and  stethoscopic 
signs  which  deserve  a  little  special  attention. 

"When  bronchial  dilatation  has  attained  the  point  at  which  we  found  it 
in  our  patient,  there  is  generally  little  to  be  done,  and  all  our  attempts  are 
failures;  but  in  the  more  usual  form  of  the  affection,  the  symptoms  improve, 
and  even  disappear,  when  the  bronchitis  is  cured.  The  fever  ceases,  the 
flux  diminishes  daily,  and  nothing  remains  of  the  affection,  except  habitual 
expectoration  in  the  morning,  which  does  not  seem  to  affect  the  health. 

The  treatment  is  similar  to  that  which  is  employed  in  common  pul- 
monary catarrh.  In  the  acute  stage,  emetics  are  given:  if  there  be  high 
fever,  digitalis  is  useful:  when  the  oppression  is  urgent,  ammoniacum, 
powerful  remedies  of  the  family  Solaneee,  and  the  fumes  of  nitre,  are  indi- 
cated ;  sometimes,  Ave  must  rely  on  cutaneous  revulsive  measures,  such  as 
smearing  with  tincture  of  iodine,  the  use  of  carrot  poultices,  frictions  with 
croton  oil,  and  the  ajDplication  of  flying  blisters.  But  if,  as  often  happens, 
the  flux  is  excessive  in  quantity,  there  are  new  indications  for  treatment 
after  the  acute  stage  is  over:  they  pertain  to  the  bronchorrhcea  or  pulmonary 
blennorrhagia,  regarding  which  I  now  proceed  to  make  some  remarks. 

In  the  case  of  a  patient  occupying  bed  No.  13  of  St.  Bernard's  "Ward, 
you  heard  me  prescribe  a  potion  of  balsam  of  copaiba  for  chronic  bronchial 
catarrh  with  copious  mucous  secretion,  a  form  of  catarrh  which  I  have 
called  pulmonary  blennorrhagia.  I  must  state  my  reasons  for  thus  speaking 
and  acting. 

Without  at  all  instituting  a  forced  analogy,  we  may  say  that  catarrh  of 
the  air-passages,  at  least  when  accompanied  by  abundant  mucous  flux, 
admits  of  comparison  with  the  catarrhal  affections  of  the  genito-urinary 
organs  to  which  we  give  the  name  of  blennorrhagia.  Recollect  that  there 
are  different  kinds  of  blennorrhagia. 

There  is  one  kind  of  blennorrhagia  to  which  the  name  is  specially 
applied,  and  the  specific  character  of  which  no  one  will  dispute :  it  is  a 
contagious  venereal  catarrh  contracted  by  sexual  intercourse  with  a  person 
who  has  the  affection. 

But  independent  of  simple  venereal  blennorrhagia,  there  is  a  form  which 
is  symptomatic  of  chancre  in  the  urethra.  It  is  syphilitic,  and  is  a  distinct 
species  of  blennorrhagia. 

Along  with  these  two  species  of  blennorrhagia  there  is  another,  which 
supervenes  under  the  influence  of  connection  with  a  menstruous  woman,  or 
with  a  woman  who  has  leucorrhoea.  This  species  is  much  rarer  than  some 
medical  men  believe,  and  much  rarer  than  many  patients  allege. 

Ozanam,  Bias  of  Magdeburg,  and  other  trustworthy  authors,  have  de- 
scribed epidemics  of  blennorrhagia  occurring  under  certain  medical  con- 


526  DILATATION    OF    THE    BRONCHI:     BRONCHORRHCEA. 

ditions  of  the  atmosphere,  in  which  the  discharge  lasted  for  some  days,  and 
then,  as  a  general  rule,  ceased  spontaneously. 

Cases  of  rheumatic  blennorrhagia  are  likewise  recorded.  It  occurs  in  per- 
sons subject  to  arthritic  pains,  and  in  whom  their  sudden  cessation  has  beeu 
followed  by  the  appearance  of  a  urethral  discharge ;  or  the  reverse  may 
occur,  and  the  sudden  stoppage  of  the  urethral  discharge  may  be  followed 
by  a  return  of  the  arthritic  manifestations  of  rheumatism.  In  gout  this 
occurrence  is  still  more  common. 

Swediaur  recognized  herpetic  blennorrhagia :  it  is  a  species  which  per- 
haps is  allied  to  the  gouty.  It  is  common  in  women,  and  rather  rare  in 
men. 

The  influence  of  diathesis  upon  the  production,  form,  and  progress  of  blen- 
norrhagia is  a  subject  which  has  recently  been  taken  up  anew  and  ably  ar- 
gued by  my  pupil  aud  friend,  Dr.  Peter.  In  a  discussion  which  he  raised 
in  the  Medical  Society  of  the  Hospitals  of  Paris,  this  physician  maintained 
that  blennorrhagia  is  not  uni vocal ;  that  it  appeal's  and  recurs  most  readily 
in  persons  of  rheumatic,  gouty,  herpetic,  or  scrofulous  diathesis ;  that  in 
such  persons  it  takes  from  the  existing  diathesis  its  specific  characters,  aud 
consequently  that  along  with,  and  in  complement  to,  the  topical  treatment 
of  the  urethra,  recourse  must  be  had  to  the  remedies  which  have  been  found 
useful  in  the  cure  of  gout,  herpes,  aud  scrofula.  Dr.  Peter  is  far  from  sup- 
posing that  when  arthritis  or  ophthalmia  supervenes  during  the  course  of 
an  attack  of  blennorrhagia  we  have  to  do  with  blennorrhagic  rheumatism 
or  ophthalmia ;  and  he  considers  it  more  correct  to  say  that  there  is  rheu- 
matic blennorrhagia,  arthritis,  or  ophthalmia.  He  considers  that  the  arth- 
ritic diathesis  gives  rise  to  all  the  complications,  the  blennorrhagia  being 
only  the  exciting  cause.  The  blennorrhagia  itself  could  not  be  produced 
unless  the  diathesis  existed. 

To  this  doctrine,  which  is  essentially  medical,  I  give  my  adhesion.  It 
explains  the  failure  which  in  certain  cases  attends  the  treatment  blindly 
followed  by  specialists,  and  opens  up  therapeutic  plans  full  of  resources. 

Hunter  pointed  out  that  among  the  complications  which  follow  in  the 
train  of  difficult  dentition,  there  occurs  a  purulent  discharge  from  the  penis, 
accompanied  by  difficult  and  painful  micturition,  and  exactly  simulating 
a  violent  gonorrhoea. 

Some  fermented  dririks,  particularly  beer,  when  taken  in  too  great  quan- 
tity, are  causes  of  blennorrhagia ;  and  everybody  admits  the  distinction 
which  exists  between  this  species  of  urethral  catarrh  and  those  other  forms 
of  which  I  have  just  been  speaking. 

Finally,  let  me  remind  you  that  blennorrhagia  is  also  sometimes  the 
result  of  mechanical  irritation  of  the  penis,  masturbation,  or  venereal  excess, 
as  well  as  of  the  other  causes  which  I  have  mentioned.  And  to  the  same 
category  belongs  the  blennorrhagia  so  frequently  the  sequel  of  the  introduc- 
tion into  the  urethra,  or  the  prolonged  continuance  therein,  of  a  sound. 

In  applying  the  term  blennorrhagia  to muco-purulent  catarrhal  Becretions 
from  the  surface  of  mucous  membranes,  from  the  mucous  membrane  of  the 
eye  fin- example,  it  is  necessary  to  distinguish  different  species,  just  as  in 
blennorrhagia  from  the  genito-urinary  organs. 

A  child  in  coming  into  the  world  contracts  a  purulent  ophthalmia  from 
its  mother  who  is  the  subject  of  vaginal  blennorrhagia:  that  is  a  case  of 
venereal  ocular  blennorrhagia.     Another  infant,  born  during  the  prevalence 


*  Peter  (Michel) :  De  la  Blennorrhagie  dans  Bea  Etapporta  avec  lea  Diatbeaea 
Rhuinatiamale,  Goutteuae,  Scrofuleuse,  el  Berpe*tique.  raris,  1867.  Bee  also  1 1 1  *  - 
"  Union  Meclicale  "  for  November  and  December,  L866;  and  February,  ivi  7. 


DILATATION    OF    THE    BRONCHI:     BRONCIIORRHCEA.  527 

of  an  epidemic  of  puerperal  fever,  will  take  purulent  ophthalmia  of  puer- 
peral character:  that  is  a  ease  of  puerperal  ocular  blennorrhagia. 

There  is  a  third  species  of  ocular  blennorrhagia  which  is  very  different 
from  either  of  the  two  I  have  already  mentioned.  I  refer  to  the  catarrhal 
ophthalmia  vulgarly  called  " cocotte" — that  strange  epidemic  ophthalmia, 
equally  prevalent  among  adults  and  children,  which  is  characterized  by  a 
muco-purulent  discharge  from  the  palpebral  conjunctiva.  It  is  very  differ- 
ent from  the  ophthalmia  produced  by  simple  mechanical  irritation  of  the 
mucous  membrane  of  the  eye,  caused  by  the  presence  under  the  eyelids  of 
dust,  snuff,  or  any  other  foreign  body. 

Well,  then,  gentlemen,  catarrhal  affections  of  the  pulmonary  apparatus 
present  an  analogy  to  the  catarrhal  affections  of  other  mucous  membranes, 
to  this  extent,  that  in  both  we  find  different  species,  and  that  to  all  of 
them  the  term  blennorrhagia  is  equally  applicable. 

Attacks  of  pulmonary  blennorrhagia  may  arise  from  simple  irritation  of 
the  mucous  membrane,  such  as  those  which  supervene  under  the  influence 
of  the  inhalation  of  cold  air,  or  the  vapors  of  chlorine,  iodine,  and  arsenic. 
The  irritation,  after  having  in  the  first  instance  given  rise  to  a  slight  muco- 
purulent discharge,  produces  (when  it  becomes  more  intense)  a  copious 
blennorrhagic  flux,  which  may  be  compared  to  those  which  we  have  seen 
occur  in  the  urethra  and  the  eye — in  fact,  a  true  pulmonary  blennorrhagia. 

Pulmonary  blennorrhagia  arises  from  very  different  causes.  The  cause 
may  be  the  existence  of  that  special,  epidemic,  and  unquestionably  con- 
tagious disease  which  we  know  under  the  name  of  influenza  [c/rippe\  :  or 
it  may  be  measles,  which  as  you  know  is  very  often  accompanied  by  a  vio- 
lent catarrh  characterized  by  cough  and  expectoration,  the  sputa  often  being 
muco-puriform,  and  so  copious  as  to  resemble  the  catarrhal  affection  in 
phthisis :  or  again,  the  pulmonary  blennorrhagia  may  be  a  simple  catarrh. 

I  have  no  intention  of  giving  you  an  account  of  these  different  species  of 
catarrh.  The  similarity  which  I  have  established  between  them  and 
urethral  blennorrhagic  discharges  will  suffice  to  explain  the  treatment 
which  I  instituted  in  the  case  of  our  patient  in  St.  Bernard's  Ward. 

The  administration  of  balsamic  preparations  in  the  treatment  of  the 
catarrhal  affections  of  the  genito-urinary  organs  in  both  sexes  is  in  the  pres- 
ent day  vulgarized  to  such  an  extent,  that  not  only  is  it  followed  by  nearly 
all  practitioners,  but  it  is  even  resorted  to  without  medical  advice  by  the 
majority  of  persons  who  find  themselves  attacked  by  urethral  blennorrhagia, 
the  medicine  principally  employed  being  copaiba.  Although  this  drug  is 
not  an  infallible  remedy  in  these  cases,  the  frequency  with  which  it  proves 
really  efficacious  is  incontestable. 

A  patient  comes  to  consult  you  in  a  case  of  this  sort :  your  first  prescrip- 
tion embraces  the  use  either  of  this  medicine,  or  of  turpentine,  or  of  cubebs 
(which  has  properties  similar  to  those  of  copaiba);  while  at  the  same 
time,  you  order  some  stimulating  solution  to  be  injected.  Whatever  may 
be  the  nature  of  the  urethral  catarrh,  your  treatment  is  pretty  nearly  the 
same ;  and  cure,  though  it  may  be  more  or  less  delayed,  according  to  the 
species  of  the  disease,  is  always  the  final  result. 

How  does  it  happen,  then,  that  pulmonary  blennorrhagia  is  not  more 
.  frequently  treated  by  balsamic  preparations,  seeing  that  so  much  success 
attends  their  administration  in  urethral  blennorrhagia  ?  We  are  too  apt  to 
imagine  that  the  mucous  membrane  of  the  lungs  being  situated  more  in  the 
interior,  and  concealed  from  our  sight,  is  consequently  more  beyond  the 
reach  of  remedies.  There  is  nothing  in  this  idea;  and  when  we  have  failed 
to  act  upon  the  affection  with  our  remedies,  it  is  because  they  have  not 
been  properly  administered. 


528  DILATATION    OF    THE    BRONCHI:     BRONCHORRHCE A. 

Whatever  may  be  the  species  of  the  pulmonary  blennorrhagia,  whether 
it  depend  on  the  specific  catarrhal  disease  called*  influenza,  or  on  morbil- 
lous  catarrh,  herpetic  catarrh,  or  on  catarrh  of  some  other  species,  it  will 
derive  real  benefit  from  the  same  medicines  which  are  appropriate  for  the 
cure  of  urethral  blennorrhagia. 

It  is,  however,  perhaps,  in  cases  of  muco-purulent  bronchorrhoea,  cases 
in  which  it  is  not  unusual  to  see  the  expectoration  amount  to  several  pounds 
in  the  twenty-four  hours,  with  very  little  cough  and  no  symptoms  of  irrita- 
tion— such  cases  as  are  particularly  common  in  old  people — that  the  bal- 
samic remedies  (at  the  head  of  which  I  place  balsam  of  copaiba  and  essence 
of  turpentine)  are  most  specially  indicated.  More  than  once  I  have  met 
with  this  form  of  pulmonary  catarrh  closely  simulating  confirmed  phthisis  ; 
and  the  frecmency  of  this  occurrence  led  physicians  of  old  times  to  accord 
a  very  high  value  to  balsamic  remedies  in  the  treatment  of  phthisis.  It 
must  be  admitted,  that  in  spite  of  all  the  improvements  attained  in  our 
local  means  of  diagnosing  pulmonary  phthisis,  the  symptoms  of  bronchor- 
rhoeal  affections,  usually  accompanied  by  general  or  partial  dilatation  of  the 
bronchial  tubes,  often  mislead  us  still,  not  only  when  there  is  apparently  a 
frightful  amount  of  purulent  softening  progressing  in  the  lungs,  combined 
with  the  coexistence  of  nocturnal  sweats,  diarrhoea,  and  marasmus ;  but 
likewise,  as  I  stated  at  the  beginning  of  this  lecture,  in  consequence  of  the 
bronchial  dilatations  sometimes  furnishing  on  auscultation  several  of  the 
signs  looked  upon  as  pathognomonic  of  the  third  stage  of  phthisis.  It  is 
proper  to  add,  however,  that  in  chronic  catarrh,  these  signs  are  most  fre- 
cmently  observed  at  the  base  of  the  lungs,  whereas  they  are,  on  the  con- 
trary, most  commonly  found  at  the  upper  part  of  the  lungs  when  there  are 
tubercles. 

The  treatment  of  pulmonary  catarrh  by  balsamic  preparations  is  far  from 
being  a  novelty.  Dioscorides,  who  perhaps  only  repeated  a  fact  in  thera- 
peutics which  had  already  been  placed  on  record  by  Hippocrates,  said  that 
turpentine  and  the  other  resins  purged  the  lungs  of  morbid  matter.  With- 
out,  however,  going  so  far  back  in  the  history  of  medicine  as  the  time-  of 
Hippocrates,  you  know  that  Morton  lauded  the  balsams,  especially  the 
balsam  of  Tolu,  which  is  one  of  the  ingredients  of  his  famous  pills.* 

At  the  beginning  of  this  century,  physicians,  looking  to  the  effects  ob- 
tained from  the  balsam  of  copaiba  in  the  treatment  of  urethral  blennorrhagia, 
and  attaching  importance  to  the  analogy  which  I  have  now  pointed  out  be- 
tween catarrh  of  the  lungs  and  catarrh  of  the  genital  organs,  conceived  the 
idea  of  employing  it  in  pulmonary  catarrh.  Halle  has  mentioned  a  re- 
markable example  in  which  a  patient  suffering  from  chronic  pulmonary 
catarrh  with  copious  expectoration .  of  purulent  appearance  was  cured  by 
the  balsam  of  copaiba.  More  recently  the  American  journals  published 
wonderful  results  obtained  by  Drs.  Armstrong  and  Laroche  by  the  a»  '■;' 
similar  means  ;  while  af  the  same  time,  in  Frauce,  Dr.  A  visard  was  Bhowing 
the  efficacy  of  turpentine. 

Gentlemen,  you  arc  acquainted  with  tin-  manner  in  which  these  medi- 
cines— copaiba  and  turpentine — are  most  easily  administered.  To  mask 
their  disagreeable  taste,  tiny  ought  to  be  given  in  gelatinous  capsules  con- 
taining from    L5  to  20  drops.     Administered  in  this  way,  a  patienl   may 

take   from    nne   to   six    grammes   of  either  of  these   substance-   within    the 
twenty-four  hours. 
The  ingestion  of  the  medicines  being  accomplished  in  tins  manner,  they 


*  Morton:   Phthisiologia ;  cap.  vii  —  De  indicationibus  curativie  phthiseoB  origi- 

nalis. 


DILATATION    OF    THE    BRONCHI:     BR0NCH0RRHCE  A .  529 

are  absorbed,  their  active  principles  are  carried  into  the  circulation,  and 
exhaled  from  the  surface  of  the  pulmonary  mucous  membrane,  quite  as  well 
as  from  any  other  mucous  surface.     The  characteristic  odor  of  the  breath 

of  persons  taking  these  medicines  clearly  indicates  that  this  statement  is 
cmiect:  moreover,  the  same  odor  is  apparent  in  their  urine  and  faeces, 
showing  that  the  balsamic  substances  have  also  been  presented  to  the 
gemto-urinary  and  intestinal  emunctory  organs.  These  remedies,  then,  act 
upon  the  different  mucous  membranes  when  affected  with  catarrh  in  such  a 
way  as  to  modify  their  condition  and  determine  a  new  state — a  sort  of 
morbid  irritation — which  brings  to  an  end  the  pathological  state,  the  mor- 
bid irritation  of  winch  they  were  the  seat.  Here,  we  have  a  substitutive 
treatment,  similar  to  that  adopted  to  subdue  many  other  specific  and  re- 
fractory inflammations  which  we  can  cure  only  by  substituting,  by  means 
of  therapeutic  agents,  an  artificial  phlogosis  with  the  nature  and  conse- 
quences of  which  we  are  acquainted. 

I  have  still  a  word  to  say,  gentlemen,  in  continuation  of  my  comparison 
of  pulmonary  with  urethral  blennorrhagia.  When  the  latter  is  accompa- 
nied by  violent  inflammation  which  is  propagated  to  the  bulb,  when  there 
is  chordee  with  ardor  urinre,  the  balsams,  acting  more  energetically  than 
was  expected,  may  exasperate  the  irritation  of  the  affected  parts,  and  prove 
more  injurious  than  useful.  In  the  same  way,  when  in  bronchial  catarrh, 
the  inflammation  by  extending  to  the  pulmonary  parenchyma,  lights  up  a 
general  febrile  condition,  balsamic  medicines  are  contraindicated.  Before 
we  employ  them  in  such  cases,  we  must  allow  the  inflammatory  fever  to 
subside ;  otherwise,  we  shall  bring  on  complications  of  a  character  more 
serious  than  those  which  we  desire  to  subdue. 

Besides  the  treatment  which  I  have  now  been  recommending,  there  is 
another  method  which  you  have  seen  me  employ  concurrently  with  it  in 
bronchial  catarrh.  It  is  likewise  topical,  but  it  is  more  direct  in  its  action 
than  the  treatment  of  which  I  have  already  spoken.  I  refer  to  the  inhala- 
tion of  medical  substances,  which  bears  the  same  therapeutic  relation  to  pul- 
monary blennorrhagia  which  stimulating  injections  bear  to  blennorrhagia  of 
the  genito-urinary  organs.  These  medicinal  inhalations  admit  of  being 
very  much  varied,  both  in  respect  of  the  substances  employed  and  the 
manner  of  employing  them. 

The  simplest  mode  of  administration  consists  in  causing  the  patient  to 
inhale  air  impregnated  with  balsamic  vapors.  To  accomplish  this  object, 
you  place  in  the  patient's  room  vessels  containing  tar,  on  which,  morning 
and  evening,  you  pour  a  small  quantity  of  essential  oil  of  turpentine  mix- 
ing it  at  the  same  time  with  the  tar.  By  adopting  this  plan,  the  patient 
is  kept  constantly  in  a  balsamic  atmosphere ;  and  to  such  an  extent  does 
absorption  take  place,  that  the  urine  acquires  a  violet  odor.  Inhalers  have 
been  invented  to  contain  hot  water,  to  which  are  added  from  fifteen  to 
thirty  grammes  [about  from  15  to  30  fl.  drachms]  of  tincture  of  benjamin, 
and  a  little  turpentine.*  The  most  effectual  method  of  bringing  modifying 
medicaments  into  contact  with  the  bronchial  mucous  membrane  is  to  em- 
ploy the  spray-apparatus  invented  by  Dr.  Sales-Girons,  an  instrument 
which  you  see  in  constant  use  in  our  wards,  and  by  the  aid  of  which,  I  be- 
lieve great  service  may  be  rendered  in  different  affections  of  the  respiratory 
passages.  By  using  a  fumigator  or  spray-apparatus  you  may  obtain  good 
results  and  vary  your  remedies. 

Some  benefit  may  be  derived  from  mercurial  fumigation,  accomplished  by 
the  patient  inhaling  the  fumes  of  metallic  mercury  produced  by  throwing 


Gaujot  :  Arsenal  de  la  Chirurgie  Contemporaine.     Paris,  1867.     T.  i,  p.  121. 
vol.  i. — 34 


530  HEMOPTYSIS. 

mercury  on  a  hot  brick ;  but  this  proceeding  has  the  drawback  of  frequently 
causing  salivation. 

Finally,  gentlemen,  in  the  treatment  of  pulmonary  blennorrhagia,  great 
relief  is  obtained  by  smoking  cigarettes  of  arseniated  or  nitrated  paper. 
When  I  come  to  speak  of  asthma,  I  shall  give  you  the  formula  by  which 
to  prepare  them. 

The  different  methods  of  treatment  which  I  have  described,  will  enable 
you  beneficially  to  modify  the  character  of  certain  catarrhal  affections 
accompanied  by  muco-purulent  secretion,  which,  when  neglected  quickly 
become  chronic,  lead  to  dilatation  of  the  bronchial  tubes  and  vesicular 
emphysema,  ending  by  being,  if  not  diseases,  at  least  serious  infirmities. 


LECTURE  XXIX. 

HAEMOPTYSIS. 

Haemoptysis. — Supplementary  Haemoptysis. — The  Differential  Diagnosis  be- 
tween the  Hemoptysis  symptomatic  of  Pulmonary  Phthisis  and  the  Hem- 
optysis of  Hemorrhagic  Pneumonia  is  by  no  means  so  easy  as  some 
physicians  allege. 

Gentlemen  :  A  short  time  ago,  a  girl  of  thirteen  years  of  age,  who 
occupied  bed  32  of  St.  Bernard's  Ward,  died  suddenly,  death  being  the  con- 
sequence of  a  terrible  attack  of  haemoptysis,  which  occurred  under  circum- 
stances which  I  shall  now  relate. 

The  patient  was  admitted  to  the  clinical  wards  with  pneumonia  under- 
going resolution.  Convalescence,  however,  was  not  thoroughly  established. 
The  continuance  of  the  local  thoracic  signs  heard  on  auscultation  through- 
out a  great  extent  of  lung,  particularly  at  the  summit,  and  the  persistence 
of  the  general  symptoms  of  the  fever  of  tubercular  consumption,  clearly 
testified  that  there  was  very  far  advanced  phthisis.  The  disease,  however, 
did  not  appear  to  be  making  rapid  progress.  For  some  days,  the  child  bad 
been  in  better  spirits  than  she  had  shown  since  she  came  into  the  hospital, 
when,  one  evening  about  six  o'clock,  nearly  two  hours  after  her  evening 
meal,  she  was  seized  with  a  fit  of  coughing,  and  at  the  same  time  copious 
hemorrhage  supervened,  which  led  to  death  in  less  than  five  minutes.  The 
patient,  who  retained  consciousness  to  the  last,  stated  that  she  fell  herself 
to  be  dying.  The  blood,  which  issued  copiously  from  the  nose  as  well  as 
from  the  mouth,  was  cot  frothy,and  had  a  dark  red,  or  almost  black  color: 
when  it  had  coagulated  in  the  vessel,  it  was  black.  The  hemorrhage  had 
more  the  appearance  of  haematemesis  than  of  haemoptysis. 

From  the  suddenness  of  the  attack,  the  antecedents  of  the  patient,  and 
the  rarity  of  hemorrhage  from  the  stomach  at  so  early  an  age,  I  concluded 
thai  t  lie  bleeding  was  from  the  Lungs.  In  coming  to  this  conclusion,  I  was 
also  influenced  by  the  recollection  of  similar  cases,  and  in  particular  of  one 
which  occurred  in  the  previous  year  in  the  same  ward,  the  subjeel  of  which 
was  a  :_rirl  of  the  same  age,  and  who  likewise  was  suddenly  carried  off  by  a 

terrible  attack  of  ha-moptysis. 

At  the  autopsy,  Bome  mighl  at  firsl  have  supposed  that  I  was  wrong  in 
my  diagnosis,  and  that  the  young  girl  had  died  of  hemorrhage  from  the 

stomach.      In  point    of  fact,  the   stomach  WBS  distended  with  blood   similar 


HAEMOPTYSIS.  531 

in  appearance  to  that  which  had  been  ejected  during  life:  but  wo  could 
find  no  lesion  in  the  stomach.  It  soon  became  evident  that  the  hemorrhage 
was  bronchial.  The  lungs  were  riddled  with  softened  tubercles,  and  in  the 
upper  part  of  both,  there  were  extensive  cavities:  from  both,  when  cut  into, 
a  huge  quantity  of  blood  welled  out  by  the  ramifications  of  the  bronchial 
tubes.  No  ruptured  vessel  was  found  ;  and,  strange  to  say,  the  cavities  did 
not  contain  blood.  The  hemorrhage  was,  however,  not  the  less  indubitably 
of  pulmonary  origin  :  blood  was  found  in  the  stomach  simply  because  the 
hemorrhage,  being  very  great,  had  not  sufficient  way  of  exit  by  the  mouth 
and  nose,  and  the  blood  was  consequently  of  necessity  forced  down  the 
oesophagus. 

Gentlemen,  this  case,  and  others  which  I  have  seen  in  the  clinical  wards, 
have  made  me  desirous  of  entering  with  you  into  some  details  relative  to 
the  diagnostic  and  prognostic  value  of  hemoptysis.  The  first  idea  sug- 
gested by  seeing  a  patient  spit  blood  is,  that  he  has  tubercles  in  the  lungs. 
Without  thinking  of  bis  age,  or  the  special  circumstances  in  which  he  is 
placed,  Ave  are  apt  to  jump  to  the  conclusion  that  he  has  tubercles,  and  is 
the  subject  of  a  threatening  phthisis.  Nevertheless,  if  I  were  to  reckon  up 
all  the  cases  of  pulmonary  hemorrhage  which  I  have  met  with  in  hospital 
and  private  practice,  I  believe  that  I  should  find,  that  in  the  majority  of 
cases,  the  bleeding  did  not  depend  on  tubeixailosis.  However  paradoxical 
this  opinion  may  seem  to  some  physicians,  it  is  not  the  less  a  truthful  state- 
ment. 

There  is  a  certain  class  of  cases  of  haemoptysis  which  is  seldom  met  with 
in  hospitals — cases  in  which  the  haemoptysis  is  the  result  of  hemorrhagic 
deviation.  We  meet  Avith  Avomen,  subject  to  nervous  attacks,  avIio  spit 
blood,  sometimes  in  considerable  quantity,  though  they  do  not  experience 
any  marked  disorder  of  the  menstrual  function.  Attentive  examination 
of  the  thoracic  organs  reveals  no  lesion  of  the  respiratory  or  circulatory 
apparatus.  Neither  do  the  patients  present  any  symptoms  of  pulmonary 
or  cardiac  disease.  When  they  reach  the  change  of  life,  the  haemoptysis 
ceases,  never  to  return. 

There  are  also  some  women,  Avho  during  pregnancy,  and  others,  avIio 
during  the  whole  time  they  are  nursing,  spit  blood  :  the  hemorrhage  ceases 
spontaneously  after  delivery,  or  at  the  end  of  lactation,  as  the  case  may  be  ; 
and  is  not  symptomatic  of  pulmonary  tubercle  nor  of  cardiac  disease. 

You  have  had  an  opportunity  of  seeing  a  case  of  this  kind.  The  patient 
was  a  nursing  Avoman  Avho  came  into  our  wards,  after  having  had  attacks 
of  profuse  haemoptysis  at  about  the  tenth  month  of  an  engagement  as  Avet- 
nurse  at  Paris.  These  attacks  recurred  at  very  short  intervals  :  the  secre- 
tion of  milk  Avas  dried  up  :  the  patient  fell  into  an  anaemic  state  :  and  I 
could  not  get  rid  of  the  idea  of  tuberculosis,  although  auscultation  and 
percussion  revealed  no  positive  signs  of  such  an  affection.  This  Avoman 
left  the  hospital,  to  return  to  her  native  place.  Two  years  afterwards,  Dr. 
Blondeau  had  an  opportunity  of  seeing  her.  She  had  then  been  for  a  long 
time  in  good  health,  and  had  regained  a  plump  appearance,  as  Avell  as  a 
good  color  :  she  had  recently  given  birth  to  a  very  healthy  infant ;  and  Avas 
again  in  a  situation  as  wet-nurse. 

How  are  we  to  explain  these  cases  of  haemoptysis  ?  I  cannot  ansAver 
that  question  ;  but  I  haA^e  uoav  become  sufficiently  instructed  in  the  subject 
by  experience  to  be  less  alarmed  than  I  used  to  be  by  haemoptysis  super- 
vening in  the  circumstances  Ave  have  now  been  considering.  It  is  an  inter- 
esting fact  in  relation  to  this  class  of  patients,  that  they  are  generally  ner- 
vous, and  sometimes  also  subject  to  menorrhagia,  at  least  to  a  very  abun- 
dant menstrual  flow.    They  seem  to  be  under  the  influence  of  a  hemorrhagic 


532  HAEMOPTYSIS. 

diathesis,  and  when  the  normal  crisis  does  not  take  place  from  the  mucous 
membrane  of  the  uterus,  it  takes  place  from  the  mucous  membrane  of  the 
bronchial  tubes.  Although  these  bronchial  hemorrhages  are  not  such  for- 
midable occurrences  as  one  might  be  inclined  to  believe — although  they 
may  recur,  at  more  or  less  regular  intervals,  during  many  years  without 
occasioning  danger — it  must  not  be  forgotten  that  their  frequent  recurrence 
causes  congestion,  which  may  give  rise  to  inflammation  of  more  or  less 
dangerous  character,  and  provoke  diathetic  manifestations  which,  were  it 
not  for  the  exciting  cause,  would  not  probably  have  been  produced. 

When  commencing  practice,  I  used  to  be  frequently  called  to  a  lady  who 
had  suckled  four  children,  and  had  had  violent  attacks  of  haemoptysis  during 
the  lactations.  For  some  years  menstruation  had  been  exceedingly  profuse, 
-a  circumstance  which  made  me  uneasy  about  her.  A  long  period  elapsed 
before  I  could  make  out  anything  abnormal  in  the  state  of  the  uterus  ; 
nevertheless,  this  patient  died  of  uterine  cancer.  I  may  add,  that  she  was 
rheumatic,  and  subject  to  serious  nervous  symptoms. 

As  an  example  of  haemoptysis  coincident  with  a  kind  of  hemorrhagic  dia- 
thesis, I  shall  now  relate  a  case;  Among  my  old  friends,  there  is  a  lady, 
who  is  the  mother  of  an  eminent  physician.  During  childhood,  she  had 
had  fits  of  somnambulism ;  and  ever  afterwards,  she  was  subject  to  nervous 
symptoms  of  the  most  curious  description.  At  present,  she  still  experiences, 
upon  the  slightest  emotion,  partial  congestion  of  the  skin,  as  is  seen  by  its 
assuming  a  scarlet  color  lasting  some  minutes.  Up  to  the  time  when  the 
catamenia  ceased,  she  was  subject  to  menorrhagic  attacks,  which  were  often 
very  alarming.  When  about  thirty  years  of  age,  she  had  had  such  profuse 
haemoptysis  accompanied  by  so  great  an  amount  of  dyspnoea,  that  my  ac- 
complished friend,  Professor  Andral,  though  unable  to  detect  any  signs  of 
phthisis,  judged  it  right  to  send  her  to  the  Eaux-Bonnes.  This  lady  now 
has  emphysema  of  the  lungs.  Age  has  deadened  the  nervous  excitability, 
which  in  her  earlier  life  was  manifested  by  the  phenomena  which  I  have 
described,  and  although  her  health  is  far  from  being  so  good  as  could  be 
desired,  she  still  looks  fresh  and  plump.  Neither  she  nor  her  children  have 
any  symptoms  to  lead  to  the  belief  that  they  have  tubercles. 

Haemoptysis  besides  proceeding  from  the  peculiar  condition  or  diathesis 
of  pregnant  and  nursing  women,  may  be  to  a  certain  extent  a  physiological 
occurrence,  if  such  a  term  be  applicable  to  a  hemorrhage  taking  the  place 
of  a  natural  or  accidental  sanguineous  discharge,  which  from  some  cause 
or  other  has  been  prevented  from  finding  an  exit  by  the  usual  outlets. 
Thus  it  is,  that  in  women  in  whom  menstruation  is  irregular  or  suppressed, 
haemoptysis  is  one  of  the  most  common  forms  in  which  hemorrhage  occurs 
as  a  supplement  of  the  menstrual  flux. 

When  in  addition  to  the  now  described  peculiar  tendency  in  the  economy, 
there  is  a  local  predisposing  cause,  it  is  obvious  that  the  pulmonary  hemor- 
rhages will  occur  still  more  easily.  We  can  understand  that  such  will  be 
the  case  in  women  having  pulmonary  tubercles,  heteromorphous  products 
here  playing  the  pari  of  van  Belmont's  thorn,  and  occasioning  a  Btate  of 
congestion  of  which  bronchial  hemorrhage  is  the  consequence. 

We  have  Been  an  example  of  this  in  a  young  woman,  who  occupied  bed 
25  bis  of  St.  Bernard's  Ward.  This  patient  had  been  recently  delivered, 
when  she  came  into  the H6tel-Dieu.  she  then  was  nursing  an  infant,  very 
Boon  afterwards  carried  off  by  pull tary  phthisis,  of  which  the  mother  her- 
self presented  the  symptoms  and  thesigns.  She  had  frequent  cough, muco- 
puriform  expectoration,  fever,  eight-sweating,  dyspepsia,  and  considerable 

toss  of  flesh.  She  had  had  antecedent  Inemopl ysis.  The  physical  exami- 
nation of  the  chest  yielded,  on  percussion,  a  harsh  sound  at  the  right  apex, 


HEMOPTYSIS.  533 

both  before  and  behind :  on  auscultation,  there  was  heard,  in  the  same  re- 
gion, prolonged  expiration,  moist  crackling,  and  coarse  mucous  rales.  These 
phenomena  became  modified:  the  patient  regained  a  certain  amount  of 
plumpness,  and  her  strength  returned :  where  the  local  signs  had  been  so 
well  marked,  there  was  now  heard  only  feeble  respiration,  without  any  rales; 
the  only  remaining  symptom  was  dyspepsia,  indicated  by  a  feeling  of  weight 
at  the  stomach  after  meals.  This  dyspepsia  yielded  to  the  administration 
of  three  drops  of  hydrochloric  acid,  which  was  taken  daily  in  sugared  water 
immediately  after  breakfast.  I  was  hoping  for,  and  even  announcing,  a 
speedy  cure,  when  on  the  18th  May,  the  patient  was  seized  with  haemoptysis. 
She  ejected  blood  from  tbe  mouth,  which  came  up  as  if  by  vomiting :  in  the 
spittoon  one  could  distinguish  sanguineous  sputa,  frothy  sputa  of  vermilion 
red,  viscid,  dark  red,  and  black  sputa,  exactly  like  that  which  is  character- 
istic of  pulmonary  apoplexy.  For  four  or  five  days,  there  was  a  recurrence 
of  the  haemoptysis,  which  came  on  in  the  evening  or  during  the  night.  It 
yielded,  or  at  least  it  seemed  to  yield,  to  the  use  of  terebinthinate  draughts, 
decoction  of  rhatany,  and  eau  de  Rabel*  The  patient,  however,  exhausted. 
and  also  alarmed,  by  the  loss  of  blood,  again  fell  off  in  strength  and  plump- 
ness. Nevertheless,  she  was  beginning  to  recruit,  when,  after  the  lapse  of 
a  month,  on  the  18th  June,  there  was  a  recurrence  of  the  hemorrhage,  which 
returned  repeatedly  during  two  days.  Having  learned  on  this  occasion  that 
she  had  not  menstruated  since  her  accouchement,  it  occurred  to  me  that  the 
haemoptysis  was  periodical,  and  depended  upon  a  hemorrhagic  deviation. 
The  first  application  of  a  leech  to  the  inside  of  each  knee  prevented  the 
return  of  the  haemoptysis ;  but  the  sputa  continued  to  be  sanguinolent,  and 
in  color  were  like  the  lees  of  wine.  The  small  local  derivative  bleeding 
was  repeated  on  the  22d  and  24th  June,  after  which  latter  date,  there  was 
no  more  sanguinolent  spitting. 

You  have  observed  that  from  that  date,  I  watched  the  symptoms  of 
uterine  congestion.  Every  twenty  or  twenty-two  days,  this  woman  had 
slight  headache,  a  feeling  of  weight  in  the  lumbar  region,  pains  in  the  hyp- 
ogastrium,  and  a  more  frequent  desire  to  make  water.  You  then  saw  me 
apply  on  three  consecutive  days  a  single  leech  to  the  inside  of  one  of  the 
knees.  By  this  proceeding,  I  have  been  able  to  prevent  return  of  the 
haemoptysis,  and  have  seen  a  retrocession,  or  at  least  an  absence  of  aggra- 
vation, in  the  pulmonary  symptoms.  The  patient  left  the  hospital,  carry- 
ing Avith  her  the  cause  of  death  inevitable  and  probably  near  ;  but  she  left 
the  hospital  in  infinitely  better  health  than  that  in  which  she  entered  it. 

The  differential  diagnosis  in  this  case,  though  difficult,  on  accouut  of  the 
pathological  elements  being  so  commingled,  appears  to  have  been  justified 
by  the  mensual  periodicity  of  the  symptoms,  and  the  success  of  the  treat- 
ment employed. 

Professor  Andral  says  that  periodical  haemoptysis  in  women  having  tuber- 
culosis ought  not  to  be  regarded  as  a  supplementary  hemorrhage,  that  it  is 
associated  with  the  existence  of  tubercle,  and  that  its  return  no  doubt  de- 
pends on  a  more  acute  congestion  taking  place  each  month  in  the  lungs, 
around  the  tuberculous  masses."}" 

*  Eau  de  Eabel  is  a  mixture  of  sulphuric  acid  and  alcohol,  which  takes  its  name 
from  Eabel,  the  person  by  whom  its  virtues  were  first  extolled.  It  consists  of  one 
part  of  sulphuric  acid  to  three  of  alcohol.  The  acid  is  added  little  by  little  to  the 
alcohol  ;  and  after  eight  days  the  mixture  is  decanted.  It  is  given  internally  as  a 
stimulant,  tonic,  and  astringent,  in  doses  of  from  10  to  100  drops,  in  mucilage.  Pure, 
it  is  a  powerful  topical  styptic. — Translator. 

t  Axdrel  :  In  a  note  at  p.  307  of  the  1st  volume  of  Laexnec's  "  Traite  do 
T Auscultation  Mediate." 


534  HEMOPTYSIS. 

This  remark  of  Professor  Andral  does  not  appear  to  me  to  weaken  the 
view  which  I  have  taken ;  for  it  remains  to  be  asked,  whether  this  more 
acute  congestion  which  takes  place  each  month  ought  not  to  be  regarded  as 
an  accidental  physiological  action  set  up  by  the  presence  of  the  heteromor- 
phous  products  in  the  lungs,  which  play  the  part,  as  I  have  already  said, 
of  Van  Helmont's  thorn ;  but  which  is  dependent  likewise  on  peculiar  con- 
ditions which  escape  us,  and  under  the  influence  of  which,  irrespective  of 
any  tubercular  affection,  haemoptysis  is  produced,  as  a  supplement  to  men- 
struation in  women  whose  courses  are  irregular.  Cases  of  this  kind  are  not 
very  common,  but  they  do  unquestionably  sometimes  occur. 

Be  that  as  it  may,  one  can  see,  that  in  similar  circumstances,  the  prog- 
nosis of  haemoptysis  has  a  degree  of  seriousness  very  different  from  that  of 
which  I  spoke  when  considering  the  hemorrhagic  deviations  which  occur 
without  local  exciting  causes.  Here  indeed,  the  symptoms  are  complicated 
by  the  local  lesion  which  has  produced  them,  just  as  the  lesion  itself  is 
necessarily  complicated  by  the  existence  of  inflammatory  congestive  hemor- 
rhage which  at  each  return  must  accelerate  the  evolution  of  hemorrhage. 

Supplementary  hemorrhages  are  rare  in  hospital  practice ;  but  haemop- 
tysis symptomatic  of  tubercular  phthisis  is  not  perhaps  the  haemoptysis 
most  frequently  met  with  :  the  most  common  kind  is  that  dependent  on 
diseases  of  the  heart. 

This  remark  must  not  be  taken  to  imply  that  tubercular  haemoptysis  is 
absolutely  less  frequent  than  haemoptysis  arising  from  cardiac  disease.  I 
merely  mean  to  say  that  in  tubercular  subjects,  the  attacks  of  haemoptysis 
are  transient,  and  occur  at  the  beginning  of  phthisical  disease,  at  a  stage 
when  the  patients  do  not  come  into  hospital.  Haemoptysis,  on  the  con- 
trary, dependent  on  cardiac  lesion,  occurs  when  disease  is  far  advanced, 
and  consequently  at  a  time  when  the  sufferers  are  obliged  to  seek  relief 
in  hospitals. 

Let  us  pause  for  a  few  minutes,  to  see  if  we  can  place  upon  a  proper 
footing  the  differential  diagnosis  of  the  two  kinds  of  pulmonary  hemor- 
rhage of  which  I  have  been  speaking. 

During  youth,  adolescence,  and  the  first  epoch  of  mature  age — from  the 
age  of  16  to  40 — haemoptysis  is  generally  dependent  on  pulmonary  tuber- 
cles. When  met  with  during  these  periods  of  lite,  whether  in  hospital  or 
private  practice,  we  may  say  in  the  words  of  the  aphorism  of  Bippocrates 
"  ah  hcemoptoe  tabes."  But  after  forty,  and  still  more  after  fifty,  it  is,  as  a 
general  rule,  the  sign  of  disease  of  the  heart,  and  not  of  tubercular  phthisis: 
at  that  period  of  life,  even  when  the  sputa  have  not  that  sauguinolenl 
character  attributed  to  apoplectic  sputa,  when  they  arc  of  a  vermilion 
color,  frothy,  or  somewhat  fluid,  auscultation  will  disclose  the  .-inn-  of  car- 
diac lesion.  But  in  youth  and  mature  age,  though  the  sputa  present  the 
characteristics  supposed  to  belong  to  the  sputa  of  pulmonary  apoplexy, 
though  they  are  black,  viscid,  and  Un mingled  with  air  (as  is  not  at  all  un- 
usual and  as  sometimes  occurred  in  the  young  woman  with  phthisis,  whose 
history  I  have  just  related  i,  the  probability  is  thai  the  haemoptysis  is  symp- 
tomatic of  the  presence  of  tubercles,  and  that,  sooner  or  later,  auscultation 
of  the  chest  will  give  positive  confirmation  of  that  diagnosis. 

There  are,  of  course,  exceptions  to  these  rules.  Even  in  very  young 
-i  bjects,  haemoptysis  may  be  the  consequence  of  disease  of  the  heart,  just  as 
in  old  people  it  may  be  symptomatic  of  pulmonary  tuberculization.  These 
exception-,  however,  do  not  weaken  the  general  rule  which  1  have  stated. 

///  pulmonary  phthisis,  sanguinolenl  ex  pectoral  ion  supervenes  either  prior 

to   every  other    manifestation    of  the   disease,  Or  after   there   is   undoubted 

evidence  of  its  existence. 


HAEMOPTYSIS.  535 

Laennec  regarded  the  haemoptysis  of  pulmonary  phthisis  as  not  profuse, 
as  frothy,  and  as  sometimes  clotted,  particularly  towards  the  end  of  the 
attack.  According  to  him,  the  very  copious  haemoptysis,  in  popular  phrase- 
ology designated  "vomiting  of  blood,"  is  almost  always  due  to  pulmonary 
apoplexy.  Professor  Andral  is  opposed  to  this  view,  maintaining  that  the 
illustrious  inventor  of  mediate  auscultation  had  observed  far  fewer  patients 
in  his  private  than  in  his  hospital  practice,  where,  as  I  have  said,  tubercular 
haemoptysis  is  rarely  met  with.  No  doubt  the  quantity  of  blood  lost  in 
these  cases  is  generally  small,  but  there  are  terrible  cases  in  which  death 
is  caused  by  the  enormous  extent  of  the  hemorrhage.  I  have  seen  three 
cases  of  this  kind ;  and  the  subject  of  one  of  them  was  one  of  the  young- 
girls  to  whom  I  referred  at  the  commencement  of  this  lecture.  In  her,  the 
blood  was  frothy,  and  bright-red  [rutilanf]  when  its  flow  was  not  profuse ; 
black  and  clotted,  when  it  was  poured  into  the  bronchial  tubes  too  rapidly 
to  be  mixed  up  with  the  blood. 

In  diseases  of  the  heart,  the  consecutive  haemoptysis  is  still  less  violent 
than  bronchial  hemorrhage  of  tubercular  origin.  We  see  cardiac  cases  in 
which  the  bleeding  recurs  on  fifteen,  thirty,  or  even  fifty  consecutive  days, 
without  causing  death.  Of  course,  if  it  depend  on  the  rupture  of  an  aneur- 
ism into  the  bronchial  tubes,  it  proves  more  rapidly  mortal  than  phthisical 
haemoptysis. 

I  have  already  said  enough  to  show  you  that  the  age  of  the  subject,  and 
the  manner  in  which  the  symptoms  advance,  are  important  elements  in  the 
differential  diagnosis  which  I  am  now  endeavoring  to  establish  between  the 
two  different  kinds  of  haemoptysis.  It  is  a  noteworthy  point  in  relation  to 
the  seat  of  the  hemorrhage,  that  in  phthisis  the  blood  generally  comes  from 
the  bronchial  surface,  and  in  heart  affections  most  frequently  from  the 
parenchyma,  taking  place,  in  the  first  instance,  into  the  vesicles  of  the 
lungs. 

Let  us  now  study  the  distinctive  characters  of  bronchial  and  pulmonary 
hemorrhage ;  and  inquire  whether  their  distinctive  characteristics  are  as 
accurately  defined  as  some  maintain. 

Bronchial  hemorrhage,  it  is  said,  occurs  in  the  form  of  sanguinolent  sputa, 
frothy,  to  a  certain  extent  diffluent,  and  in  fact  presenting  the  appearance 
of  whipped  air  and  blood,  or  of  the  froth  produced  in  a  vessel  into  which 
an  animal  has  been  bled :  it  has  a  bright- red  hue  [tine  rutilance~],  which,  to 
a  certain  extent,  is  regarded  the  classical  sign  of  this  kind  of  haemoptysis. 
Again,  it  has  been  said  that  sometimes  the  blood  flows  profusely — an 
opinion  opposed  to  that  of  Laennec,  as  we  have  seen — and  at  other  times 
in  small  quantity ;  that  is  to  say,  that  sometimes  the  subjects  of  these 
accidents  will  for  several  days  expectorate  naatter  tinged  with  bright  blood, 
while  at  other  times  they  will  seem  to  vomit  a  quantity  of  blood  sufficiently 
large  to  abruptly  terminate  life.  Finally,  it  has  been  said  that  in  these 
hsemoptoic  expectorations  there  is  no  admixture  of  food  or  mucus. 

It  is  much  to  be  regretted  that  the  characters  are  not  always  so  well 
defined  as  now  represented  in  description.  Of  this  you  will  see  a  striking 
example  in  a  woman  occupying  bed  27,  St.  Bernard's  Ward.  She  is  a 
phthisical  subject,  without  any  lesion  of  the  heart,  and  has  haemoptysis 
constituted  of  ropy  sanguinolent  sputa,  such  as  are  seen  in  the  first  stage  of 
pneumonia,  or  in  pulmonary  apoplexy.  This  probably  arises  in  her  case 
and  similar  cases,  from  there  being,  in  addition  to  the  hemorrhagic  affec- 
tion, a  slight  inflammatory  action,  which  imparts  to  the  sputa  the  viscidity 
characteristic  of  peripneumonia.  Or,  it  may  arise  from  the  hemorrhage 
having  been  rather  abundant,  and  the  lung  being,  at  the  same  time,  suffi- 
ciently tolerant  of  the  presence  of  the  blood  to  allow  it  to  accumulate  and 


536  HAEMOPTYSIS. 

remain  for  a  certain  time  in  the  pulmonary  vesicles.  Under  these  circum- 
stances, should  no  new  hemorrhage  occur,  the  patieut  will,  after  a  few  days, 
bring  up  black  sputa,  and  they  will  sometimes  be  as  black  as  the  sputa  of 
pulmonary  apoplexy.  This  color  is  explained  by  the  sputa  not  having 
been  in  contact  with  air,  which,  when  it  mingles  with  the  blood,  renders  it 
red  and  frothy. 

In  cases  in  which  the  haemoptysis  is  unquestionably  connected  with 
tubercular  phthisis,  we  find  the  expectoration  mingled  with  portions  of  food, 
as  in  the  case  of  the  patient  whose  history  I  have  given  you.  In  that  case, 
the  spittoon  contained  sanguinolent  diffluent  sputa,  mixed  up  with  a  con- 
siderable quantity  of  vomited  food  and  mucus. 

The  stethoscopic  signs  of  bronchial  hemorrhage  are  often  at  fault.  Noth- 
ing more  perhaps  than  mucous  rales  will  be  detected  upon  the  most  careful 
auscultation  of  a  person  who  has  been  spitting  blood  for  a  long  period.  At 
other  times  we  may  hear  subcrepitant  or  moist  rales,  attributable  to  blood 
in  the  bronchial  tubes,  but  which,  as  they  are  also  heard,  when  there  is  no 
haemoptysis,  in  the  first  and  second  stages  of  tubercle,  are  not  of  diagnostic 
value.  To  be  of  real  diagnostic  value,  it  is  essential  that  the  rales  should 
not  have  been  heard  prior  to  the  occurrence  of  the  sanguinolent  expectora- 
tion, and  that  when  it  ceases  they  too  should  cease.  It  is  evident,  therefore, 
that  there  are  absolutely  no  stethoscopic  signs  of  haemoptysis.  The  stetho- 
scopic signs  which  may  belong  to  it  belong  equally,  and  indeed  perhaps 
more,  to  the  pulmonary  lesion  upon  which  it  depends. 

Generally  speaking,  upon  opening  the  bodies  of  persons  who  have  died 
after  having  had  attacks  of  bronchial  hemorrhage,  we  find  nothing  more 
than  the  morbid  appearances  of  phthisis,  and  a  redness  of  the  bronchial 
mucous  membrane,  due  probably  to  imbibition.  If  cavities  exist,  they  may 
contain  a  certain  quantity  of  coagulated  blood,  particularly  if  the  vascular 
ruptures  have  taken  place  in  large  cavities :  under  other  circumstances 
there  will  be  found  little  blood  accumulated  in  the  bronchial  tubes. 

Before  proceeding  to  the  comparative  examination  of  the  sputa  of  pul- 
monary hemorrhage,  I  have  a  word  to  say  regarding  this  affection,  with  a 
view  to  point  out  that  it  is  a  mistake,  in  my  opinion,  to  employ  pulmonary 
apoplexy  as  its  synonym. 

Pulmonary  hemorrhage  generally  supervenes  during  the  progress  of  heart 
disease.  On  making  the  autopsy  of  individuals  who  have  had  this  kind  of 
hemorrhage,  we  generally  find  small  portions  of  lung  which  are  centres  of 
congestion,  as  dark  in  color  as  the  spleen,  and  as  hard  as  pneumonic  nuclei 
in  their  second  stage.  The  lung  tears  under  the  fingers,  and  presents  the 
granular  appearance  of  hepatized  tissue,  with  this  difference,  as  Laennec 
remarked,  that  in  inflammatory  hepatization  the  vermilion  color  of  the 
inflamed  pulmonary  tissue  enables  us  to  distinguish  the  black  pulmonary 
spots,  the  vessels,  and  the  slight  partitions  of  cellular  tissue  which  separate 
the  lobules  of  the  lung:  hut  in  hsemoptoic  engorgement  the  indurated  part 
presents  a  perfectly  homogeneous  color,  almost  black,  or  very  deep  brown- 
red,  which  renders  it  impossible  to  recognize  in  the  pulmonary  texture  more 
than  the  bronchial  tubes,  and  the  Largesl  bloodvessels,  the  tunics  of  which 

have  lost  their  white  appearance  from  being  soaked  in  and  stained  with 
blood.      During     last     month    you    hail    an    opportunity    of    seeing     these 

anatomical  characters  at   the  autopsies  of  two  of  our  patients  who  died 

from  heart  disease.  In  these  cases  the  lesions  were  made  known  during 
life  by  the  signs  of  that  morbid  state  to  which  the  name  of  pulmonary  <i/»>- 
plexy  has  been  given,  an  objectionable  designation  tor  which  sanguineous 
infiltration  oughl  to  he  substituted.     The  affection  has  in  fact  no  characters 

in  common  with  cerebral  apoplexy  with  which  some  wish  to  compare  it  : 


II  .KMOPTYSIS.  537 

the  term  apoplexy  always  implies  the  idea  of  sudden  seizure  and  active  con- 
gestion, characters  belonging  much  more  to  bronchial  than  to  pulmonary 
hemorrhage,  which  latter  is  usually  more  or  less  passive.  It  is  true  that 
cases  have  been  recorded  of  true  pulmonary  apoplexy  occasioning  sudden 
death,  and  presenting  at  the  autopsy  more  or  less  extensive  effusion  of  blood 
into  the  middle  of  a  lacerated  lung,  presenting  very  nearly  the  same  appear- 
ance as  cerebral  tissue  into  which  there  has  been  violent  hemorrhage.  Apo- 
plexy is  a  term  which  would  be  much  more  applicable  to  active  congestion 
of  the  lung,  a  disease  which  is  not  very  uncommon,  but  which  is  very  sel- 
dom accompanied  by  sanguineous  effusion  which  can  be  properly  called  a 
hemorrhage.  Dr.  Gendrin*  has  substituted  for  pulmonary  apoplexy  the 
term  "  pneumo-hemorrhagie"  which  succinctly  expresses,  without  any  am- 
biguity, extravasation  of  blood  into  the  tissue  of  the  lungs.  Pie  rejects  the 
term  "apoplexy,"  because  the  invasion  of  the  disease  is  seldom  sudden,  and 
is  not  accompanied  by  rapidly  dangerous  symptoms  like  those  of  cerebral 
apoplectic  seizures — because  the  alterations  of  tissue  differ  in  many  respects 
from  the  alterations  of  tissue  produced  by  encephalic  hemorrhage — and 
because,  in  a  word,  it  does  not  embrace  all  the  forms  and  degrees  of  the 
pathological  state  in  question. 

To  return  to  the  subject  more  immediately  before  us,  let  me  ask :  What 
are  the  characters  of  haemoptysis  in  cases  of  sanguineous  pulmonary  infil- 
tration ? 

We  are  told  that  the  sputa  are  sanguinolent,  copious,  mixed  with  air  and 
viscid  like  the  sputa  of  peripneumonia,  excepting  that  they  are  not  frothy. 
This  description  may  be  considered  as  generally  applicable.  The  sputa  of 
parenchymatous  pulmonary  hemorrhage  certainly  are  viscid  and  aerated, 
but  have  sometimes  a  bright-red  color  [coloration  rutilante]  like  the  sputa 
of  the  patient  who  occupied  bed  17  of  St.  Agnes's  Ward,  who,  after  having 
had  attacks  of  pulmonary  hemorrhage,  sank  under  disease  of  the  heart : 
sometimes  they  are  blackish,  or  very  deep  red,  a  color  which,  as  I  have 
already  remarked,  is  met  with  in  certain  cases  of  tubercular  bronchial 
haemoptysis. 

The  sanguinolent  expectoration  of  parenchymatous  hemorrhage  may 
assume  the  appearance  of  bronchial  hemorrhage  in  so  far  as  to  become 
frothy,  a  character  dependent  upon  the  quantity  of  blood  wdiich  is  brought 
up.  Indeed,  in  contradiction  of  what  has  generally  been  said,  it  maybe 
stated,  that  if  the  blood  escape  in  small  quantity,  if  brought  up  after  having 
been  slowly  infiltrated  into  the  pulmonary  parenchyma,  it  is  not  frothy, 
because  it  is  not  mixed  with  air.  But  if  the  hemorrhage  take  place  sud- 
denly, if  the  blood  is  thrown  off  pretty  copiously,  if  it  flow  briskly  from  the 
bronchial  tubes,  it  will  be  whipped  up  with  the  air  therein  contained,  and 
in  this  way,  the  expectoration  will  become  frothy. 

In  the  man  of  whom  I  have  just  been  speaking,  the  haemoptysis  presented 
this  double  character.  There  was  some  bright-red  frothy  sputa  (exactly 
similar  to  the  luemoptoic  expectoration  seen  in  phthisis)  mixed  with  other 
sputa,  which  were  viscid  and  of  a  darker  color,  while  some  were  quite  black. 
We  shall  find,  on  making  the  autopsy  of  this  patient,  that  the  opinion 
formed  during  life  was  correct,  to  the  effect  that  his  lungs  are  without 
trace  of  tubercle. 

In  these  cases  of  pulmonary  hemorrhage,  from  the  stethoscopic  signs 
being  so  uncertain,  and  the  diagnostic  difficulties  so  great,  Professor  Bouil- 
lamf  ha*s  said,  that  the  nature  of  the  disease  has  to  be  divined  rather  than 
diagnosed. 

*  Gendrin  :  Traite  de  Medecine  Pratique,  t,  i,  p.  638. 


538  HEMOPTYSIS. 

Should  the  sanguineous  infiltration  have  been  extensive,  should  large 
hemorrhagic  nuclei  exist,  there  will  be  heard,  around  the  points  invaded 
by  the  hemorrhage,  local  signs  similar  to  those  of  pneumonia — a  blowing 
sound,  subcrepitant,  and  sometimes  crepitant  rales.  Should  the  nuclei  be 
circumscribed  and  disseminated,  in  place  of  being  somewhat  extensive,  the 
blowing  sound  will  be  absent,  and  the  rales  only  will  be  heard.  These 
rales  are  caused  by  the  exudation  of  blood  around  the  hemorrhagic  nuclei, 
and  into  the  neighboring  minute  divisions  of  the  bronchial  tubes.  Like 
the  mucous  rales,  they  are  produced  by  the  passage  of  air  through  a  liquid. 
These  signs,  which  be  it  observed  belong  equally  to  congestion  of  the  lung, 
to  engorgement,  or  to  catarrh  of  the  small  tubes,  may  be  entirely  absent : 
if  the  hemorrhagic  nuclei  are  not  only  small,  but  situated  at  a  distance 
from  the  surface  of  the  lung,  the  most  that  we  shall  be  able  to  hear  will  be" 
coarse  mucous  rales  in  the  large  tubes. 

Cardiac  lesions  are  very  frequent  causes  of  pulmonary  hemorrhage :  the 
cardiac  lesion  which  is  the  most  common  of  these  frequent  causes  is  con- 
traction with  inadequacy  of  the  mitral  valve.  The  hemorrhage  will  be  the 
more  apt  to  occur,  if,  along  with  the  lesion  of  the  auriculo- ventricular 
orifice,  there  is,  as  is  usually  the  case,  hypertrophy  of  the  ventricles. 

These  hemorrhages  are  in  some  cases  very  considerable,  and  recur  three, 
four,  six,  eio-ht,  or  ten  times  in  the  course  of  the  disease  of  the  heart :  in 
other  cases,  not  often,  however,  they  are  insignificant  in  quantity,  very 
transient,  or  altogether  absent.  When  the  cardiac  affection  is  far  advanced, 
the  patients  may  go  on  spitting  blood  for  a  month,  or  even  up  to  their 
death. 

I  was  lately  seeing,  at  the  Hotel  des  Princes,  an  American  gentleman  of 
sixty-five,  avIio,  consecutively  to  repeated  attacks  of  articular  rheumatism, 
became  the  subject  of  chronic  endocarditis,  with  contraction  of  the  auriculo- 
ventricular  opening,  and  insufficiency  of  the  mitral  valve.  He  had  had 
many  attacks  of  haemoptysis  which  did  not  continue  more  than  a  few  days. 
Six  weeks  before  his  death,  these  attacks  recommenced,  and  to  the  last, 
the  patient  brought  up  by  the  mouth  every  day  four  or  five  tablespoonfuls 
of  hlood.  In  this  patient,  at  first,  the  signs  furnished  by  auscultation  of 
the  lungs  were  negative:  afterwards,  we  heard  subcrepitant  rales,  and  a 
slight  blowing  sound.  These  signs  did  not  appear  till  near  the  close  of  life. 
The  blowing  sound  was  heard  throughout  the  whole  of  the  right  Lung. 

At  the  time  I  was  attending  the  American  gentleman,  I  was  seeing 
along  with  another  physician,  a  gentleman  of  sixty-four  years  of  age,  who 
had  formerly  come  to  me  in  my  consulting-room.  At  the  end  of  last 
autumn,  he  had  been  suddenly  seized,  after  a  hunting  party,  with  difficulty 
of  breathing  and  very  acute  pain  in  tiie  region  of  the  heart.  The  malady 
was  almost  overlooked  by  the  patient,  who  did  not  give  himself  much  con- 
cern about  it.  But  from  the  symptoms  becoming  more  severe  he  came  to 
consult  me.  I  had  no  difficulty  in  recognizing  the  existence  of  pericarditis, 
lor  the  effusion  into  the  pericardium  was  such,  that,  approximately,  it 
might    he  estimated    at    half  a    litre   [nearly   18  ll.  ounces],  due   allowance 

being  made  for  the  extenl  of  the  precordial  dulness  and  the  degree  of 

arcliin?-  of  the  chest,  a-  well  as  to  the  sounds  of  the  heart  being  inaudible 

from  their  great  distance  from  the   ear.      Under  the   influence   of  repeated 

bleedings,  flying  blisters,  and  the  use  of  preparations  of  foxglove,  the  peri- 
carditis disappeared.     Some  months  later,  1  could  aol  detect  the  leasl  sign 

of  that  af&Ction;    hut  along  with  the  first  and  second   sounds  of  the  heart, 

1  heard  over  the  apex,  a  harsh  blowing  sound,  which  told  me  that  there 

was  a   lesion    of  the   auriculo-vciit  ricular  valve.      For  some   days   al.-o   the 
patient   had    hainoptysis,  and   in  some   parts  of  the  chest    I   heard,  on  aus- 


HAEMOPTYSIS.  539 

cultation,  subcrepitant  rales  and  a  blowing  sound.  My  prognosis  was 
unfavorable.  After  some  deceitful  rallies,  this  individual  died  like  fche 
American  of  whom  I  have  been  speaking. 

It  is  usual  for  these  attacks  of  haemoptysis  to  become  more  frequent  and 
more  profuse,  as  the  disease  of  the  heart  advances. 

I  have  now  spoken  of  the  different  kinds  of  haemoptysis,  and  of  the 
difficulty  which  often  occurs  in  practice  of  distinguishing  the  one  from 
the  other ;  but  I  have  still  a  few  words  to  say  upon  the  differential  diag- 
nosis of  haemoptysis  and  haematemesis. 

Gentlemen,  I  do  not  think  that  this  differential  diagnosis  ought  ever  to 
be  very  embarrassing.  It  appears  to  me,  that  failing  the  precursory  symp- 
toms, usually  in  themselves  sufficient  to  inform  the  physician  whether  the 
blood  ejected  by  the  mouth  has  come  from  the  lungs  or  stomach,  there 
would  still  be  no  room  for  mistake,  as  the  manner  in  which  the  blood  is 
ejected  and  the  physical  characters  which  it  presents  are  distinctively 
characteristic.  It  is  said  that  haemoptysis  takes  place  after  efforts  to  cough  : 
the  blood  then  coming  from  the  lungs  is  at  the  time  of  its  expulsion  fluid, 
red,  and  frothy ;  on  the  other  hand,  in  haematemesis,  the  blood  ejected  by 
vomitive  efforts  is  often  set  in  coagulated  masses,  is  black,  and  non-aerated. 
Further,  it  is  almost  always  mixed  with  alimentary  substances.  Finally, 
this  vomiting  of  blood — the  haematemesis — is  frequently  followed  by  black 
stools,  to  which  we  give  the  name  of  rnelaena. 

While  it  is  quite  true  that  in  general  the  differential  diagnosis  of  haemop- 
tysis and  haernatemesis  offers  few  difficulties,  there  are  exceptional  cases 
in  which  hesitation  is  quite  allowable. 

There  may  be  something  in  the  physical  characters  of  the  blood,  and  in 
the  manner  in  which  it  is  injected,  to  oblige  us  to  hesitate  in  our  diagnosis. 
I  have  already  called  your  attention  to  the  fact,  that  the  blood  may  be 
black  in  haemoptysis  when  it  is  ejected  very  rapidly  and  with  force.  On 
the  other  hand,  persons  affected  with  haematemesis  may  bring  up  perfectly 
liquid,  bright-red  blood.  This  occurs  when,  owing  to  the  hemorrhage  from 
the  stomach  being  copious,  the  blood  does  not  remain  sufficiently  long  in 
the  stomach  to  be  acted  on  by  the  gastric  secretions. 

We  must  not  .attach  too  much  diagnostic  value  to  the  manner  in  which 
the  blood  is  expelled,  nor  to  the  presence  or  absence  of  alimentary  sub- 
stances, because,  as  I  have  already  said,  violent  haemoptysis  and  vomiting 
take  place  exactly  in  the  same  way,  without  any  preceding  efforts  to  cough. 
In  haemoptysis,  patients  frequently  eject  the  contents  of  the  stomach,  true 
vomiting  being  excited  by  the  efforts  to  expectorate,  or  by  the  titillation  of 
the  uvula  causing  sympathetic  contractions  of  the  stomach.  On  the  other 
hand,  in  haematemesis,  the  blood  may  be  poured  out  in  perfect  purity, 
unmixed  with  food,  bile,  or  mucus.  And  this  takes  place,  not  only  wheu 
the  gastrorrhagia  is  consecutive  to  the  rupture  and  perforation  of  a  blood- 
vessel, but  also,  even  when  it  is  symptomatic  of  an  organic  affection,  and 
not  dependent  on  any  appreciable  vascular  lesion. 

The  melaenotic  stools  do  not  in  themselves  absolutely  declare  that  the 
hemorrhage  is  from  the  stomach.  No  doubt,  in  haematemesis,  the  stools 
are  nearly  always  black,  but  then  they  may  also  be  black  when  the  blood 
is  primarily  from  the  lungs,  as  it  may  have  passed  down  the  oesophagus 
into  the  stomach ;  as  occurred  in  the  young  woman  of  St.  Bernard's  Ward, 
whose  case  I  mentioned  at  the  beginning  of  this  lecture. 

Again,  haemoptysis  supervenes  pretty  frequently  in  patients  who  have 
neither  tubercular  nor  cardiac  disease.  When  speaking  of  bronchial  dila- 
tation, I  dwelt  upon  the  fact  that  spitting  of  blood  often  takes  place  in 
cases  in  which,  at  the  autopsy,  no  tubercles  can  be  discovered.     Haemop- 


540  HEMOPTYSIS. 

tysis  also,  is  often  observed  in  connection  with  hydatids  of  the  lung.  We 
have  at  present  an  example  of  this  in  a  young  man  of  seventeen  years  of 
age  who  occupies  bed  9  of  St.  Agnes's  Ward. 

I  can  add  nothing  to  what  I  have  told  you  a  hundred  times  about  the 
treatment  of  pneumorrhagia  or  parenchymatous  hemorrhage  from  the 
lung.  When  it  is,  as  is  usual,  connected  with  disease  of  the  heart,  de- 
cided benefit  is  obtained  by  very  moderate  bleedings,  the  preparations  of 
digitalis  in  full  doses,  acids,  and  rhatany.  It  is  specially  necessary  to 
moderate  the  intensity  of  the  determination  of  blood  to  the  lungs,  which, 
when  it  forms  nuclei  near  the  surface  of  the  pleura  may  lead  to  inflamma- 
tion of  that  membrane,  and  become  the  cause  of  pleuritic  effusion,  consti- 
tuting a  formidable  complication  of  disease  of  the  heart.  You  saw  a  case 
of  this  kind  in  a  man  who  came  into  our  wards  in  June,  1863.* 

When  the  parenchymatous  hemorrhage  is  obstinately  recurrent  ipe- 
cacuanha is  a  remedy  which  seldom  fails.  I  am  not  at  present  referring  to 
ipecacuanha  administered  as  an  emetic,  which  is  more  to  be  relied  on  in 
the  treatment  of  what  is  called  bronchial  hemorrhage. 

You  remember  an  old  man,  aged  sixty-two,  who  lay  in  bed  7,  St.  Agnes's 
Ward.  He  was  resident  in  the  hospital  from  the  beginning  of  1863  ;  and 
during  the  preceding  year,  he  had  asked  my  advice  on  account  of  his  having 
serious  symptoms  of  tubercular  disease.  For  several  years,  he  had  been 
phthisical ;  and  from  time  to  time,  the  upper  lobe  of  the  right  lung,  in  which 
there  were  large  cavities,  became  the  seat  of  acute  inflammation,  by  which 
life  was  placed  in  jeopardy.  Twice,  within  the  space  of  five  months,  he  had 
frightful  haemoptysis:  twice  it  was  immediately  arrested  by  four  grammes 
[rather  more  than  a  drachm]  of  powder  of  ipecacuhan,  administered  within 
the  space  of  half  an  hour,  in  such  a  way  as  to  cause  violent  vomiting.  A 
similar  result  was  obtained,  you  remember,  in  the  young  man  who  occupied 
bed  8  in  the  same  ward  ;  and  also  in  another  patient  now  occupying  bed  16. 

Some  months  ago  I  was  summoned  in  consultation  to  a  provincial  town, 
in  the  case  of  a  tuberculous  man,  aged  forty-two,  who  had  had  haemoptysis 
going  on  for  forty  days.  A  great  diversity  of  very  rational  plans  of  treat- 
ment had,  in  succession,  been  fruitlessly  employed.  I  recommended  three 
grammes  [46  grains]  of  ipecacuhan  to  be  divided  into  four  packets,  one  of 
which  was  to  be  given  every  ten  minutes.  The  haemoptysis  had  ceased 
before  the  last  vomiting  took  place;  and  from  that  time, when  it  did  recur, 
it  was  only  to  an  insignificant  extent. 

Should,  however,  there  be  a  relapse  of  the  haemoptysis,  the  use  of  the 
ipecacuhan  must  be  resumed.  I  never  hesitate  in  such  circumstances  to 
return  to  it  two  or  three  times,  if  necessary,  and  I  have  never  yet  seen  the 
leas!  inconvenience  result  from  this  proceeding.  Gentlemen,  this  is  not  a 
new  method  of  treatment.  For  the  last  two  centuries,  physicians  have 
lauded  the  Brazilian  root  as  a  remedy  in  all  forms  of  hemorrhage ;  and 
Baglivi  says:  "  lindix  ipmiciiini/ur  tsl  s/ >i cificumet quasi  infalRbile remedium 
in  fluxibus  tli/si intends,  aliisque  hcemorrhagiis." 

Nevertheless,  gentlemen,  the  hand  trembles  when  it  administers  this  rem- 
edy for  the  first  time  in  the  treatment  <A'  haemoptysis.  We  arc  accustomed 
to  prescribe  the  greatest  possible  quietude  to  our  hsemoptoic  patients :  we 
counsel  them  to  keep  absolute  silence :  we  tell  them  to  restrain  the  slightest 
effort  to  cough :  the  very  most  we  allow  them  to  do  is  to  breathe,  and  so 
frightened  are  we  for  congestion,  even  passive  congestion  of  the  lung,  that 

'  111-1 

we  act  as  [f  we  placed  them  in  peril  by  permitting  them  to  make  the  slightest 


*  This  case  will  be  found  Fully  detailed  in  the  lecture  on  paracentesis  of  the  chest, 

Lecture   X  X  X  II. 


PULMONARY    PHTHISIS.  541 

effort.   Yet  here  we  are  giving  ;i  medicine  which  produces  vomiting, during 

which  the  lace  swells,  the  blood  stagnates  in  the  veins  by  which  it  is  being 

conveyed  to  the  auricles:  and  consequently,  the  pulmonary  veins  become 
distended.  One  might  expect  that  such  treatment  would  cause  the  haem- 
optysis to  return  in  a  much  more  profuse  degree;  but  in  place  of  this,  it  is 
stopped  in  nearly  every  case.  Here  is  one  proof  more  of  the  small  reliance 
to  be  placed  on  theoretical  explanations,  and  of  the  value  of  empirical  facts, 
without  which,  indeed,  therapeutics  would  be  a  nullity. 


LECTUKE  XXX. 

PULMONARY  PHTHISIS. 

Eapid  Phthisis. — Acute  Phthisis,  or  Galloping  Consumption. — 
Rapid  Phthisis  is  simply  Ordinary  Phthisis  accomplishing  its  coarse  in  a 
very  Short  Period  of  Time. — Acute  Phthisis  is  a  Distinct  Morbid  Species, 
of  which  there  are  Two  Forms,  the  Catarrhal  and  the  Typhoid. 

Gentlemen  :  You  have  seen  in  bed  5,  St.  Bernard's  Ward,  a  young 
woman  between  twenty-four  and  twenty-five  years  of  age,  the  subject  of 
rapid  phthisis.  Take  special  note  that  I  do  not  use  the  term  galloping 
phthisis.  I  purposely  avoid  employing  that  word.  This  does  not  arise 
from  my  having  any  repugnance  to  a  universally  accepted  epithet,  but 
because  the  epithet  with  a  great  many  physicians  has  a  meaning  totally 
different  from  rapid.  This,  therefore,  is  a  point  upon  which  you  are 
entitled  to  an  explanation.  Befoi'e  I  give  it,  however,  let  me  succinctly 
recapitulate  the  history  of  our  patient. 

This  young  woman  was  confined  on  the  14th  March.  When  upon 
several  occasions,  I  interrogated  her  regarding  her  antecedents,  with  a  view 
to  discover  whether  she  had  any  previous  symptoms  of  chest  disease,  she 
replied,  that  no  one  was  less  subject  to  catarrhal  affections  of  the  chest  than 
she  was.  She  said  that  from  time  to  time,  she  had  colds  in  the  head,  but 
had  never  had  cough. 

She  became  pregnant  eleven  months  ago,  and  during  the  whole  of  her 
pregnancy,  she  had  remarkably  good  health.  Labor  was  easy,  and  in  all 
respects  propitious.  Some  days  after  delivery,  that  is  to  say,  on  the  23d 
of  last  March — five  weeks  ago — she  began  to  cough.  From  the  first,  her 
cough  was  severe,  though  it  could  not  be  called  very  violent.  Not  being 
able  by  any  means  to  get  rid  of  it,  she  resolved  to  come  into  the  hospital. 

At  my  first  visit  after  her  admission,  I  detected  by  percussion  a  notable 
diminution  of  sound  on  the  right  side  of  the  chest,  posteriorly,  in  the  infra- 
spinous  scapular  fossa,  particularly  between  the  scapula  and  the  vertebral 
column.  We  also  heard,  by  auscultation,  in  the  same  situation  prolonged 
expiratory  sound,  almost  bronchial  blowing,  mixed  with  moist  rales.  On 
the  left  side,  the  respiratory  murmur  and  the  thoracic  resonance  presented 
nothing  abnormal.  The  patient  had  fever ;  but  no  night  sweating,  no 
morbid  affection  of  the  digestive  canal,  and  no  tendency  to  diarrhoea  :  on 
the  contrary,  she  had  constipation. 

What  was  the  nature  of  this  woman's  disease  ?  She  had  been  ill  for  a 
fortnight.  The  signs  furnished  by  auscultation  and  percussion  led  me  to 
conclude  that  there  was  induration  of  the  pulmonary  parenchyma;  but  the 


542  PULMONARY    PHTHISIS. 

obscurity  of  the  sound  in  the  infraspinous  scapular  fossa,  the  moist  rales, 
the  prolonged  expiration,  and  even  the  expectoration,  which  had  the  char- 
acters of  phthisical  expectoration,  the  globular,  nummular  sputa  floating 
in  nearly  clear  serosity — these  signs  were  insufficient  to  convince  me  that 
the  malady  was  tubercular.  Such  a  conclusion  seemed  all  the  more 
unsound  from  the  patient  stating  that  a  fortnight  ago,  she  was  in  the 
enjoyment  of  perfect  health,  and  that  she  had  never  had  the  slightest 
attack  of  chest  disease.  I  was  therefore  inclined  to  believe  that  there  was 
pneumonia  of  the  summit  of  the  right  lung,  although  the  elements  of  a  cor- 
rect diagnosis  were  so  incomplete  as  to  cause  me  to  have  some  doubt  on 
the  subject. 

However,  by  attentive  daily  auscultation,  I  found  that  the  blowing,  in 
place  of  decreasing,  increased  notably  every  day.  The  mucous  rales 
became  changed  into  crackling.  Eight  days  after  the  arrival  of  this 
woman  in  our  wards,  I  began  to  hear,  on  the  left  side,  a  little  of  the  pro- 
longed expiration,  and  some  subcrepitant  rales :  conditions  similar  to  those 
on  the  left  side  were  then  recognized  on  the  right  side :  expiration  became 
more  and  more  blowing  :  the  rales  became  converted  into  crackling  :  and# 
at  last,  we  heard  gurgling  on  both  sides. 

Thus,  an  opportunity  was  afforded  of  being  present  to  witness  the  advance 
of  the  disease :  we  saw  the  seizure  take  place  in  the  hitherto  healthy  side, 
not  as  in  pneumonia,  but  as  in  tuberculization.  Hesitation  as  to  the  diag- 
nosis was  no  longer  possible.  It  was  only  too  evident  that  there  was 
tubercular  induration  of  the  summits  of  both  lungs,  that  phthisis  progressing 
with  fearful  rapidity  was  threatening  to  carry  off  this  young  woman  in  a 
very  brief  space  of  time — perhaps  in  two  months,  in  six  weeks,  or  even 
sooner. 

That,  gentlemen,  is  an  example  of  rapid  phthisis.  Another  example  was 
lately  presented  to  our  notice  in  the  youth  who  lay  in  bed  2,  St.  Agries's 
Ward. 

The  young  man  to  whom  I  refer,  who  came  into  hospital  on  the  30th 
January,  had  no  chest  symptoms  till  ten  days  prior  to  that  date:  be  died 
on  the  25th  March.  A  month  before  his  death,  and  thirty-five  days  from 
the  beginning  of  his  illness — that  is  to  say,  on  the  25th  February — I  de- 
tected hydro-pneumothorax,  one  of  the  most  serious  complications  of  pul- 
monary phthisis.  At  the  autopsy,  we  found  three  perforations  in  the  anterior 
and  lateral  part  of  the  right  lung,  and  in  both  lungs  a  vast  number  of  tuber- 
cular masses  of  the  size  of  a  pea:  there  were  no  cavities. 

With  the  exception  of  the  rapidity  of  its  pace,  this  form  of  the  disease,  to 
which  we  apply  the  term  rapid,  presents  the  same  symptoms  during  life, 
and  the  same  anatomical  lesions  aftei  death  as  ordinary  phthisis,  the  prog- 
ress of  which  is  generally  chronic.  It  is  the  same  disease  a>  ordinary 
phthisis,  though  it  generally  runs  its  course  with  much  more  rapidity. 
There  are  also  cases  to  which  the  term  latent  phthisis  is  given,  because  the 
symptoms  remain  obscure,  and  are  masked  by  complications  which  are  apt 
to  lead  us  astray  in  our  diagnosis.  Nevertheless,  whether  the  form  be  rapid 
or  latent,  regular  or  irregular,  it  is,  1  repeat,  always  the  same  disease.  Bui 
aeute,  or  galloping  phthisis  as  it  is  more  generally  called,  is  do1  the  same 
disease  as  ordinary  phthisis. 

'I  he  anatomical  character  of  galloping  phthisis  is  the  presence  in  the  en- 
tire thickness  and  in  every  pan  of  the  lungs,  from  base  to  apex,  of  yellowish- 
gray,  Bemi-transparenl  granulations.  This  specific  character,  recognized  by 
men  of  high  authority,  by  Rokitansky  among  others,  is  doI  denied  by  any 
one  in  the  present  day;  Bui  there  is  a  greal  diversity  of  opinion  a-  to  the 
nature  of  these  granulations. 


PULMONARY    PHTHISIS.  543 

According  to  sonic  pathological  anatomists,  granulation*  (\\t\\>r  in  no  respect 
from  tubercles,  of  which  they  present  the  ordinary  microscopical  characters 
— they  are  "  globules,"  to  use  Leudet's  words,  "  round  or  ovoid,  and  angular 
in  their  outline,  containing  a  more  or  less  transparent  matter,  and  molecular 
granulations;  and  there  is  also,  particularly  in  the  semi-transparent  grayish 
tubercle,  an  interglobular  substance  of  a  grayish-yellow  color  and  tolerably 
firm  consistence."*  These  authors,  then,  believe  with  Laennec  that  miliary 
granulations  arc  tubercles  in  a  less  advanced  state  of  development,  and 
while  they  fully  recognize  the  fact  that  galloping  pulmonary  tuberculiza- 
tion specially  presents  this  form  of  semi-transparent,  grayish,  or  nearly  yel- 
lowish granulations,  they  likewise  admit  that  it  is  altogether  exceptional 
not  to  find,  in  addition  to  these  granulations,  traces  of  tubercle  in  a  more 
advanced  state  of  development,  even  cavernous  ulceration.  Finally,  accord- 
ing to  the  same  pathological  anatomists,  miliary  granulations  may  exist  in 
organs — in  the  bronchial  and  mesenteric  glands,  in  the  spleen,  kidneys,  and 
meninges  of  the  brain — precisely  as  the  yellowish  tubercles  of  ordinary 
phthisis. 

But  opposed  to  these  pathological  anatomists,  others,  whose  opinions  pos- 
sess unquestionable  value,  maintain  that  miliary  granulations  are  morbid 
products  quite  different  from  tubercle.  On  this  point,  gentlemen,  let  me 
quote  the  views  of  a  man,  with  whose  high  standing  you  are  all  acquainted. 

My  accomplished  colleague,  Dr.  Charles  Robin,  in  a  manuscript  note, 
kindly  communicated  to  me  in  relation  to  some  pathological  specimens  taken 
from  the  body  of  a  patient  who  died  in  our  wards,  says,  that  under  the  name 
of  miliary  tubercle,  four  species  of  morbid  products  have  been  described. 

The  first  species,  he  says,  consists  of  concrete  pus.  This  was  the  species  of 
miliary  tubercle  found  in  the  patient  to  whom  I  alluded. 

The  second  is  formed  by  epidermic  products  of  the  lung.  These  products 
are  most  frequently  met  with  in  children,  particularly  in  infants  at  the 
breast ;  but  they  are  also  found  in  adults.  Sometimes  they  are  scattered 
here  and  there  throughout  the  pulmonary  parenchyma,  and  at  other  times, 
they  exist  in  close  contiguity  to  one  another,  being  almost  confluent :  their 
starting-point  is  the  pulmonary  epithelium,  just  as  in  the  parenchyma  of 
glands,  different  affections  have,  as  their  characteristic  lesion,  augmentation 
in  the  quantity  and  volume  of  these  organs.  These  epidermic  products  are 
the  least  common  of  the  four  species  of  morbid  products  now  under  review. 

A  third  species  embraces  the  gray  or  semi-transparent  granulations,  iso- 
lated or  confluent,  in  the  latter  case  constituting  what  is  called  gray  infil- 
tration. These  gray  granulations  have  a  structure  essentially  distinct  from 
that  of  tubercles.  They  occur  in  the  form  of  isolated  grains,  deposited  in 
layers,  or  in  indeterminate  masses :  they  are  the  same  as  granulations. 

The  meningeal  granulations  met  with  in  inflammatory  affections  of  the 
meninges  are  sometimes  tubercles ;  but  more  frequently  they  are  the  pecu- 
liar productions  now  under  consideration.  Granulations  of  the  pleura?  and 
peritoneum  are  of  a  different  character.  In  these  situations,  this  morbid 
product  has  been  confounded  with  tubercle,  even  when  examined  by  the 
microscope,  by  persons — observe  !  it  is  still  Professor  Robin  who  speaks — by 
persons  under  the  influence  of  the  old  ideas  of  the  school  of  observation,  as 
it  has  been  called,  and  who  perhaps  from  neglecting  to  employ  the  reagents 
generally  used,  have  regarded  it  as  the  corpuscle  of  tubercle,  a  special  ele- 
ment, to  which  I  shall  return  forthwith.  It  exists  in  a  great  number  of  in- 
flammatory and  other  products,  such  as  the  vegetations  which  form  on  the 
surface  of  wounds,  and  on  syphilitic  mucous  patches. 

*  Letjdet:  Recherches  sur  la  Phthisie  Aigue  chez  l'adulte.     Paris.  1851. 


544  PULMONARY    PHTHISIS. 

The  following  are  the  anatomical  elements  of  this  granular  product: 

1st.  The  small  spherical  corpuscles  of  which  I  have  been  speaking; 

2d.  A  very  considerable  quantity  of  amorphous  substance,  granular, 
semi-solid,  infiltrated  into  the  pulmonary  tissue,  and  filling  the  minute  sub- 
divisions of  the  respiratory  passages  ; 

3d.  Fibro-plastic  elements ; 

4th.  Granular  bodies,  to  which  the  term  inflammatory,  has  been  given  ; 
and 

5th.  A  small  quantity  of  epithelium  coming  from  the  minute  bronchial 
tubes. 

It  is  a  curious  fact  that  occasionally,  only  occasionally,  however,  small 
masses  of  tubercle  are  found  in  the  centre  of  these  peculiar  morbid  products 
situated  it  may  be  in  the  membranes  of  the  brain,  in  the  pleura?,  or  in  the 
lungs.  This  occurrence,  I  repeat,  is  not  usual.  It  is  chiefly  observed  in 
subjects  who  present  large  masses  of  gray  infiltration.  However  small 
these  tubercles  may  be,  they  have  a  yellowish  color.  They  are  always  in- 
significant in  quantity,  as  compared  with  that  of  the  granulations.  These 
granulations  have  no  similarity  in  disposition  with  those  which  constitute 
the  characteristic  element  of  ordinary  phthisis;  and  it  would  be  an  error 
to  say,  as  has  been  said,  that  the  former  are  merely  the  latter  in  a  less  ad- 
vanced stage.  The  latter  never  succeed  the  former  species,  galloping 
phthisis  always  proving  fatal  long  before  the  tubercular  deposit  is  abun- 
dant. 

Thus,  gentlemen,  you  perceive  that  three  species  of  morbid  products  are 
included  in  the  improperly  applied  term,  miliary  tubercle,  viz.,  concrete  pus, 
epidermic  productions,  and  gray  granulations. 

The  fourth  species  described  by  Dr.  Robin  is  only  a  variety  of  the  third 
species, — the  gray  granulations. 

True  tubercle  is  sometimes  found  along  with  the  products  called  miliary 
tubercles.  Dr.  Robin  says,  that  however  small  the  morbid  products  may 
be  which  contain  the  tubercular  corpuscles,  they  have  always  the  yellowish- 
white  or  yellowish-gray  color  characteristic  of  tubercle,  and  never  the  gray 
color  of  the  products  anatomically  characteristic  of  galloping  phthisis. 
When  the  naked  eye  only  is  used,  there  may  be  a  difficulty  of  distinguish- 
ing them  from  concrete  pus,  but  with  the  others,  there  is  no  risk  of  con- 
founding them:  and  by  the  microscope,  they  can  be  quite  easily  distin- 
guished from  one  another. 

In  relation  to  the  general  disposition  of  these  products,  I  must  state,  that 
from  the  autopsies  I  have  had  occasion  to  make,  1  have  learned  that  when 
cavities  are  found  in  the  lungs  in  galloping  phthisis,  they  are  simply  small 
abscesses;  and  however  large  the  cavities  may  lie,  they  are  never  divided 
by  hand-  or  columns  formed  of  shreds  of  cellular  tissue.  Again,  it  is  im- 
portant to  know  that  the  glands  are  only  attacked  in  exceptional  cases. 

Putting  aside  the  anatomical  lesion,  the  nature  of  which  is  very  open  to 
discussion,  the  form  of  phthisis  properly  called  galloping  will  he  found  to 
diner  both  from  rapidly  progressing  ami  chronic  ordinary  phthisis.  W  e 
shall  see  thai  the  difference  is  Btill  greater  in  respect  of  the  symptoms  than 
of  the  lesions. 

Some  of  you  no  doubt   remember  a  young  woman  of  twenty-one  years  of 

age,  who  lay  in  \>n\   H),  St.   Bernard's  Ward.     When  she  came  into  hos- 

pital,she  had  only  hem  ill  three  months.  Till  then,  the  period  at  which 
she  came  lo  live  in  Paris,  her  Usual  health  had  hecn  -cod.  From  that  lime, 
however,  it  wa-  out  of  order:  she  had  less  inclination  for  food,  and  her 
strength  was  perceptibly  failing.      She  continued,  however,  to  attend  to  hi  r 

domestic  duties,  till  three  weeks  before  admission  to  hospital,  when  -he  was 


PULMONARY    PHTHISIS.  545 

obliged  to  take  to  her  bed.  At  that  time,  she  had  diarrhoea  and  colic:  at 
first,  the  diarrhoea  occurred  at  considerable  intervals  ;  but  it  soon  recurred 
every  day,  and  became  profuse.  At  the  same  time,  chest  symptoms  set  in  : 
she  had  cough  and  expectoration,  but  no  spitting  of  blood :  there  was  a 
great  deal  of  fever. 

When  she  came  into  our  wards,  I  was  struck  with  her  appearance  of 
prostration  and  stupor.  The  fever  was  intense:  the  skin  was  hot  and  dry  : 
the  pulse  was  quick,  full,  regular,  and  not  rebounding.  There  was  profuse 
diarrhoea  :  the  stools  were  yellow. 

Five  days  later,  delirium  supervened.  There  was  a  great  deal  of  cough. 
Observing  muco-purulent  sputa  in  the  spittoon,  I  was  led  to  make  a  more 
particular  examination  of  the  respiratory  apparatus.  On  auscultation,  I 
heard  posteriorly,  disseminated  over  the  whole  of  both  lungs,  coarse  mucous 
rales,  as  well  as  sibilant  rales.  Anteriorly,  percussion  over  the  left  clavicle 
produced  the  cracked- vessel  sound  [bruit  cle  pot  fele]  :  I  found  diminished 
•thoracic  resonance:  I  heard,  moreover,  coarse  mucous  rales,  gurgling  in 
fact,  and  at  one  point  there  was  cavernous  blowing.  A  few  days  afterwards 
the  patient  died.  At  the  autopsy,  we  found  such  lesions  as  I  have  just  de- 
scribed to  you. 

What,  then,  gentlemen,  are  the  symptoms  of  galloping  phthisis  f 

A  young  woman — I  say  a  young  woman,  for  it  is  chiefly  women,  and 
chiefly  young  women  whom  I  have  seen  the  victims  of  this  malady — a 
hitherto  healthy  young  woman,  without  appreciable  cause,  falls  into  an 
uncomfortable  state  of  health,  which  it  is  not  easy  to  describe  :  she  is  dys- 
peptic, and  loses  her  appetite :  her  strength  flags,  and  a  more  or  less  fever- 
ish condition  shows  the  disorder  which  pervades  her  system.  This  state  of 
discomfort  and  languor  lasts  from  a  fortnight  to  three  weeks  or  a  month. 
During  this  period,  the  patient  continues  to  go  about  her  usual  avocations, 
complaining,  however,  all  the  while,  of  unaccustomed  weakness,  and  of 
great  incapacity  to  do  anything  requiring  mental  application.  She  has  at 
the  same  time  night-sweats  and  a  short  dry  cough  :  on  auscultating  the 
chest,  we  hear  loud  rales  in  various  parts.  When  the  symptoms  have  only 
existed  for  a  few  days,  they  are  attributed  to  catarrh  or  slight  bronchitis  ; 
and  in  fact,  there  is  nothing  in  the  aspect  of  the  case  to  lead  to  any  serious 
apprehensions.  But  the  catarrh  goes  on,  and  the  fever  continues.  On 
examining  the  chest,  it  is  found  that  the  rales  have  become  more  numerous 
and  more  moist :  they  are  heard  throughout  the  whole  extent  of  the  lungs, 
from  base  to  apex,  before  and  behind.  Time  passes  on,  and  matters,  in 
place  of  improving,  become  worse  :  there  is  an  increase  of  fever  :  there  is 
insomnia  :  the  cough,  becoming  more  and  more  urgent,  is  accompanied  by 
expectoration,  which  is  at  first  mucous  and  then  muco-purulent :  the  finest 
rales  audible,  the  subcrepitant,  are  at  some  points  mingled  with  prolonged 
expiration,  and  even  with  a  blowing  sound.  The  thoracic  resonance  on 
percussion  remains  normal.  Respiration  is  embarrassed,  short,  and  quick; 
and  the  dyspnoea  increases  to  such  an  extent  that  the  patient  is  obliged  to 
keep  the  sitting  posture.  The  symptoms  go  on  increasing  in  severity  :  the 
strength  becomes  more  and  more  exhausted  :  the  countenance  assumes  an 
anxious  expression  :  the  discoloration  of  the  skin  is  succeeded  by  an  as- 
phyxial  hue,  and  in  five,  six,  seven,  or  eight  weeks  from  the  beginning  of 
the  symptoms,  the  patient  sinks  in  a  state  of  emaciation  analogous  to  that 
which  occurs  during  the  course  of  severe  fevers  ;  but  in  a  state  quite  dif- 
ferent from  the  emaciation  which  attends  ordinary  phthisis. 

The  picture  of  galloping  phthisis  which  I  have  now  rapidly  sketched 
would  be  very  incomplete  were  I  to  present  it  to  you  as  the  absolute  type 
of  the  disease.  It  only  brings  before  you  one  form,  which  may  be  called 
vol.  i. — 35 


546  PULMONARY    PHTHISIS. 

the  catarrhal  form :  there  is  another,  the  typhoid  form,  which'it  is  quite  as 
important  to  be  acquainted  with. 

In  the  typhoid  form,  though  we  meet  with  the  thoracic  signs  and  symp- 
toms to  which  I  have  been  directing  your  attention,  it  is  the  general  condi- 
tion of  the  patient  which  characterizes  his  malady,  and  so  closely  does  this 
general  state  simulate  typhoid  fever  that  the  case  may  be  mistaken  for  one 
of  that  disease.  The  symptoms  complained  of  by  the  patient,  and  the 
phenomena  observed  by  the  physician,  are  intense  headache,  a  stupid  ex- 
pression of  countenance,  low  delirium  (changing  sooner  or  later  into  more 
or  less  violent  delirium),  and  frequently  subsultus  tendinum.  The  counte- 
nance in  place  of  being  pale  is  florid  ;  but  the  red  is  not  confined  to  patches 
over  the  cheek-bones,  as  is  remarked  in  the  subjects  of  ordinary  phthisis, 
particularly  during  the  evening  exacerbations  of  hectic  fever.  There  is 
high  fever,  and  the  heat  of  the  skin,  which  is  not  complained  of  by  the 
patient,  corresponds  with  the  acceleration  of  the  pulse.  The  abdomen 
retains  its  natural  degree  of  softness  and  tension.  Pressure  made  over  the 
right  iliac  fossa  does  not  produce  gurgling  :  there  is  no  diarrhoea  :  and  it 
is  important  to  note  that  there  are  none  of  the  true  rosy  lenticular  spots  of 
dothinenteria.  In  the  typhoid  form  of  galloping  phthisis,  the  invasion  of 
the  disease  is  generally  more  abrupt  than  in  the  catarrhal  form,  and  its 
beginning  is  marked  by  more  or  less  violent  rigors.  The  course  of  the 
disease  is  also  more  rapid  ;  and  it  terminates  by  asphyxia  or  nervous 
seizures. 

In  cases  in  which  galloping  phthisis  simulates  typhoid  fever,  examina- 
tion of  the  temperature  furnishes  us  with  a  valuable  means  of  diagnosis. 
It  is  only  in  exceptional  cases,  that  the  temperature  is  as  high  in  acute 
tuberculization  as  in  typhoid  fever :  the  morning  and  evening  oscillations 
too,  are  greater;  thus,  in  gallopiDg  phthisis,  the  evening  temperature  differs 
one  or  two  degrees  from  the  morning  temperature,  while  in  typhoid  fever, 
there  is  very  seldom  as  much  as  one  degree  of  difference  between  the  tem- 
perature of  the  patient  in  the  morning  and  the  evening. 

Neither  in  the  catarrhal  nor  typhoid  forms  of  galloping  phthisis,  do  you 
find,  gentlemen,  the  symptoms  of  ordinary  phthisis,  even  when  the  latter 
runs  an  exceedingly  rapid  course.  There  is,  however,  one  point  at  which 
galloping  and  ordinary  phthisis  seem  to  have  a  connecting  link:  both  attack 
persons  in  whose  families  tuberculosis  is  hereditary :  at  the  same  time,  I 
must  add,  that  they  also  attack  those  in  whom  no  hereditary  taint  can  In- 
discovered. 

For  the  reasons  now  laid  before  you,  one  of  my  former  excellent  pupils, 
now  my  colleague  in  the  Faculty  of  Medicine,  as  well  as  in  the  medical 
service  of  the  hospitals,  Dr.  Empis,  has  come  to  the  conclusion,  that  gallop- 
ing phthisis  ought  to  be  considered  as  distinct  from  tuberculization,  from 
which  he  says  it  differs  not  less  in  respect  of  its  lesions  than  of  its  symp- 
toms. With  the  view  of  fully  preserving  this  distinction,  he  has  gives  the 
name  of  granular  disease  [gramdie]  to  the  affection  which  is  characterized 
anatomically  by  the  production  of  granulations  in  the  parenchyma  or  serous 
membranes."  According  to  this  doctrine  galloping  phthisis  is  the  thoracic 
form  of  granular  disease  \/<i  finite  l/ujrarii[iir  dv  la  i/ramtlie]:   the   cerebral 

form  is  seen  in  brain  fever  or  tubercular  meningitis,  and  the  abdominal 
form  in  cases  having  typhoid  symptoms." 

In   galloping  phthisis,  the   prognosis  is  death.      I>calh,  sooner  or  later,  is 

invariably  the  termination.  Hitherto,  gentlemen,  art  has  unfortunately 
proved  unable  to  contend  against  this  redoubtable  malady :  it  is  still  more 

*  Empis  (G.  S. ) :   De  La  GranuLio,  on  Maladie  Granuleuae.     Paris,  1865. 


pulmonahy   phthisis.  547 

distressing  to  know  that  we  have  not  the  power  even  to  alleviate  the  con- 
dition of  sufferers  by  whom  we  may  be  consulted. 

I  must  give  you  the  particulars  of  one  more  sad  example  of  this  disease  : 

On  the  2d  February,  1861,  my  colleague  Dr.  Barth  and  1  were  sent  for 
to  Les  Oiseaux  convent,  to  see  a  young  Spanish  lady,  sixteen  years  of  age. 
Her  ordinary  medical  attendant,  Dr.  Vosseur,  informed  us  that  this  young 
lady  had  a  fortnight  previously  begun  to  have  uncomfortable  feelings,  and 
to  sutler  from  fever,  without  experiencing  any  local  symptoms,  excepting 
decided  oppression  in  breathing.  As  the  symptoms  continued,  Dr.  Barth 
was  sent  for,  eight  days  later :  at  that  visit,  he  was  struck  with  the  lividity 
of  the  lips  and  face.  The  lividity  extended  to  both  hands.  There  was 
great  oppression  of  the  breathing,  and  ardent  fever.  Nothing  abnormal 
could  be  detected  by  the  most  careful  auscultation  :  there  was  neither  rale 
nor  the  sound  of  prolonged  expiration.  The  functions  of  the  stomach  were 
as  well  performed  as  it  was  possible  to  desire. 

Eight  days  after  that  visit  of  Dr.  Barth,  I  again  met  him  in  consultation 
on  the  case.  There  was  then  extreme  frequency  of  pulse  and  respiration, 
and  a  frightful  increase  in  the  lividity  of  the  skin.  During  the  night,  the 
patient  had  had  insomnia  and  some  raving.  Throughout  the  whole  extent 
of  the  left  lung,  we  heard  very  fine  subcrepitant  rales :  throughout  the 
whole  of  the  right  lung,  we  heard  coarse  subcrepitant  rales  mingled  with 
mucous  rales :  there  was  no  expectoration.  Our  opinion  was,  that  there  was 
very  little  probability  of  the  patient  surviving  more  than  three  or  four  days. 

She  died  on  the  4th  February,  seventeen  or  eighteen  days  from  the  be- 
ginning of  the  attack. 


Pulmonary  Tuberculization,  and  Chronic  Peripneumonic 
Catarrh  in  Children. 

Gentlemen  :  Permit  me  now  to  fix  your  attention  for  a  short  time  upon 
a  little  patient  in  bed  13  of  the  nursery  attached  to  St.  Bernard's  Ward. 
For  some  time  past  his  condition  has  been  very  anxious,  and  the  diagnosis 
of  his  malady  very  embarrassing. 

This  child  is  between  seven  and  eight  years  of  age.  Since  he  was  about 
three  months  old,  he  has  had  a  severe  catarrh,  accompanied  by  fever,  which 
has  never  left  him  since  the  catarrhal  malady  began.  He  has  nevertheless 
continued  to  take  the  breast,  and  it  is  assuredly  in  consequence  of  his  appe- 
tite for  nourishment  that  he  is  still  alive.  He  was  brought  here  a  fortnight 
ago.  He  had  at  that  time  a  great  deal  of  cough,  and  much  oppression  at 
the  chest  in  breathing. 

On  examining  the  chest  I  found  tubal  blowing  on  the  left  side,  extending 
from  the  infraspinous  fossa  of  the  scapula  to  about  the  base  of  the  lung,  and 
resonance  of,  I  cannot  say  the  voice,  but  of  the  cry :  the  blowing  and  the 
resonance  were  well-marked,  particularly  during  expiration.  At  intervals 
there  exploded  under  my  ear  cracks  of  submucous  crepitant  rale,  some  of 
which  were  very  fine.  Comparative  percussion,  posteriorly,  of  both  lungs 
showed  us  that  there  was  very  evident  dulness  on  the  left  side. 

The  child  had  fever.  In  consideration  of  the  general  symptoms  and 
physical  sigus,  I  thought  that  the  case  was  pneumonia,  or  rathSr  pleuro- 
pneumonia :  I  believed  that  the  lung  was  indurated,  and  that  there  was 
false  membrane  on  its  surface.  But  there  was  still  a  question  to  solve : 
What  was  the  nature  of  the  induration?  Again,  was  it  recent,  or  of  old 
date?  And  again,  was  the  induration  purely  inflammatory,  or  was  it  asso- 
ciated with  the  presence  of  accidental  products  in  the  pulmonary  paren- 
chyma?    Finally,  had  we  to  do  with  acute  pneumonia,  chronic  pneumonia, 


548  PULMONARY    PHTHISIS. 

or  tubercular  pneumonia  ?  The  solution  of  these  problems  was  attended 
with  more  than  one  difficulty. 

In  children,  particularly  in  infants  at  the  breast,  and  during  the  first 
three  years  of  life,  the  characters  of  pneumonia  are  different  from  those 
which  the  disease  presents  in  adults.  In  the  young  subjects  lobular  pneu- 
monia, such  as  is  observed  in  adults,  is  a  very  rare,  and  not  a  very  serious 
affection ;  whereas  peripneurnonic  catarrh,  or  bronchopneumonia,  at  a  very 
early  age,  is  one  of  the  most  dangerous  diseases  with  which  we  are  acquainted, 
inasmuch  as  it  nearly  always  proves  fatal. 

If  you  study  catarrh,  you  will  find  out  that  there  is  no  disease  so  uncer- 
tain in  its  course.  It  has  no  fixed  limits  of  duration  :  it  will  sometimes  con- 
tinue for  thirty-six  or  forty-eight  hours;  and  at  other  times  it  will  go  on, 
in  an  acute  or  subacute  form,  for  two  or  three  months.  You  never  can 
tell  a  patient  with  catarrh  when  he  will  get  rid  of  it ;  whereas,  when  the 
disease  is  pneumonia,  it  is  more  easy  to  give  an  answer.  Generally  speak- 
ing, in  from  nine  to  twelve  days,  pneumonia  terminates  in  death,  or  the 
general  symptoms  improve,  and  convalescence  begins.  Do  not  suppose 
that  the  uncertainty  which  belongs  to  the  course  of  catarrh  is  peculiar  to 
bronchial  catarrh :  what  I  have  said  applies  to  catarrh  in  general,  whether 
it  affect  the  mucous  membrane  of  the  bronchial  tubes,  intestines,  or  bladder, 
or  of  the  genital  organs  in  either  sex. 

That  proposition  established,  you  are  able  to  understand  that  as  catarrh 
is  the  starting-point  of  pneumonia  in  children,  similar  difficulties  of  prog- 
nosis will  exist  as  in  bronchitis :  like  bronchitis,  it  will  maintain  indeter- 
minate characters,  and  the  same  tendency  to  relapses,  to  which  you  can 
assign  no  term. 

A  child  is  attacked  with  a  severe  feverish  catarrh:  at  the  end  of  four  or 
five  days,  on  auscultation  of  the  chest,  you  hear  disseminated  over  it  sub- 
crepitant  rales,  and  by  and  by  a  blowing  sound:  thus  you  arrive  at  the 
legitimate  conclusion  that  there  is  pleuropneumonia.  To  subdue  this 
malady,  you  have  in  vain  had  recourse  to  the  most  energetic  medicines; 
and  some  days  later  the  rales  and  the  blowing  sound,  which  had  disap- 
peared, in  a  very  short  time  will  be  again  audible.  You  will  find  them  in 
a  different  point  from  that  which  they  previously  occupied,  whether  that 
was  in  another  part  of  the  same  lung,  or  in  the  other  lung:  very  soon  after- 
wards, without  leaving  the  newly-invaded  parts,  they  may  occupy  those 
where  they  were  first  heard.  Such  is  the  condition  of  the  malady,  the  signs 
of  which  you  will  recognize  much  better  by  auscultation  than  by  percussion, 
which  will  only  tell  you  that  an  entire  lobe,  or  a  great  part  of  a  lobe,  has 
been  invaded. 

Thus  peripneurnonic  catarrh  may,  within  a  few  days,  abandon  the  points 
which  it  lir.-t  occupied  and  take  possession  of  others,  last  uf  all,  however, 
wholly  disappearing;  and  thus  peripneumonia  may  come  and  go  successively 

for  one,  two,  or  three  nths.      The  successive  attacks  are  tint  relapses,  hut 

returns  of  a  cured  disease.  It  is  always  the  same  in  catarrh  :  the  long  series 
of  interrupted  and  resumed  symptoms  which  characterize  it  results  from  a 
similar  cause. 

In  the  pure  pneumonia  of  adults  matters  pursue  an  entirely  difierenl 
course.  A  lolie  is  attacked  :  the  inflammation  extends  to  the  parts  in  the 
vicinity  of  these  which  were  primarily  and   principally  affected,  but  it  does 

nut  leap  from  one  poinl  to  another  like  catarrhal  peripneumonia:  it  remain- 
within  the  limit-  where  it  circumscribed  Itself  from  the  first,  or  it  advances 
step  by  step. 

There  is  nu  difficulty  in  understanding  that  in  bronchopneumonia  the 
pulmonary  parenchyma,  under  the  influence  of  the  morbid  action  of  which 


PULMONARY    PHTHISIS.  5$d 

it  has  been  the  seat  during  different  attacks, permanently  retains  a  more  or 
less  indurated  state.  Hence  it  is  impossible  to  avoid  admitting  that  bron- 
chitic  catarrh  will  soon  be  accompanied  by  chronic  pneumonia;  also,  let 
me  add,  that  chronic  pneumonia  is  a  somewhat  less  uncommon  affection  in 
children  than  in  adults. 

In  the  adult,  chronic  pneumonia  is  so  rare,  that  (as  you  know),  its  exist- 
ence has  long  been  disputed  by  a  certain  number  of  physicians.  How- 
ever, the  majority  of  clinical  observers  of  the  present  day,  while  they  point 
out  its  great  rarity,  hold  that  about  the  tenth  or  twelfth  day  of  an  attack 
of  pure  pneumonia,  the  general  phenomena  may  disappear,  the  local  symp- 
toms remaining.  The  fever  subsides :  the  sputa  regain  their  natural  ap- 
pearance :  and  the  appetite  returns.  Nevertheless,  dulness  on  percussion 
remains:  on  auscultation,  there  is  heard  bronchial  blowing,  crepitant  rales, 
bronchophony  to  a  somewhat  considerable  extent ;  or — and  many  examples 
of  this  have  been  cited — neither  normal  nor  abnormal  sound  can  be  heard 
in  the  seat  of  the  lesion.  This  state  of  matters  may  last  for  fifteen,  twenty, 
thirty,  forty,  and  even  for  seventy  days,  as  you  will  learn  from  a  case  de- 
tailed by  Dr.  A.  Raymond  in  his  thesis.*  I  should  also  wish,  in  relation  to 
this  topic,  to  recall  to  your  recollection  the  man  whom  we  had  for  so  long 
a  time  in  bed  19  of  St.  Agnes's  Ward,  who,  at  the  date  of  his  admission, 
had  acute  pneumonia  in  a  very  aggravated  form.  In  this  individual,  for 
nearly  two  months,  we  noted  subcrepitant  rales,  and  a  blowing  sound,  on 
the  right  side,  in  the  infraspinous  fossa  of  the  scapula :  he  always  retained 
a  certain  degree  of  fever :  nevertheless,  when  he  left  the  hospital,  his  health 
was  quite  restored,  his  respiration  had  become  natural,  and  there  was  no 
longer  any  abnormal  sound  to  be  heard  in  the  chest.  It  is  evident  that  in 
this  case,  the  inflammatory  lesion,  the  induration  of  the  pulmonary  tissue, 
had  persisted  for  a  much  longer  period  than  is  generally  required  for  its 
resolution.  The  hepatization,  doubtless,  did  not  keep  the  same  form  which 
it  had  at  the  fourth  or  fifth  day  from  the  invasion  of  the  disease,  but  never- 
theless it  continued  to  exist,  and  was  quite  independent  of  any  tubercular 
affection. 

Chronic  pneumonia  has  been  correctly  stated  to  be  connected,  not  always 
(as  those  who  deny  its  separate  existence  maintain),  but  almost  always, 
with  the  presence  of  accidental  products  in  the  pulmonary  parenchyma : 
or  in  other  words,  this  form  of  pneumonia  is  almost  always  tubercular. 
This  is  true  in  respect  of  adults :  it  is  also  true  in  respect  of  children ;  but 
in  the  latter,  it  is,  speaking  comparatively,  a  little  more  usual  to  meet  with 
simple  chronic  pneumonia,  that  which  terminates  sometimes,  though  sel- 
dom, in  resolution,  but  wdiich  under  certain  circumstances  causes  suppura- 
tion of  the  lobules,  giving  rise  to  small  disseminated  abscesses  emptying 
themselves  into  the  bronchi,  their  most  propitious  termination,  or  opening 
into  the  pleura,  so  causing  very  formidable  symptoms.  It  sometimes  hap- 
pens that  these  abscesses  become  encysted  in  the  midst  of  lobules  restored 
to  a  healthy  state. 

Be  reserved,  even  in  respect  of  children,  in  stating  your  diagnosis,  when 
the  patient  has  been  suffering  for  a  long  time  from  severe  catarrh  accom- 
panied by  fever,  if  you  have  ascertained  that  bronchial  blowing  has  been 
obstinately  persistent  at  the  same  point  for  more  than  a  month,  and  is 
accompanied  by  subcrepitant  mucous  rales,  and  does  not  depend  on  pleuritic 
effusion;  be  reserved  in  your  diagnosis,  for  there  is  reason  to  fear  that  the 
child  is  a  tuberculous  subject. 

Tubercular  disease  is  more  common  during  infancy  and  early  childhood, 


Raymond  (A.) :  Sur  la  Pneumonie  Chronique.     These  de  Paris,  1842. 


DoyJ  PULMONARY    PHTHISIS. 

than  at  any  other  period  of  life.  Physicians  who  have  had  charge  for  a 
long  period  of  institutions  for  infants  at  the  breast  know  that  most  of  their 
little  patients  die  of  tubercular  disease  of  the  chest. •  Unfortunately,  the 
diagnosis  of  pulmonary  tuberculization  is  much  more  difficult  in  very  young 
subjects  than  in  others.  Many  of  the  elements  which  auscultation  can 
alone  furnish  to  enable  us  to  form  an  exact  opinion  as  to  the  existence  of 
the  characteristic  lesion  are  absolutely  wanting.  The  vesicular  murmur, 
the  anomalous  sounds  by  which  it  is  replaced,  or  accompanied,  are  heard 
with  difficulty,  as  children  often  breathe  badly,  and  never  breathe  (as  adults 
do)  in  accordance  with  your  directions.  The  same  remark  applies  to  vocal 
resonance ;  for,  as  I  have  already  remarked,  the  resonance  of  the  voice  is 
in  children  replaced  by  the  resonance  of  the  cry.  The  same  remark  is  also 
applicable  to  auscultation  of  the  cough,  which  is  so  often  an  assistance  in 
the  stethoscopic  examination  of  the  chest.  We  cannot  count  upon  the  ap- 
pearance of  the  sputa  throwing  any  light  upon  the  character  of  the  dis- 
ease, because,  as  a  general  rule,  children  do  not  expectorate. 

If  pulmonary  tuberculization  be  so  difficult  of  diagnosis  in  the  child, 
how  much  more  difficult  will  it  be  in  the  child  to  establish  the  differential 
diagnosis  between  tuberculization  and  chronic  pneumonia,  inasmuch  as  it 
is  in  many  cases  almost  impossible  even  in  the  adult  to  distinguish  between 
the  two. 

I  am  aware  that  an  attempt  has  been  made  to  lay  down  characteristic 
signs,  with  a  view  to  reach  a  solution  of  the  difficulty.  It  is  said  that  in 
the  adult,  the  progress  of  the  two  diseases  is  different,  and  that  purely 
inflammatory  induration  of  the  lung  is  generally  the  result  of  acute  pneu- 
monia, and  that  tubercular  induration  arises  slowly,  and  seldom  follows 
pure  inflammation.  The  value  of  the  first  test  is  obviously  open  to  dispute, 
because  it  is  by  no  means  unusual  for  an  attack  of  pneumonia  to  determine 
the  manifestation  of  the  tubercular  diathesis  in  the  lungs,  and  leave  behind 
it  induration  of  specific  character. 

If  the  summit  of  one  of  the  lungs  is  the  chosen  seat  of  tubercular  indu- 
ration, we  can  generally  by  attentive  examination  detect  something  on  the 
opposite  side.  In  chronic  pneumonia,  the  lesion  is  only  on  one  side,  and  is 
generally  at  the  base  or  middle  of  the  lung.  It  was  otherwise,  however,  in 
the  patient  in  St.  Agnes's  Ward  to  whom  I  referred.  In  him,  the  lesion 
occupied  that  part  of  the  lung,  on  the  right  side,  corresponding  to  the 
infraspinous  fossa  of  the  scapula,  that  situation  in  which  it  is  so  common 
to  meet  with  tubercular  engorgement. 

The  absence  of  haemoptysis  in  cases  of  chronic  pneumonia,  and  their  t'n  ■- 
quency  in  phthisis  might  furnish  characteristic  phenomena  ;  but  we  know- 
how  often  we  discover  tubercular  induration  in  persons  who  have  never 
spit  blood. 

General  symptoms,  such  as  rapid  emaciation  and  night-sweats,  which 
Bupervene  in  tuberculization  and  are  absent  in  chronic  pneumonia,  are  by 
no  means  unexceptionable  differential  signs,  for  it  is  not  unusual  to  detect 
tubercles  in  their  first  stage  in  persons  of  apparently  excellent  health,  and 
who  only  complain  of  a  slight  catarrhal  affection  :  and  we  sometimes  meet 
with  others  in  whom  there  was  nothing  to  arouse  attention,  but  in  whom. 
on  careful  examination,  the  presence  of  the  serious  and  unsuspected  dis 
was  found.  The  resistance  offered  to  the  finger  used  in  percussion,  observed 
in  chronic  pneumonia  as  contrasted  with  the  less  complete  dulness  met 
with  in  tubercular  induration,  is  another  differential  sign  which  has  been 

mentioned;    hut    it    ifl   one  of  80    niu<li    delicacy,  that    I    think  it  would   be 
exceedingly  difficult  to  prov<'  it-  clinical  value. 
To  sum  up:  ft  i-  rather  by  induction,  by  an  appreciation  of  the  general 


GANGRENE    OF    THE    LUNG.  551 

character  of  the  symptoms,  by  careful  examination  of  the  patient,  by 
repeating  the  examination  several  times,  and  by  watching  the  patient,  that 
we  can  recognize  the  nature  of  his  disease.  We  often  learn  more  from 
the  sequel  of  the  case,  and  from  supervening  modifications  in  the  phe- 
nomena recognized  by  auscultation  and  percussion,  than  from  the  previous 
history,  or  the  tacts  we  ascertained  at  the  outset. 

In  the  child,  the  differential  diagnosis  is  still  more  difficult  than  in  the 
adult.  In  the  adult,  coarse  mucous  rales,  gurgling,  cavernous  blowing — 
the  signs  of  the  formation  of  a  pulmonary  cavity,  by  the  softening  of  tuber- 
cular deposit — when  they  follow  blowing  sounds  and  subcrepitant  rales, 
give  ultimately  almost  complete  evidence  of  the  existence  of  the  tubercular 
affection  ;  but  in  the  child,  these  signs  will  not  afford  you  any  absolute 
certainty,  because  the  coarse  rales,  gurgling,  and  cavernous  blowing  may 
be  signs  of  the  small  pulmonary  abscesses  which  are  common  in  the  pneu- 
monia of  childhood,  as  well  as  of  tubercular  cavities.  I  repeat,  however, 
what  I  have  already  said,  that  when  you  are  consulted  about  a  child  who 
has  been  suffering  for  a  long  time  from  severe  catarrh  accompanied  by  fever, 
in  whom  you  hear  bronchial  blowing  which  has  been  obstinately  persistent 
for  a  month  in  the  same  situation,  when  the  blowing  is  accompanied  by 
subcrepitant  mucous  rales,  and  when  you  are  sure  that  it  does  not  depend 
on  pleuritic  effusion,  do  not  pronounce  an  unreserved  diagnosis ;  for  there 
is  reason  to  fear  that  the  child  is  a  tubercular  subject.  That  is  precisely 
the  case  of  our  little  patient  in  the  nurseiy  ward.  The  duration  of  the 
symptoms  for  three  months,  and  the  persistence  of  the  blowing  heard  upon 
his  admission  to  the  hospital,  by  making  me  at  once  reject  the  idea  of  acute 
pneumonia,  and  at  the  same  time  demonstrating  the  existence  of  chronic 
pulmonary  induration,  led  me  to  the  conclusion  that  there  was  tubercular 
deposit. 


LECTURE  XXXI. 

GANGRENE  OF  THE  LUNG. 

Difficulties  of  Diagnosis. — Several  Species  of  Gangrene  of  the  Lung:    One  of 
them,  the  Species  here  more  particularly  considered,  is  Curable. 

Gextlemex  :  I  have  to  speak  to  you  to-day  of  a  patient  lying  in  bed  1, 
St.  Agnes's  Ward.  The  pulmonary  affection  under  which  he  is  suffering 
has  certain  peculiarities  which  demand  your  earnest  attention. 

This  man,  about  fifty  years  of  age,  has  long  been  subject  to  attacks  of 
catarrh,  which  have  often  proved  violent  and  obstinate.  He  states  that 
upon  one  occasion,  some  years  ago,  the  attack  was  complicated  with  symp- 
toms similar  to  the  present.  At  the  time  he  entered  the  hospital,  some 
months  ago,  he  was  tormented  by  a  frequent  cough  accompanied  by  catarrhal 
expectoration,  which  at  first  had  nothing  remarkable  in  its  character  in 
respect  of  the  quantity  and  physical  characters  of  the  sputa.  He  was  in  a 
decidedly  febrile  state.  In  other  respects,  things  went  on  with  so  much 
regularity  as  to  give  us  no  anxiety,  when,  quite  suddenly,  a  few  days  after 
his  arrival  in  our  wards,  he  expectorated  matter  of  so  exceedingly  pene- 
trating a  fetor,  that  the  nursing  sister  was  obliged  to  keep  the  windows  near 
his  bed  always  open.     All  the  patients  in  an  adjoining  ward,  as  well  as  in 


552  GANGRENE    OF    THE    LUNG. 

hLs  own  ward,  complained  of  being  poisoned  by  the  horrible  smell :  and  on 
one  occasion,  at  the  visit,  I  felt  myself  very  much  inconvenienced  by  his 
coughing.  His  breath  and  sputa  diffused  an  insupportable  gangrenous 
odor.  After  twelve,  twenty-four,  thirty-six,  or  forty-eight  hours,  the  gan- 
grenous odor  was  replaced  by  a  sickly  smell  of  honey,  very  disagreeable, 
and  perhaps  constituting  a  specific  character  of  the  disease. 

These  occurrences  took  place  at  intervals  of  a  fortnight,  eight  days,  or 
even  of  only  four  days :  they  were  sometimes  accompanied  by  fever  of 
greater  or  less  severity,  or  perhaps  there  was  no  fever  at  all. 

At  each  visit,  I  auscultated  the  chest  with  the  greatest  care,  but  I  never 
heard  gurgling,  blowing,  nor  any  sign  of  cavities  in  the  lungs :  I  only  heard 
sonorous  rhonchus  at  the  angle  of  the  right  scapula,  and  occasionally  coarse 
mucous  rales,  which  after  being  scarcely  audible  for  twenty-four  or  forty- 
eight  hours,  all  at  once  ceased.  Percussion,  however,  elicited  a  very  decided 
dull  sound  at  the  summit  of  the  right  lung,  particularly  behind. 

In  the  absence  of  stethoscopic  signs  of  softening  of  the  pulmonarv  tissue, 
and  of  a  cavity  communicating  with  the  bronchial  tubes,  I  was  naturally 
led  by  the  characteristic  odor  of  the  sputa  and  breath,  to  think  of  gangrene 
of  the  lung:  but  the  progress  of  the  symptoms,  their  intermittence,  and  the 
predominance  of  the  catarrhal  element,  also  told  me  that  I  had  to  do  with 
one  of  those  special  forms  of  gangrene  to  which  Dr.  Briquet  first  called 
the  attention  of  practitioners,  and  regarding  which  I  shall  immediately 
speak.* 

Gangrene  of  the  lung  has  been  rarely  observed  to  follow  pure  pneumonia ; 
and  I  have  never  seen  a  single  case  in  which  this  has  occurred.  It  Was  the 
opinion  of  Laennec  that  gangrene  of  the  lung  can  hardly  be  placed  among 
the  natural  terminations  of  pneumonia.  But  it  may  occur,  when  the  pneu- 
monia is  of  a  septic  nature.  By  a  curious  chance  the  only  two  cases  of 
gangrene  of  the  lung  which  I  have  seen,  presented  themselves  to  me  in  my 
wards  at  the  Hotel-Dieu  within  a  fortnight  of  one  another:  the  first  occurred 
in  a  patient  with  malignant  small-pox:  the  second,  in  a  man  with  severe 
dothinenteria.  I  am  not  at  present  speaking  of  traumatic  gangrene,  to 
which  attention  has  been  directed,  and  of  which  you  saw  a  case  in  bed  1. 
St.  Agnos's  Ward.  This  man  was  operated  upon  for  empyema,  and  re- 
covered :  I  shall  return  to  his  case  on  a  future  occasion. 

Laennec  believed  that  gangrene  of  the  lung  is  generally  allied  in  its 
nature  to  affections  which  are  essentially  gangrenous,  such  as  anthrax, 
malignant  pustule;  and,  as  in  these  affections,  the  inflammation  developed 
round  the  gangrenous  part  seems  to  be  the  effect  rather  than  the  cause  of 
the  mortification. 

Gangrene  of  the  lung  has  been  often  observed  in  diabetic  subjects :  as 
you  will  see  by  the  cases  related  by  Griesinger,  Monneret,  ( iharcot,  Marchal, 
and  Fritz.  There  is  here  a  sphacelus  of  the  lung  similar  to  thai  observed 
in  the  cases  upon  which  Marcjba]  (DeCalvi)  has  justly  laid  so  much  Btn 
The  had  general  condition  of  the  system  induced  by  diabetes,  produces 
necrosi-  in  the  pulmonary  passages,  jusl  as  it  produces  the  same  effecl  in 
the  limbs,  and  in  the  crystalline  Lens  in  cases  of  diabetic  cataract 

Finally,  1  am    inclined   to   think   that    pulmonary  embolism    may  be  the 

cause  of  more  or  less  extensive  gangrene  of  a  porti f  the  lung,  gangrene 

limited  to  the  tissue  in  whieh  ramify  the  branches  and  small  ramifications 

of  the  obliterated  vessel. 

This  was  evidently  the  case  in  a  young  woman,  whom   BOme  of  you   may 

Briquet:   Archives  Gen.  deM6decine:  8roe  se>ie,  T.  \i. 
I  Makciial  (])<■  Calvi):  Recberchea  Bur  lea  Accidents  Diab6tiques.     Paris,  L864, 


GANGRENE    OF    THE    LUNG.  553 

remember,  who,  in  October,  1858,  occupied  bed  2,  St.  Bernard's  Ward.  She 
had  been  recently  confined,  and  after  delivery  had  had  phlegmasia  alba 
dolens.  One  day  she  suddenly  complained  of  dyspnoea,  and  pain  in  the 
right  side  of  the  chest:  the  expectoration  was  very  soon  afterwards  charac- 
teristic of  the  sputa  in  pulmonary  apoplexy,  and  I  entertained  no  doubt 
that  the  pain  in  the  side,  the  dyspnoea,  and  the  apoplexy  of  the  lung  were 
the  consequences  of  an  embolus.  Some  days  later,  the  sputa  were  charac- 
teristic of  gangrene  of  the  lungs.  The  patient  sunk  rapidly.  At  the 
autopsy,  J  found  sphacelus  of  that  part  of  the  lung  supplied  by  the  vessel 
in  which  the  embolus  was  situated.  When  an  opportunity  occurs  of  re- 
turning to  the  subject  of  embolism,  I  shall  give  you,  in  extenso,  the  details 
of  this  case.  For  the  present,  I  have  said  enough  to  convince  you  that 
gangrene  of  the  lung  may  be  the  result  of  an  embolus  in  the  pulmonary 
artery,  although  that  vessel  is  not  concerned  in  the  nutrition  of  the  organ. 
Afterwards,  should  an  opportunity  arise,  I  shall  discuss  this  question  in  all 
its  bearings  ;  but  at  present,  in  support  of  the  clinical  fact,  and  to  give  it  a 
more  authoritative  sanction,  let  me  remind  you  that  Virchow,  in  his  experi- 
mental researches,  has  fully  recognized  this  cause  of  gangrene  of  the  lung. 
He  says :  "  When  the  alterations  produced  by  the  embolus  extend  to  the 
periphery  of  the  lung,  when  the  organ  becomes  gangrenous  throughout  a 
certain  extent,  the  pleura  itself  sphacelates  in  the  part  corresponding  there- 
with, and  then  ruptures,  giving  rise  to  pneumothorax."  This  is  what  took 
place  in  the  young  woman,  our  patient ;  for  besides  gangrene  of  the  lung, 
she  had  pneumothorax  and  gangrene  of  the  pleura. 

I  shall  not  dwell  on  this  kind  of  parenchymatous  gangrene,  the  history 
of  which  was  originally  written  in  a  complete  manner  by  the  author  of  the 
Traite  de  l'Auscultation  Mediate.  I  shall  only  add,  that  among  the  causes 
predisposing  to  this  affection  have  been  mentioned  excess  in  alcoholic 
stimulants,  and  inanition,  the  influence  of  the  latter  being  very  great.  In- 
deed, gangrene  of  the  lung  is  a  pretty  frequent  cause  of  death  in  insane 
persons  who  have  long  refused  to  take  food.  Finally,  let  me  remind  you 
that  hemorrhagic  nuclei  are  frequently  the  starting-points  of  this  kind  of 
gangrene,  as  is  shown  by  the  cases  published  by  Dr.  Genest,*  and  by  a  case, 
still  more  characteristic,  communicated  to  the  Anatomical  Society  of  Paris 
by  Dr.  Firmin. 

When  I  review  the  recollections  of  my  personal  experience,  when  I  con- 
sult what  has  been  written  on  this  disease,  I  am  struck  with  the  inadequacy 
of  the  signs  by  which  to  determine  the  existence  of  gangrene  of  the  lung. 

The  stethoscopic  signs  are  at  first  nearly  the  same  as  those  which  we  find 
in  cases  of  pulmonary  abscess ;  at  a  later  stage,  when  the  portions  of 
sphacelated  parenchyma  have  been  eliminated,  the  physical  signs  are 
exactly  the  same  as  those  which  reveal  the  existence  of  a  cavity  in  the 
substance  of  the  lung,  whatever  cause  may  have  produced  the  cavity. 

The  expectoration,  though  presenting  something  more  characteristic, 
does  not  always  furnish  pathognomonic  indications ;  it  is  only  the  odor 
which  has  a  decisive  import,  for  the  aspect  and  color  of  the  expectoration 
is  exceedingly  variable,  and  often  differs  in  no  respect  from  the  muco-pur- 
ulent  sputa  of  catarrh.  The  odor  is  sometimes  absent  at  the  beginning  of 
the  disease,  and  also  at  the  end  when  there  is  a  tendency  to  recovery.  The 
peculiar  gangrenous  fetor  of  the  breath  is  the  only  pathognomonic  sign  of 
gangrene  of  the  lung. 

But  even  to  this  sign  we  must  not  attach  too  much  importance,  as  it  may 
signally  deceive.     I  have  several  times  seen  circumscribed  pleurisy,  and 

*  Gexest  :  Gazette  Medicate  de  Paris. 


554  GANGRENE    OP    THE    LUNG. 

particularly  interlobular  pleurisy,  give  rise  to  symptoms  simulating  gan- 
grene of  the  parenchyma.  This  occurs  when  perforation  of  the  lung  takes 
place.  In  a  case  of  that  kind  the  pus  expectorated  is  small  in  quantity, 
and  has  at  times  a  horrible  fetor,  auscultation  furnishing  the  signs  of  a 
limited  cavity. 

When  speaking  of  dilatation  of  the  bronchial  tubes,  I  sufficiently  insisted 
on  the  fact,  observed  by  Laennec,  that  the  pulmonary  catarrhal  affection 
sometimes  assumes  a  strange  fetor,  well  fitted  to  lead  to  the  belief  that  it  is 
gangrenous  fetor.  In  certain  persons,  under  the  influence  of  violent  inflam- 
mation, the  secretion  of  the  bronchial  mucous  membrane,  like  that  from 
the  nose,  urethra,  and  vagina,  has  a  disgusting  smell,  exactly  like  the  gan- 
grenous odor;  but  as  I  pointed  out  to  you  in  our  patient,  the  fetor  of  the 
sputa,  even  when  the  gangrene  is  evident,  notably  differs  from  that  which 
is  observed  in  ordinary  parenchymatous  gangrene. 

It  is  principally  in  the  peculiar  species  of  gangrene  of  the  lung  of  which 
the  patient,  the  subject  of  the  present  lecture,  offers  an  example,  that  the 
diagnostic  difficulties  are  greatest.  Here,  in  fact,  the  signs  furnished  by 
auscultation  and  percussion  differ  in  no  respect  from  those  which  charac- 
terize catarrhal  affections  of  the  lungs,  viz.,  mucous  rales,  bronchial  blowing 
(sometimes  amphoric),  bronchophony,  all  the  phenomena  dependent  on 
pulmonary  catarrh,  on  dilatation  of  the  bronchial  tubes,  or  on  small  cavi- 
ties. This  arises  from  the  fact,  that  in  this  particular  species  of  gangrene 
of  the  lung,  the  affection  does  not  involve  the  pulmonary  parenchyma,  but 
the  extremities  of  the  minute  bronchial  ramifications. 

Here,  in  fact,  are  the  anatomical  lesions  mentioned  by  Dr.  Briquet  in  the 
two  cases  constituting  the  basis  of  his  memoir  in  the  Archives  Generales  de 
Medecine  for  1841.  The  extremities  of  the  bronchial  tubes,  dilated  into 
pouches,  form  cavities  on  the  surface  of  the  lung,  containing  a  viscid, 
grayish,  very  fetid  liquid:  the  pouches  are  lined  internally  by  a  very  soft, 
flaccid,  whitish  membrane,  which  can  be  removed  by  scratching,  and  which 
exhales  a  strong  odor  of  gangrene. 

I  was  led  to  conclude  that  our  patient  had  this  particular  form  of  gan- 
grene from  the  great  similarity  which  his  symptoms  presented  to  those  of 
which  my  friend  Dr.  Lasegue  has  drawn  the  picture.* 

A  person  of  no  particular  age,  of  constitution  more  or  less  robust,  a 
person  generally  speaking  tried  by  previous  hard  work  or  much  bad  health, 
is  seized  with  bronchitis,  which  at  first  has  no  special  characters :  the 
dyspnoea  is  not  great,  nor  is  the  cough  severe:  the  eipectoration  is  pretty 
abundant,  such  as  it  is  in  the  advanced  stage  of  bronchial  catarrh.  The 
general  health,  however,  shows  a  change  for  the  worse:  the  sputa  become 
more  profuse  and  more  purulent,  and  sometimes  their  fetor  is  such  as  to 
attract  the  attention  of  the  patient  and  of  those  who  are  with  him.  This 
first  critical  period  passes  wholly,  or  to  a  great  extent,  without  being  per- 
ceived :  the  expectoration  ami  the  fetor  diminish  or  disappear,  the  bronchitis 
however,  remaining:  there  is  little  or  no  i'cxcv. 

After  a  period,  varying  in  duration,  the  bronchitis  seems  to  revive  to  a 
certain  extent.  The  expectoration  becomes  greenish-yellow,  sometimes 
brown,  or  at  other  times  gray;  it  again  acquires  a  let  or  which  is  peculiar 
and  gangrenous:  it  increases  in  quantity,  and  may  become  exceedingly 
profuse.  Usually,  it  occurs  in  fits  during  the  daytime,  in  the  morning,  in 
the  evening,  or  during  the  eight,  leaving  intervals  of  rest  to  the  patient, 
during   which    the   breath    retains    more   or   less  of  its  disagreeable  smell: 

I,  \si';<;ei: :  Gangrfenes  Curablea  du  Poumon.     [Archives  GSntrales  de  Midecine, 

1857,  t.  ii.] 


GANGRENE    OP    THE    LUNG.  555 

strength  diminishes,  and  there  is  less  appetite:  the  digestive  functions  are 
not  much  disturbed,  and  there  is  little  or  no  fever.  On  auscultation,  we 
hear  moist  rules,  coarse  or  subcrepitant,  occupying  a  greater  or  less  extent, 
persistent  in  some  places,  disseminated,  mobile,  accompanied  or  not  accom- 
panied by  bronchial  resonance  of  the  voice,  and  without  decided  dulness: 
at  times,  there  supervene  rigors  of  short  duration,  followed  by  profuse 
spitting:  the  cough  has  no  specific  character.  This  state  of  matters  may 
go  on  from  weeks  to  months,  and  from  months  to  years,  to  the  great  detri- 
ment of  the  general  health,  which,  however,  while  it  becomes  feebler,  does 
not  reach  that  state  of  hectic  debility  characteristic  of  advanced  tubercular 
disease:  there  is  little  or  no  haemoptysis.  Notwithstanding  the  continuity 
of  the  malady,  its  activity  is  suspended  from  time  to  time,  the  expectoration 
diminishing,  for  whether  the  amendment  is  persistent  or  temporary,  it 
always  begins  by  a  diminution  in  the  expectoration :  the  fetor  gradually 
ceases,  or  suddenly  disappears.  During  the  intermissions,  the  stethoscopic 
signs  become  more  faint,  or  are  not  at  all  changed. 

If  the  patient  get  a  long  period  of  repose,  he  seems  to  become  quite 
restored :  but  if  his  rest  be  short,  the  economy  hardly  derives  any  benefit. 
Whatever  may  be  the  course  followed  by  the  disease,  from  this  point  of 
view,  the  bronchorrhoea  is  always  an  essential  fact.  It  is  excess  in  quan- 
tity, rather  than  the  nature  of  the  expectoration,  which  seems  to  exert  a 
prejudicial  influence. 

In  the  exposition  now  made  of  the  phenomena  which  characterize  this 
special  form  of  gangrene  of  the  lung,  do  you  not  find,  gentlemen,  most  of 
the  symptoms  complained  of  by  our  patient  and  observed  in  him  by  us  ? 

Although  presenting  more  than  one  point  of  resemblance  to  that  form 
of  gangrene  of  the  lung  which  may  be  called  the  classical  form,  it  essen- 
tially differs  from  the  classical  in  being  chronic  in  its  progress,  the  other 
generally  progressing  in  a  more  acute  manner.  It  differs,  too,  in  the  pre- 
dominance of  the  catarrhal  element,  in  the  expectoration  being  always 
very  abundant,  and  consisting  almost  exclusively  of  mucus  of  a  fetid  gan- 
grenous odor  ;  while  in  gangrene  of  the  parenchyma,  the  sputa  usually 
assume  an  altogether  special  appearance  of  animal  detritus. 

This  form  of  gangrene  differs  from  the  other  most  of  all  in  its  being 
relatively  a  milder  affection  ;  for  although  parenchymatous  gangrene  has 
sometimes  a  propitious  termination,  it  is  evidently  cases  of  the  kind  we 
have  now  been  observing  together  which  have  furnished  most  of  the  exam- 
ples of  recovery. 

The  cures  have  generally  been  obtained  by  pulmonary  atmidiatria.  As 
you  are  aware,  atmidiatria  is  a  method  of  treatment  which  consists  in 
administering  medicines  by  the  respiratory  passages  :  it  is  sometimes  prac- 
ticed with  a  view  to  obtain  a  general  action  on  the  economy,  as  when  chlo- 
roform is  inhaled  to  induce  ansesthesia ;  or,  at  other  times,  it  is  employed 
to  modify  an  inflammatory  state  of  the  pulmonary  apparatus. 

Inhalations  of  the  vapor  of  turpentine-water  have  been  found  of  real 
service  in  cases  of  gangrene  of  the  lung,  by  Professor  Skoda  of  Vienna, 
who  was  the  first  to  praise  them.  I  used  them  in  the  case  of  our  patient, 
employing  Richard's  fumigatory  apparatus.  This  instrument  consists  of  a 
tin  vessel,  into  which  water  is  put,  and  then  heated  by  means  of  a  spirit- 
lamp  placed  below  it.  Within  this  tin  vase  is  a  large  glass  flask,  to  which 
two  tubes  are  attached,  and  which  is  filled  with  tepid  water,  kept,  by  means 
of  this  water-bath,  at  a  temperature  between  45°  and  50°  C.  The  temper- 
ature is  regulated  by  a  thermometer  placed  in  one  of  the  tubes :  to  the 
other  tube  is  adapted  a  bent  tube  terminating  in  the  form  of  the  beak  of  a 
clarionet.     The  patient  puts  this  beak  into  his  mouth,  and  through  it  in- 


556  PLEURISY. 

spires  air  impregnated  with  the  vapor  of  the  water  contained  in  the  vessel, 
and  charged  with  the  medicinal  substance.  This  instrument  may  now  be 
replaced  by  the  spray-apparatus  of  Sales-Girons,  of  which  I  have  spoken 
to  you  on  more  than  one  occasion. 

The  spray-apparatus  allows,  as  you  are  aware,  the  vapor  of  the  medicinal 
substances  used  to  enter  the  deep  recesses  of  the  respiratory  passages — not 
only  the  vapor  of  volatile  substances,  such  as  the  essence  of  turpentine,  the 
essential  oils  of  cubebs  and  copaiba,  which  may  also  be  administered  by 
Richard's  instrument,  but  it  enables  us  to  introduce  into  the  lungs  non- 
volatile therapeutic  agents,  provided  they  are  soluble  in  water.  In  the 
form  of  gangrene  of  which  I  have  now  been  speaking,  I  have  also  made 
use  of  preparations  of  tannin,  of  solutions  of  the  extract  of  rhatany,  of  sul- 
phate of  copper,  of  corrosive  sublimate,  of  arseniate  of  soda — powerful 
modifiers,  which,  when  introduced  into  the  bronchial  tubes,  act  upon  the 
diseased  surfaces  in  a  manner  wonderfully  conducive  to  recovery.  I  need 
not  say  that  at  first  the  solutions  used  must  be  exceedingly  weak,  and  that 
their  strength  requires  to  be  slowly  increased  in  proportion  to  the  increased 
tolerance  of  the  economy. 


LECTUEE  XXXII. 

PLEURISY:    PARACENTESIS  OP  THE  CHEST. 

Pleurisy. —  Ordinary  Signs. — Skoda' s  Bruit. — Interpretation  of  the  Rubbing 
Sound. —  Crepitant  Rales  of  Pleurisy. — Persistence  of  Blowing  Sound  in 
Cases  of  Excessive  Effusion. — Blowing  Sound,  and  Amphoric  Voice,  are 
signs  of  Pleurisy. — Mistakes  in  Diagnosis  may  sometimes  occur. — Inter- 
costal Fluctuation. 

Gentlemen  :  I  readily  admit  that  in  the  immense  majority  of  cases 
pleurisy  is  an  easily  recognized  disease.  In  proof  of  the  correctness  of  thai 
statement,  I  only  require  to  remind  you  of  the  signs  of  the  disease  given 
by  all  your  classical  authors,  and  to  which  I  never  cease  to  direct  your 
attention  at  the  bedside  of  the  patient.  The  stitch  in  the  side,  the  cough, 
the  absence  of  expectoration,  the  obscurity  and  then  the  dulness  of  sound 
in  the  parts  most  dependent,  the  increased  volume  of  the  chest  on  the 
a  fleeted  side,  the  absence  of  thoracic  vibration  and  respiratory  murmur, 
the  blowing  sound,  the  regophony,  the  bronchophony,  and  other  signs,  are 
familiar  to  you. 

Nevertheless,  in  some  cases,  fortunately  very  exceptional  eases,  all  tibe 
signs  of  pleurisy  exist,  and  yet  the  autopsy  reveals  a  different  lesion. 
Quite  recently,  my  colleague  in  the  service  of  the  hospitals,  Dr.  ESmpis, 
found  all  the  signs  of  pleuritic  effusion  in  a  young  woman,  received  into  Ins 
wards  at  La  Piti6,  with  pain  in  the  right  side,  dyspnoea,  and  lever.  Per- 
cussion elicited  absolute  dulness  in  tbe  two  interior  thirds  of  the  righl  side 
of  the   cliest  :   by  auscultation,  il  was  found  that  in  the   lowe8l   pari    of  the 

righl  lung  there  was  an  almosl  total  absence  of  respiratory  murmur,  while 
in  the  two  middle  thirds,  both  before  and  behind,  there  was  very  loud 
bronchial  respiration, accompanied  bya  considerable  amounl  ofsegophony. 
The  patient  died  ;  when  it  was  discovered  thai  the  case  was  one  of  enceph- 

aloid  tumor,  and  that    theiv  did   uol   exist   the    least   ellii.-ioii    of  fluid.      Two 


PLEURISY.  557 

years  ago,  the  same  physician  communicated  to  the  Medical  Society  of  the 
Hospitals  a  curious  example  of  hydatid  cyst  of  the  liver,  which  had  push  d 
up  the  diaphragm  and  the  lung  in  such  a  manner  as  to  occupy  the  two 
interior  thirds  of  the  right  side  of  the  chest,  and  so  given  rise  to  the  Bigns 
of  pleuritic  effusion,  though  there  was  no  effusion.  I  shall  now  quote  the 
account  of  this  case,  which  has  been  published  by  Dr.  Empis. 

"When  Dr.  Monneret  intrusted  me  with  his  wards,  on  leaving  town  for 
the  holidays,  he  told  me  that  the  patient  whose  case  is  the  subject  of  the 
following  history  was  suffering  from  profuse  pleuritic  effusion,  to  effect  the 
removal  of  which  he  had  in  vain  exhausted  the  resources  of  medicine,  and 
for  which  he  thought  paracentesis  of  the  chest  was  indicated.  He  added, 
that  he  had  attempted  the  operation  some  days  previously,  but  having,  as 
he  had  thought,  made  the  puncture  too  low  clown,  he  had  not  given  exit 
to  any  fluid,  and  had,  he  believed,  penetrated  the  liver.  He  requested  me 
to  repeat  the  operation,  and  to  make  the  puncture  a  little  higher  up.  Tie 
existence  of  a  pleuritic  effusion  did  not  seem  to  be  a  matter  of  doubt. 
There  was  bronchial  blowing,  and  segophony,  than  which  nothing  could  be 
more  characteristic,  at  the  junction  of  the  superior  third  with  the  lower 
part  of  the  chest.  The  patient  was  in  a  cachectic  state,  and  was  sinking 
day  by  day.  I  concurred  in  Dr.  Monneret's  opinion  that  thoracocentesis 
was  indicated.  M.  Regnault,  the  interne,  performed  the  operation  in  my 
presence,  introducing  the  trocar  between  the  fourth  and  fifth  ribs:  greenish 
pus  immediately  issued  from  the  canula  in  such  quantity  as  to  fill  the  basin : 
then,  almost  of  a  sudden,  this  flow  of  pus  ceased,  and  could  not  be  re-estab- 
lished. The  stethoscopic  signs  were  little  changed  :  bronchial  blowing  and 
segophony  could  still  be  heard,  and  the  dulness  had  not  diminished  in  pro- 
portion to  the  quantity  of  fluid  which  had  been  drawn  off.  We  left  the 
patient  quiet  for  two  days  and  then  gave  him  an  emetic  :  he  brought  up  a 
great  quantity  of  pus.  The  pus  had  evidently  made  a  way  for  itself  through 
the  lung.  Soon  afterwards,  the  patient  died.  At  the  autopsy,  we  found 
that  there  was  no  trace  of  effusion  into  the  pleura  ;  and  that  the  disease 
was  a  large  hydatid  cyst  of  the  liver  which  had  suppurated,  and  which, 
from  the  enormous  size  it  had  acquired,  had  crushed  up  the  diaphragm 
and  the  lung  into  the  upper  third  of  the  chest,  and  so  occasioned  the  dul- 
ness and  the  signs  of  pleuritic  effusion  which  have  been  described.  This 
case  proves  that  bronchial  blowing,  segophony,  and  dulness  are  not  always 
sufficient  signs  of  effusion  into  the  pleura,  seeing  that  they  may  be  produced 
by  fluid  encysted  below  the  diaphragm  pushing  up  the  lung,  and  remaining 
in  contact  with  it."* 

I  have  spoken  to  you  a  hundred  times  of  the  modifications  which  the 
signs  of  pleurisy  may  undergo  in  various  patients  compared  with  others ; 
and  in  the  same  patient,  according  to  the  stages  of  his  disease,  as  well  as 
according  to  the  quantity  and  nature  of  the  effusion.  I  do  not  wish  to  go 
back  upon  these  points  to-day,  and  shall  limit  my  remarks  to  some  new 
signs,  certain  of  which  are  universally  accepted,  while  the  value  of  others 
is  still  under  discussion. 

Some  years  ago,  gentlemen,  the  peculiar  thoracic  resonance  described  by 
Skoda  [retenUssement  skodique]  was  recognized  by  very  few  physicians :  at 
the  present  day,  it  is  generally  admitted,  that  in  pleurisy,  on  percussing 
below  the  clavicle  and  in  the  region  nearest  to  the  sternum,  there  is  heard 
a  peculiar  semi- tympanitic  sound,  to  which  my  illustrious  colleague  of  the 
Vienna  School  was  the  first  to  draw  the  attention  of  observers . 

*  Empis:  Bulletin  de  la  Societe  MSdicale  des  Hopitaux  (Seance  du  9  Octobre, 
1861). 


558  PLEURISY. 

It  is  quite  true  that  in  some  exceptional  cases,  where  it  is  evident  that 
there  is  only  pneumonia,  Skoka's  resonance  may  be  produced,  as  I  have 
repeatedly  pointed  out  to  you  at  the  bedside.  Other  physicians,  among 
whom  is  Dr.  Woillez,  have  arrived  at  the  same  conclusion  with  me  on  this 
point ;  but  this  sign  is  almost  never  absent  in  pleurisy,  when  the  effusion 
does  not  come  up  above  the  fourth  rib,  and  it  is  only  met  with  exceptionally 
when  pneumonia  exists  alone,  uncomplicated  with  pleurisy. 

-I  must,  however,  gentlemen,  somewhat  limit  the  statement  I  have  now 
made.  I  have  told  you  that  a  patient  may  have  pleuritic  effusion,  although 
by  the  most  attentive  examination  we  cannot  hear  blowing,  segophony,  or 
bronchophony ;  and  when  no  other  signs  can  be  discovered,  except  dulness 
and  absence  of  the  respiratory  murmur.  I  lately  received  in  bed  6  St. 
Bernard's  Ward  a  woman,  who,  along  with  serious  lesions  of  the  heart,  had 
pleuritic  effusion  on  the  right  side.  Not  finding  the  usual  signs  of  the  dis- 
ease, I  carefully  practiced  auscultation  every  day,  but  I  never  once  heard 
blowing,  segophony,  or  bronchophony.  Although  there  were  no  other  phys- 
ical signs  than  dulness,  with  absence  of  vibration  and  respiratory  murmur, 
I  had  no  hesitation  in  affirming  that  there  was  effusion.  At  the  autopsy, 
I  found  so  great  an  amount  of  serous  fluid  in  the  pleura,  that  I  exceedinglv 
regretted  not  having  performed  paracentesis  of  the  chest. 

You  are  aware  that  the  friction-sound  has  been  considered  as  a  precious 
diagnostic  sign  of  pleurisy.  At  the  beginning  of  an  attack,  before  any 
effusion  has  taken  place,  or  while  the  quantity  of  fluid  is  as  yet  very  small, 
the  sound  is  supposed  to  be  produced  by  the  respiratory  movements  causing 
a  rubbing  upon  one  another  of  the  two  folds  of  pleura,  the  surfaces  of  which 
are  covered  with  a  thin  layer  of  fibrinous  exudation.  Towards  the  close  of 
the  pleurisy,  when  the  diminished  quantity  or  complete  absorption  of  the 
effused  fluid  permits  the  two  pleural  surfaces  to  come  into  contact,  the  fric- 
tion-sound is  attributed  to  their  being  coated  with  false  membrane,  more  or 
less  thick  and  resisting. 

Gentlemen,  the  real  friction-sound  of  pleurisy  is  much  more  rare  than  is 
generally  said  and  believed. 

I  have  seldom  had  an  opportunity  of  hearing  it  at  the  beginning  of  a 
pleurisy,  a  circumstance  sufficiently  explained  by  the  fact,  that  I  am  seldom 
called  in  at  that  early  stage  of  the  disease  ;  and  that  a  few  hours  are  sufficient 
to  allow  a  more  or  less  considerable  effusion  to  take  place.  It  is  generally 
towards  the  end  of  the  attack  that  we  have  the  best  opportunity  of  recog- 
nizing the  sound  produced  by  the  rubbing  of  the  pleural  surfaces.  1  again 
repeat  that  this  friction-sound  is  much  less  common  than  has  been  alleged. 

I  wish  to  put  an  end  to  any  misunderstanding  with  the  physicians  who  do 
not  concur  in  that  opinion. 

In  the  first  place,  the  kind  of  sound  which  is  heard  at  the  beginning  of 
an  attack  of  pleurisy,  resembling  the  rustling  produced  by  the  friction  of 
two  sheets  of  very  fine  criBp  paper,  and  to  which  the  name  of  friction-sourid 
[bruit  dr  j'n,lh  im  ,il  \  has  been  given,  18  in  my  opinion  a  blowing  sound.  1 
base  this  opinion  on  the  following  considerations.  If  you  auscull  your 
patient  twice  or  thrice  a  day  you  will  find  thai  this  alleged  friction-sound 
becomes  more  and  more  harsh,  till  at  the  end  of  twenty-four  or  forty-eight 

hours,  it  has  become  a  true  blowing  sound  [irritable  hntil  </<■  souffU  |  such  as 
may  lie  heaid  in  pneumonia.  The  voice  at  the  same  t  ime  has  a  di.M  inct 
segophonic  resonance,  ami,  in  proportion  to  the  degree  in  which  the  friction 
becomes  decided,  the  voice  passes  from  a  Ideating  bronchial  resonance  to  a 

pure  bronchial  resonance  [d  l'6gobronchophonie}  enfin  a  la  bronchophonie  la 
plus  nette],     I  am  consequently  justified  in  declining  to  call  the  sound  in 


PLEURISY.  559 

question  a  friction-sound,  and  to  regard  it,  with  many  other  clinical  ob- 
servers, aa  a  modification  of  bronchial  blowing. 

The  friction-sound  heard  in  the  decline  of  a  pleurisy  also  demands  a  few 
explanatory  words.  Quite  at  first,  when  coexistent  with  the  pleurisy  there 
is  pulmonary  emphysema  or  chronic  bronchitis,  we  sometimes  hear  vibrating 
rales,  which  continue  audible  for  a  long  time  in  the  same  part  of  the  lungs, 
and  which  resemble  so  much,  as  to  be  liable  to  be  mistaken  for,  the  peculiar 
sound  produced  by  rubbing  the  point  of  the  finger  on  the  hand  when  the 
skin  is  dry,  or  by  pressing  a  bit  of  snow  between  the  fingers;  but  if  this 
sound  continue  at  a  determinate  part  of  the  lung,  particularly  in  the  ante- 
rior, middle,  and  lateral  regions,  if  it  continue  to  be  found  after  we  have 
made  the  patient  cough  and  expectorate,  it  is  hardly  possible  to  confound 
it  with  a  sonorous  rale — it  is  then  the  friction-sound,  the  existence  of  which 
I  never  had  the  least  intention  to  deny. 

Again,  there  is  a  sound  of  another  kind  which  is  heard  at  the  end  of  a 
pleuritic  attack,  which  has  also  been  regarded  as  a  friction-sound:  it  re- 
sembles fine  crepitation,  and  is  a  very  different  sound  from  that  about  which 
I  have  been  speaking.  This  sound,  which  is  met  with  in  the  great  majority 
of  cases  of  pleurisy,  is,  in  fact,  a  crepitant  rale;  and  I  have  called  it  the 
crepitant  rale  of  pleurisy.  My  interpretation  of  it  is  very  simple.  Just  as 
we  never  have  erysipelas  without  engorgement  of  the  cellular  tissue,  there 
cannot  be  erysipelas  of  the  pleura,  or  pleurisy,  without  an  irritative  en- 
gorgement of  the  subpleural  cellular  tissue  or  of  the  peripheric  pulmonary 
parenchyma.  This  fluxion  naturally  carries  with  it  into  the  pulmonary 
vesicles  a  serous  exudation  analogous  to  that  of  pulmonary  oedema.  We 
also  meet  with  a  fine  subcrepitant  rale,  which  is  very  often  heard  quite  at 
the  beginning  of  the  pleurisy,  and  which  likewise  nearly  always  continues 
for  some  weeks,  when,  the  fluid  being  absorbed,  there  only  remains  sub- 
inflammatory  oedema  of  the  more  superficial  parts  of  the  lung. 

I  must  not  forget  to  mention  a  sign  to  which  I  have  already  often  called 
your  attention :  I  refer  to  the  persistence  of  bronchial  blowing  and  bron- 
chophony in  cases  of  excessive  effusion.  I  had  long  believed,  on  the  state- 
ment of  my  teachers,  and  of  the  best  authors  on  the  subject,  that  the  blow- 
ing disappeared  when  the  effusion  became  considerable;  but  after  I  had 
many  times  performed  the  operation  of  paracentesis  of  the  chest,  I  became 
convinced  that  not  unfrequently,  in  cases  in  which  the  effusion  amounts  to 
several  litres,  and  when  the  dulness  extends  up  to  the  clavicle,  when  the 
diaphragm  is  pushed  out  of  place,  and  the  intercostal  spaces  dilated,  bron- 
chojihony  and  the  blowing  sound  continue  up  to  the  very  moment  at  which 
the  trocar  affords  an  exit  to  the  fluid.  You  recollect  that  I  have  often  in- 
vited you  to  ascertain  for  yourselves  the  presence  of  this  sign  ;  and  you  also 
had  an  opportunity  of  observing,  in  the  same  cases,  that  when  the  puncture 
was  made,  there  was  a  large  quantity  of  fluid  evacuated. 

Gentlemen,  in  cases  of  pleurisy  we  often  meet  with  all  the  stethoscopic 
signs  which  belong  to  the  third  stage  of  tubercular  phthisis.  The  attention 
of  practitioners  has  been  particularly  called  to  this  important  point  in 
diagnosis  by  Drs.  Rilliet  and  Barthez,*  Dr.  Behier,t  and  (more  recently; 
Dr.  Landouzy.t     It  is  now  a  recognized  fact  in  medical  science;  and  if — 

*  Barthez  et  Rilliet:  Sur  quelques  Phenomenes  Stdthoseopiques  rarement 
observes  dans  la  Pleurisie  Chronique.     [Archives  Gen   de  Medecine,  March,  1853] 

f  Bkhier:  Note  sur  un  Souffle  Amphorique  observe  dans  cb-ux  eas  de  Pleurisie 
Purulente  Simple  du  cote  droit.     [Archives  Gen.  de  Medecine,  August,  1854.] 

%  Lasdoi'Zy  :  Nouvellea  Donnees  sur  le  Diagnostic  de  la  Pleurisie  et  les  indica- 
tions de  la  Thoracocentese.  [Archives  Gen.  de  Medecine,  November  and  December, 
1856.] 


560  PLEURISY. 

as  I  am  about  to  tell  you — there  is  still  a  risk  of  committing  great  mistakes 
in  diagnosis,  it  is  not  the  less  incumbent  on  us  to  bear  in  mind  that  till  the 
publication  of  the  researches  of  the  physicians  whom  I  have  just  named, 
this  curious  point  in  the  history  of  pleurisy  had  not  been  well  studied. 

Amphoric  respiration,  gurgling,  and  cavernous  voice  are  sometimes  so 
well  marked,  that  it  is  impossible  to  avoid  attributing  them  to  the  existence 
of  cavities  in  the  lungs,  particularly  when  the  sounds  emanate  from  the 
summit  of  the  lung;  and  even  when  they  are  heard  towards  the  inferior 
angle  of  the  scapula  the  same  idea  presses  itself  upon  us,  so  identical  seems 
the  gurgling  and  blowing  with  similar  sounds  proceeding  from  large  exca- 
vations in  the  centre  of  the  pulmonary  parenchyma. 

But,  nevertheless,  the  mode  in  which  the  disease  commences  and  pro- 
gresses, the  dulness  of  the  dependent  parts,  the  disjDiacement  of  neighboring 
organs,  the  volume  of  the  chest,  the  absence  of  lesions  at  the  summit  of  the 
lungs,  iu  a  word,  the  general  condition  of  the  individual,  usually  enable  us 
to  form  a  diagnosis.  However,  it  is  sometimes  difficult  to  avoid  error.  In 
the  memoir  of  Drs.  Barthez  and  Rilliet,  you  will  find  a  very  interesting  case 
in  which  a  mistaken  diagnosis  was  formed  by  a  very  experienced  physician. 

In  acute  or  chronic  pleurisy,  what  are  the  conditions  which  give  rise  to 
gurgling,  and  to  amphoric  breathing,  voice,  and  cough?  Drs.  Barthez 
and  Rilliet,  recollecting  that  in  a  case  of  pleurisy  complicated  with  pneu- 
monia they  had  observed  increase  of  the  bronchial  blowing,  were  led  to 
think  that  in  chronic  pleurisy  with  bronchial  respiration  of  cavernous  tone, 
there  existed,  along  with  the  effusion,  more  or  less  induration  of  the  pul- 
monary parenchyma.  Dr.  Behier  says  that  the  amphoric  sound  is  not 
heard  in  cases  of  effusion  into  the  pleura,  unless  the  lung,  compressed  and 
indurated,  is  in  contact  with  the  trachea  or  one  of  the  large  bronchial  tubes. 
We  can  understand  that  the  laryngeal  sounds  may  assume  an  amphoric 
tone  by  transmission  through  indurated  lung  and  through  effusion  com- 
pressing tubes  of  large  calibre,  such  as  one  of  the  chief  divisions  of  the 
trachea :  then  again,  if  the  trachea  or  bronchial  tubes  contain  a  certain 
quantity  of  mucous  secretion,  the  beating  about  of  that  fluid  by  the  air 
will  produce  gurgling.  This  explanation  given  by  Dr.  Behier,  and  not 
very  different  from  that  formerly  furnished  by  Drs.  Barthez  and  Rilliet,  is 
applicable  to  some  cases,  but  not  to  all. 

It  appears  that  when  extensive  effusion  takes  place  into  the  cavity  of  the 
pleura,  the  lung,  pushed  up  to  the  top  of  the  chest  and  into  the  hollow  of 
the  vertebral  column  towards  the  root  of  the  bronchi,  is  in  a  condition 
favorable  to  the  production  of  'amphoric  sounds:  but  that  nevertheless  they 
are  not  always  produced.  It  also  appears,  however,  that  amphoric  sounds 
may  be  produced  when  the  effusion  is  so  small  in  quantity  as  to  allow  the 
lung  to  retain  very  nearly  its  normal  relations.  The  ease  which  1  am  now 
going  to  describe  afforded  you  an  opportunity  of  verifying  this  statement 
for  yourselves. 

On  the  14th  April,  1862,  a  woman  aged  twenty-one,  became  the  occu- 
pant of  bed  30,  St.  Bernard's  Ward.  She  had  been  confined  at  the  hos- 
pital of  Lariboisierc  on  an  early  day  in  November,  I  Kb]  ;  and  a  few  days 
alter  delivery,  she  had  had  sonic  affection  of  the  right  side  of  the  pelvis. 
This  affection  could  not  have  been  serious,  for  she  was  aide  lo  Leave  the 
hospital    fifteen    days   after    the    birth   id'  the   child.      From    that  time,  she 

had  fever  and  vomiting  at  each  menstrual  period.  On  the  first  occasion 
of  my  examining  her,  1  discovered  a  large  tumor  in  the  right  iliac  fossa; 

it  reached  up,  on  both  sides,  to  the  crest  id' the  ilium,  and  descended  to  the 
lateral  parts  of  the  pelvis,  posteriorly  enveloping  the  uterus,  which  was 
inclosed  by  it.    The  tumor,  \\  bich  seemed  to  me  t.>  be  a  pelvic  abscess,  very 


PLEURISY.  501 

slowly  diminished  in  size,  and  in  a  month  had  nearly  disappeared.  As  it 
did  not  occasion  any  unfavorable  symptoms,  it  was  let  alone,  so  that  I 
might  attend  to  the  patient's  other,  and  much  more  important,  pathological 
conditions — conditions  upon  which  I  now7  wish  to  fix  your  special  attention. 

On  the  18th  April,  that  is  to  say  four  days  after  admission  to  the  hos- 
pital, our  young  patient  complained  of  pain  at  a  particular  spot  of  the  left 
side.  Auscultation  did  not  disclose  to  us  any  signs  other  than  those  of 
acute  general  catarrh.  The  chest  symptoms  seemed  to  be  improving,  when 
on  the  29th  April,  that  is  to  say,  nine  days  from  the  beginning  of  the  bron- 
chitis and  the  stitch  in  the  side,  she  showed  evident  signs  of  pleurisy  on  the 
right  side  ;  and  at  the  same  time  we  detected  an  obscure  blowing  sound  and 
subcrepitant  rales  over  the  angle  of  the  left  scapula.  We  had,  therefore, 
a  case  of  double  pleurisy,  complicated  with  slight  bronchopneumonia. 
During  the  following  days,  the  signs  on  the  right  side,  which  were  those  of 
pleurisy,  viz.,  absolute  dulness,  bronchial  blowing  at  the  base,  aegobronch- 
ophony  within  the  limits  of  the  situation  occupied  by  the  effusion,  became 
more  and  more  decided :  on  the  left  side,  I  only  found  segophony  aloug  the 
vertebral  column  ;  but  at  the  same  time,  I  heard  gurgling,  and  moist  crack- 
ling such  as  is  observed  at  the  summit  of  the  lungs  when  full  of  softening 
tubercular  masses. 

While  -the  stethoscopic  signs  on  the  left  side  remained  without  any  sen- 
sible change,  those  which  characterized  the  effusion  on  the  right  side  became 
more  and  more  decided.  Paracentesis  was  resolved  upon.  The  operation 
was  performed  by  Dr.  Dumonpallier,  who  followed  the  rules  and  observed 
the  precautions  which  I  have  long  ago  laid  down.  Nine  hundred  grammes 
[about  a  quart]  of  a  purely  limpid  serosity  were  withdrawn.  The  opera- 
tion was  followed  by  a  great  amelioration  in  the  state  of  the  patient ;  but 
the  serous  effusion  rapidly  reaccumulated,  and  in  four  days  it  w7as  necessary 
to  tap  a  second  time.  It  was  the  last  time ;  for  there  was  no  recurrence  of 
the  effusion :  the  dulness,  however,  continued  up  to  the  end,  and  eight  days 
before  death,  there  was  heard  slight  aegophony  near  the  angle  of  the  right 
scapula.  A  few  days  after  the  operation,  a  new  morbid  cardiac  sound  was 
heard. 

On  the  4th  May,  I  began  to  hear  distinctly  on  the  left  side,  principally 
near  the  angle  of  the  scapula,  a  blowing  sound,  amphoric  respiration,  and 
amphoric  gurgling.  From  day  to  day,  the  amphoric,  cavernous  gurgling 
and  respiration  were  objects  of  attention  :  they  continued  to  be  heard  up  to 
the  death  of  the  patient.  Each  day,  five  or  six  persons  verified  the  stetho- 
scopic signs.  Dr.  Landouzy  of  Rheims,  who  was  at  the  time  on  a  few 
days'  visit  to  Paris,  honored  me  with  his  presence  at  the  visit ;  and  after 
examining  the  patient,  had  no  hesitation  in  concurring  with  my  opinion, 
to  the  effect  that  bronchitis  and  pleurisy  existed  on  the  left  side.  Pay 
particular  attention  to  the  fact,  that  while  we  heard  mucous  and  subcrepi- 
tant rales  in  the  middle  and  lowTer  parts  of  both  lungs,  nothing  of  the  kind 
could  be  observed  in  their  summits. 

Upon  comparing  the  signs  furnished  by  auscultation  and  percussion  in 
the  case  of  this  young  woman,  with  the  signs  found  in  phthisical  subjects, 
it  will  be  seen,  that  there  is  no  difference  in  the  seat  of  the  sounds.  The 
expectoration  was  always  that  of  bronchitis:  there  were  no  sputa  coming 
from  large  cavities,  nor  was  there  any  expectoration  from  pulmonary  or 
pleural  vomicae.  The  effusion  was  apparently  diminishing,  the  dulness  was 
not  complete,  and  was  non-existent  above  the  inferior  angle  of  the  scapula, 
but  the  amphoric  blowing  and  the  gurgling  continued  in  the  dependent 
part  of  the  lung,  and  along  the  vertebral  column.  The  patient  very  soon 
had  oedema  of  the  extremities  and  puffiness  of  the  face ;  but  the  urine  did 
vol.  i.— 36 


562  PLEURISY. 

not  contain  any  albumen.  She  rapidly  lost  strength  from  intractable 
diarrhoea.  The  oppression  in  breathing  became  greater;  and  up  to  the 
evening  before  her  death,  the  amphoric  respiration  and  gurgling  were 
heard  in  the  situation  already  described.  I  shall  at  present  only  notice 
the  anatomical  lesions  which  were  found  in  the  lung.  The  right  lung  was, 
in  its  whole  extent,  adherent  to  the  costal  pleura  :  there  was  no  trace  of 
tubercle ;  and  the  bronchial  tubes  were  filled  with  muco-purulent  secretion. 
The  left  lung  was  elastic,  free  from  all  adhesions,  devoid  of  tubercle  and 
all  other  abnormal  deposits.  On  making  a  section  of  the  lung,  muco- 
purulent matter  flowed  from  the  divided  bronchial  tubes.  The  sac  of  the 
pleura  contained  from  300  to  400  grammes  [nearly  a  pint]  of  yellow 
serosity  unmingled  with  fibrinous  deposits:  there  was  no  false  membrane 
on  the  surface  of  the  lung.  The  pleural  effusion  then  was  inconsiderable, 
and  the  lung  was  hardly  at  all  compressed,  although  the  amphoric  blow- 
ing had  been  heard  on  the  evening  preceding  death. 

It  must,  therefore,  gentlemen,  be  accepted  as  an  unquestionable  fact, 
that  amphoric  blowing  may  exist  without  the  lung  being  indurated  or 
crushed  up  in  a  mass  [sans  tassement]  ;  without  there  being  any  adhesions, 
or  any  pseudo-membranous  deposits  on  the  pleura  ;  and  finally,  without 
there  being  any  compression  of  the  large  bronchial  trunks.  The  gurgling 
sound,  the  seat  of  which  was  in  bronchial  tubes  filled  with  muco-purulent 
secretion,  was  transmitted  to  the  ear  by  superficial  compression  of  the  lung 
in  the  situation  of  the  pleural  effusion.  It  appears  then,  that  other  con- 
ditions besides  those  mentioned  by  Drs.  Barthez,  Pulliet,  and  Behier  may 
give  rise  to  amphoric  sounds. 

It  is  curious  to  observe  what  takes  place  during  the  flow  of  the  serum 
from  the  puncture  made  by  the  trocar,  as  well  as  what  occurs  subsecpient 
to  that  operation.  Proportionately  to  the  escape  of  the  fluid,  the  displaced 
organs  resume  their  normal  position  :  the  chest  tends  to  return  to  its  natural 
shape  ;  and  very  soon  the  play  of  the  ribs  and  diaphragm  is  again  seen. 
Skoda's  resonance  ceases,  and  the  lung  expands:  although  dulness  is  per- 
sistent over  the  greater  part  of  the  chest,  we  can  discover,  on  applying  the 
ear,  rales  of  variable  volume,  rales  deepseated  and  distant  ;  and  frequently, 
it  is  not  till  after  the  lapse  of  some  time  that  the  blowing  and  segophony 
disappear.  Let  me  now  state  what  is  generally  observed  in  cases  of  acute 
effusion,  when  the  puncture  is  made  ere  the  lung  has  contracted  adhesions, 
and  before  it  has  become  incased  in  thick,  resisting,  undilatable  false  mem- 
brane. In  effusion  of  old  date,  the  lung  is  enveloped  in  thick  false  mem- 
brane, the  thoracic  walls  are  immovable,  and  it  is  only  the  displaced 
abdominal  organs  which  regain  their  normal  position  consequent  upon  the 
draining  off  of  the  fluid:  the  hum-,  impermeable  to  air,  remains  fixed  in  the 
vertebral  hollow:  rales  are  no  longer  -audible:  if  blowing  and  segophony 
existed  before  the  puncture,  they  remain,  and  are  sometimes  louder  than 
previously.  The  enunciation  of  these  phenomena,  which  are  described  in 
a  memoir  by  Dr.  Landouzy,  show,  that  effusion  of  fluid  into  the  pleura 
has  not  in  itself  the  power  to  produce  blowing  sounds  and  tremulous  voice, 

I  am  verv  far,  therefore,  from  professing  Laennec's  theory,  a  theory 
accepted  by  all,  which  attributes  the  metallic  tinkle.  Punch  and  Judy 
tone,  or  goat-like  sound  of  the  voice,  to  the  presence  of  more  or  less  fluid 
in  the  pleura.      Bui    IS    it    COITecl  to  conclude  that  the  effusion  has  no  part 

in  producing  bronchial  blowing,  amphoric  blowing,  and  segophony  ?  No: 
hut  the  effusion  operates  in  the  production  of  these  sounds  only  by  com- 
pressing the  Lung,  condensing  it,  so  rendering  it  a  better  conductor  of  the 
sound  produced    in    the   bronchial   tubes,  or  only  transmitted  by  them  and 

the  trachea.    The  fluid,  consequently,  acts  in  the  same  way  as  false  mem- 


PLEURISY.  563 

brane,  bv  tightly  squeezing  the  lung,  so  that,  in  extreme  cases  of  effusion, 
the  blowing,  as  well  as  the  segophony,  arc  sometimes  persistent.  Let  me 
remark,  however,  that  bronchophony  is  more  usually  observed  in  these 
cases,  and  that  it  is  the  almost  necessary  companion  of  bronchial  blowing. 
JEgophony,  with  its  different  modalities,  is,  nevertheless,  a  very  valuable 
diagnostic  sign  in  eases  of  moderate  pleuritic  effusion. 

Gentlemen,  while  in  many  eases  of  pleurisy,  we  find  all  the  signs  which 
belong  to  the  third  stage  of  tubercular  phthisis,  and  while  under  such  cir- 
cumstances an  error  in  diagnosis  is  excusable,  it  also  sometimes  happens 
that  patients  presenting  all  the  signs  of  that  form  of  pleurisy  on  which  Drs. 
Killiet,  Barthez,  Behier,  Landouzy,  and  I  have  so  much  insisted  are  really 
phthisical  subjects,  in  whom  the  disease  is  localized  in  the  middle  and  lower 
parts  of  the  lung,  and  in  whom  there  likewise  exists  chronic  phlegmasia  of 
the  pleura,  which  is  necessarily  present  when  the  tubercular  lesion  is  in  a 
very  advanced  stage. 

You  no  doubt  distinctly  remember  a  young  woman  who  lay  in  bed  28  of 
St.  Bernard's  Ward,  with  whose  case  our  attention  was  particularly  occu- 
pied for  a  whole  month.  I  shall  now,  in  a  summary  manner,  state  the 
history  of  her  case. 

The  patient,  eighteen  years  of  age,  who  had  been  subject  to  cough  for 
two  months,  but  had  only  been  confined  to  bed  for  a  fortnight,  was  admit- 
ted to  St.  Bernard's  Ward  on  the  23d  May,  1863.  The  disease  began  like 
bronchitis  with  severe  catarrh.  There  had  been  no  hsemoptysis.  The  fever 
was  slight.  The  expectoration  was  mucous  and  scanty.  There  was  a  little 
pain  on  the  right  side  of  the  chest.  Diarrhoea,  accompanied  by  abdominal 
pain,  had  existed  for  a  fortnight. 

The  resonance  of  the  chest  was  normal  on  the  left  side,  both  at  base  and 
summit ;  but  on  the  right  side,  there  was  complete  dulness  posteriorly  of 
the  two  lower  thirds,  the  resonance  of  the  summit  being  good.  Auscul- 
tation of  the  left  side  only  revealed  vibrating  or  mucous  rales  disseminated 
in  the  middle  and  inferior  but  not  in  the  upper  part  of  the  lung :  on  the 
right  side,  at  the  summit,  there  were  no  signs  more  marked  than  those  found 
in  the  corresponding  region  on  the  left  side ;  but  in  the  situation  where 
there  was  dulness  on  the  left  side,  that  is  to  say  about  the  middle  of  the 
chest,  there  were  coarse  rales,  blowing  sounds,  and  amphoric  voice. 

The  diagnosis  was — general  bronchitis,  and  pleurisy  on  the  right  side 
with  amphoric  sounds.  This  diagnosis  was  based  on  the  progress  of  the 
disease,  on  the  nature  and  small  quantity  of  the  expectoration,  and  on  the 
seat  of  dulness  and  abnormal  sounds. 

For  a  fortnight,  matters  remained  in  this  position  ;  and  at  the  end  of  that 
period,  there  was  a  marked  increase  of  fever  and  diminution  of  strength. 
Mucous  rales  were  heard  at  the  summit  of  the  left  lung :  but  it  was  in  the 
centre  of  the  lung  that  the  rales  were  most  numerous  and  the  bullae  least 
voluminous :  towards  the  base,  they  were  as  stationary  as  in  capillary  bron- 
chitis.    On  the  right  side,  the  respiration  and  the  voice  were  amphoric. 

From  the  twentieth  day  after  her  admission,  she  had  a  paroxysm  of  fever 
every  evening :  her  general  state  became  very  bad :  her  aspect  was  that  of 
an  individual  with  typhoid  fever :  she  had  headache,  noises  in  the  ears, 
deafness,  and  giddiness  when  standing  upright.  Her  tongue  was  dry,  and 
she  had  urgent  thirst.  She  had  passed  her  motions  involuntarily  for  two 
days. 

On  the  25th  day,  I  heard  on  the  left  side,  and  for  the  first  time,  gurgling 
and  amphoric  blowing  in  the  subspinous  fossa  of  the  scapula :  some  rales 
had  an  almost  metallic  resonance.  The  rales  continued  to  predominate  at 
the  base,  towards  which  situation  thev  were  more  numerous,  finer,  and 


564  PLEURISY. 

nearly  crepitant.  In  the  middle  of  the  right  side  of  the  chest,  towards  the 
vertebral  hollow,  there  were  still  heard  the  blowing  sound,  rales,  and  ampho- 
ric voice.  The  expectoration  remained  mucous  and  scanty  :  in  the  twenty- 
four  hours,  she  only  filled  a  fourth  part  of  her  spittoon. 

Death,  which  had  been  foreseen,  in  consequence  of  the  rapid  wasting  of 
the  body  and  the  intensity  of  the  fever,  occurred  on  the  22d  June,  exactly 
a  month  from  the  date  of  the  patient's  admission  to  our  wards. 

At  the  autopsy,  there  was  found  general  tubercular  peritonitis,  and 
ulcerations  of  the  intestine,  which  explained  the  persistent  diarrhoea. 
During  life,  the  existence  if  these  lesions  was  not  indicated  by  any  pain  in 
the  abdomen. 

There  was  very  little  fluid  found  in  the  right  pleural  sac,  although  the 
thoracic  pleura  was  injected  with  blood  and  studded  with  crude  tubercle. 
There  were  no  pulmonary  adhesions.  The  two  inferior  thirds  of  the  right 
lung  were  transformed  into  an  almost  compact  mass.  In  the  vertebral 
hollow,  the  situation  in  which  the  amphoric  sounds  had  been  heard,  there 
was  a  tubercular  mass,  the  size  of  a  small  orange,  presenting  the  aspect  and 
consistence  of  mastic.  In  its  most  superficial  part,  there  was  hollowed  out 
a  cavern  the  size  of  a  small  filbert-nut,  separated  from  the  surface  of  the 
lung  by  a  partition  which  at  most  did  not  exceed  two  millimetres  in  thick- 
ness :  in  the  neighborhood  of  the  cavity  now  described,  there  were  five  or 
six  smaller  ones  in  course  of  formation.  A  tolerably  large  cavity  and  three 
smaller  ones  were  found  at  the  base  of  the  lung,  which  was  bound  to  the 
diaphragm  by  close  and  almost  cartilaginous  adhesions.  The  summit  of 
the  lung  was  supple  and  crepitant.  When  cut  into,  the  section  showed 
tubercular  granulations,  which  at  certain  points  were  joined  together  in 
twos  or  threes.  Around  the  tubercular  masses,  the  pulmonary  tissue 
seemed  healthy  and  perfectly  permeable  to  air. 

At  the  middle  of  the  upper  lobe  of  the  left  lung,  there  was  found  a  cavity 
large  enough  to  contain  a  hazel-nut :  around  this  cavity  were  three  much 
smaller  cavities,  which  accounted  for  the  cavernous  rales  with  metallic 
resonance  heard  during  the  latter  days  of  life.  Throughout  this  lobe, 
numerous  crude  tubercles  were  disseminated.  We  found  pulmonary  ob- 
struction, and  concomitant  bronchitis.  The  inferior  lobe  was  everywhere 
pervaded  by  tubercles  :  in  its  superior  part,  there  were  crude  tubercles,  and 
at  the  base  gray  granulations. 

The  patient,  though  a  woman  in  respect  of  development  of  organs,  was  a 
child  when  regarded  from  a  pathological  point  of  view.  She  had  the 
tuberculization  of  childhood — generally  disseminated  and  not  circumscribed 
tuberculization — the  acute  and  not  the  chronic  form  of  the  disease.  Not 
only  had  she  tubercles  almost  everywhere;  but  the  pulmonary  tuberculiza- 
tion exhibited  that  irregularity  in  localization  which  is  peculiar  to* child- 
hood, that  is  to  say,  a  development  of  the  disease  proceeding  sometimes 
from  the  base  to  the  summit,  and  not  always  from  the  summit  to  the  base, 
as  in  the  adult.  The  result  was  an  occurrence,  quite  exceptional  in  a 
woman,  though  perfectly  usual  in  a  very  young  child, — the  formation  of 
cavities  at  the  base  of  the  lungs  before  tubercles  had  appeared  in  their 
summits. 

You    now    understand    how,  taking    into   accounl    the    rarity   of  cavities 

being  produced  at  the  base  of  the  lungs  in  the  adult,  when  none  exisl  in 
their  upper  parts,  and  on  the  oiler  hand,  considering  that  pleurisy  witli 
Bigns  of  cavities,  thougb  in  itself  unusual,  is  more  frequently  met  with  than 
thai  rare  form  of  tubercular  disease,  it  was  more  rational  to  conclude  that 

the  young  woman  had  pleurisy  than  tuberculization. 

Gentlemen,]  have  still  a  few  words  to  say  regarding  intercostal fluctna- 


PLEURISY:     PARACENTESIS    OF    THE    CHEST.  565 

Hon,  a  sign  which  appears  to  me  to  have  a  certain  degree  of  importance, 
because,  in  cases  of  effusion  into  the  pleura,  ii  confirms  the  information 
furnished  by  thoracic  dulness.  Surgeons  have  pointed  out  that  fluctuation 
in  the  intercostal  spaces  is  met  with  in  eases  in  which  purulent  effusion  has 
formed  an  exit  for  itself  through  the  thoracic  walls;  but  I  am  not  aware 
that  intercostal  fluctuation  has  been  described  as  a  sign  of  pleural  effusion. 
Let  me  explain  to  you  how  I  was  led  to  suspect,  investigate,  detect,  and 
finally  to  produce  at  pleasure  this  special  fluctuation. 

In  practicing  percussion,  I  had  for  a  long  time  been  in  the  habit  of 
employing  a  pleximeter  and  a  hammer.  When  measuring,  in  my  hospital 
patients,  by  striking  on  the  pleximeter,  the  extent  of  the  dulness  discovered, 
the  hypothenar  region  of  my  left  hand  resting  on  the  wall  of  the  chest,  I 
felt  that  at  each  stroke  of  the  hammer  an  impulse  was  conveyed  to  the 
pleximeter.  With  a  view  to  ascertain  whether  or  not  the  vibrations  were 
imparted  by  the  hammer  to  the  chest,  and  transmitted  by  the  ribs,  I  so 
placed  my  hand  that  its  hypothenar  region  chiefly  rested  on  an  intercostal 
space ;  I  thought  I  then  felt  fluctuation.  Placing  the  palmar  surface  of 
my  index  finger  upon  an  intercostal  space  (I  percussed  between  different 
intercostal  spaces)  I  distinctly  felt  fluctuation  at  each  stroke:  by  making 
repeated  experiments,  I  was  easily  able  to  determine  the  difference  between 
the  vibrations  transmitted  by  the  thoracic  Avails  and  by  the  fluctuation  of  the 
fluid.  In  thoracic  vibration,  there  was  felt  under  the  hand  the  vibration 
of  a  mass,  whereas  on  applying  the  palmar  surface  of  the  index  finger  to 
an  intercostal  space,  the  sensation  was  that  of  a  fluctuating  liquid.  This 
fluctuation,  which  many  of  you  have  been  able  to  verify  along  with  me,  is 
not  at  all  a  matter  of  doubt,  when  the  observer  proceeds  in  the  manner  I 
have  now  described.  By  a  little  practice  one  easily  acquires  the  art  of 
detecting  the  fluctuation.  I  must  add  that  it  is  not  easily  perceived,  when 
there  is  a  large  amount  of  effusion.  I  do  not  wish  to  attach  too  much 
importance  to  this  sign  ;  but  I  think  it  is  one  which  deserves  to  be  men- 
tioned. 

Before  speaking  to  you  of  paracentesis  of  the  chest,  an  important  subject 
which  will  occupy  us  during  several  meetings,  I  was  anxious  to  discuss  some 
of  the  new  questions  connected  with  the  diagnosis  of  pleurisy.  It  will  be 
easier  for  me  to  lay  before  you  what  I  have  to  say  upon  puncturing  the 
chest,  now  that  I  do  not  require  to  digress  from  my  principal  subject,  to 
explain  details  regarding  the  diagnosis  of  effusion. 


Paracentesis  of  the  Chest. —  Cases. — Historical  Sketch  of  the  Operation  for 
Effusion  into  the  Cavity  of  the  Pleura. 

In  1855,  I  performed  paracentesis  of  the  chest  in  a  female  patient  of 
thirty  years  of  age,  who  had  pleurisy  with  extensive  effusion.  The  woman 
to  whom  I  refer  was  the  occupant  of  bed  12,  St.  Bernard's  Ward.  She  had 
always  enjoyed  good  health.  '  At  least,  she  said,  and  repeated  many  times, 
that  she  had  never  had  illness  in  any  degree  serious,  till  attacked  by  the 
malady  on  account  of  which  she  came  to  the  hospital.  The  beginning  of 
the  malady  she  thus  described. 

About  two  months  before  her  admission  to  the  Hotel-Dieu,  without  any 
preceding  discomfort,  without  exposure  to  cold,  without  appreciable  cause 
of  any  kind,  she  was  suddenly  seized  during  the  night  with  exceedingly 
violent  pain  in  the  side.  Next  morning,  however,  she  went  to  work  as 
usual,  although  there  was  still  some  pain,  which  was  increased  by  the 
smallest  exertion.     The  breathing  was  oppressed,  and  much  shorter  than 


56Q  PLEURISY:     PARACENTESIS    OF    THE    CHEST. 

usual.  For  seven  weeks,  the  only  constitutional  symptoms  which  showed 
themselves  were  slight  general  discomfort  and  loss  of  appetite ;  but  eight 
days  later,  they  had  so  greatly  increased  in  severity,  that  she  was  compelled 
to  relinquish  her  ordinary  avocations,  to  keep  her  room,  and  indeed  her 
bed,  for  the  greater  part  of  the  day. 

She  had  rigors  on  the  2d  May.  On  that  day,  her  difficulty  in  breathing, 
till  then  not  very  great,  became  more  urgent,  and  during  the  afternoon, 
she  was  admitted  as  a  patient  to  the  Hotel-Dieu.  During  the  evening,  she 
was  seen  by  Dr.  Beylard,  my  chef  de  clinique,  who  found  her  in  a  feverish 
state.     He  noted  the  following  particulars. 

On  uncovering  the  chest,  he  was  at  once  struck  with  the  conspicuous 
thoracic  deformity.  The  left  side  was  greatly  arched  ;  the  left  was  more 
flattened  than  the  right  subclavicular  region,  and  during  great  inspiratory 
movements,  the  left  side  did  not  appear  to  move.  On  percussion,  absolute 
dulness  was  detected,  extending  from  below  upwards  in  front,  till  within 
four  or  five  centimetres  of  the  clavicle,  and  behind,  to  the  crest  of  the 
scapula.  Above  the  region  of  dulness,  both  in  front  and  behind,  there  was 
resonance.  On  applying  the  ear  to  the  chest  in  that  situation,  bronchial 
blowing  and  bronchophony  were  heard.  The  blowing  extended  to  the  top 
of  the  scapula ;  and  in  the  infraspinous  fossa  well-marked  segophony  was 
heard. 

The  patient  had  slight  cough  without  expectoration.  There  was  not 
much  fever. 

The  diagnosis  was  easy.  It  was  evidently  a  case  of  extensive  pleuritic 
effusion,  produced  by  one  of  those  singular  pleurisies  which  are  accom- 
panied by  slight  general  symptoms,  and  yet  lead  to  very  profuse  serous 
exudation. 

This  case,  gentlemen,  merits  all  your  attention,  as  a  proof  that  there  is  a 
species  of  pleurisy,  in  which,  if  we  are  to  form  an  opinion  from  the  general 
symptoms,  inflammation  has  little  to  do,  and  in  which  the  functional  dis- 
turbance dependent  upon  the  lesion  of  the  respiratory  apparatus  is  so  insig- 
nificant as  to  escape  notice.  In  ordinary  acute  pleurisy,  along  with  fever 
and  other  decided  symptoms  of  constitutional  disturbance,  there  is  a  violent 
stitch  in  the  side  and  great  dyspnoea  :  but  in  that  particular  form  of  pleurisy 
of  which  I  am  now  speaking,  there  is  hardly  any  fever,  the  stitch  in  the 
side  is  scarcely  felt,  and  respiration  seems  to  go  on  as  usual.  Well,  then, 
gentlemen,  mark,  that  it  is  this  species  of  pleurisy,  to  a  certain  extent  latent, 
which  gives  rise  to  the  most  profuse  effusion.  The  constitutional  disturb- 
ance, I  repeat,  caused  by  the  effusion  is  apparently  so  insiguiiicant,  that  the 
individuals  allow  a  very  long  time  to  elapse  before  they  seek  medical  aid  ; 
and  consequently,  the  physician  has  only  the  signs  furnished  by  ausculta- 
tion and  percussion  to  guide  him  in  his  diagnosis. 

Our  patient  consulted  two  physicians;  and  one  of  them,  to  whom  she  ap- 
plied for  advice  for  a  uterine  affection,  did  not  even  suspeel  l  hat  she  had 
effusion  into  the  pleura,  because  be  saw  that  she  had  come  to  bis  house  on 
fool,  and  did  not  make  I  he  slightest  complaint  of  being  winded  from  ascend- 
ing his  stair.  Clearly  understand,  gentlemen,  that  in  mentioning  this  cir- 
cumstance, I  do  not  reproach  my  colleague  for  having  committee!  an  error 
in  diagnosis;    for  be   certainly  did  not  make  an  error:    I  only  wish  to  show 

you  bow  easy  it  is  to  allow  an  affection  to  pass  unperceived,  when  it  docs  not 
declare  itself,  and  when  its  physical  signs  have  to  be  searched  out. 

I  remember  that,  in  L845,  a  nurse  came  on  foot,  carrying  her  infant, 
from  the  Pointe  Saint-Eustache,  where  she  lived,  to  the  Necker  Hospital, 

where  I  was  then  one  of  the  physicians  on  duty.  She  had  walked  that  dis- 
tance, about  four  kilometres  [two  and  a  half  English  miles],  without  being 


PLEURISY:  PARACENTESIS  OF  THE  CHEST.        5(37 

much  tired.  The  effusion  was  nevertheless  so  considerable,  that  on  the  very- 
day  she  came  into  our  wards,  I  judged  it  indispensably  necessary  to  per- 
form paracentesis.  I  withdrew  L>  ■">(>()  grammes  [two  and  a  half  litres]  of 
fluid.  This  woman  certainly  seemed  to  he  very  little  of  an  invalid,  and  so 
slightly  did  she  feel  out  of  sorts,  that  on  the  evening  before  the  day  on 
winch  she  came  into  the  hospital,  she  was  working  as  usual. 

The  absence  of  oppression  in  breathing  is  a  very  important  feature  for 
consideration  in  these  cases:  I  cannot  too  earnestly  impress  on  your  minds 
what  I  have  now  described,  and  what  you  yourselves  have  seen  in  our 
patient  of  St.  Bernard's  Ward.  Although  her  chest  contained  two  litres 
and  a  half  of  serous  effusion,  her  breathing  seemed  to  be  scarcely  affected. 
Treasure  this  fact  in  your  memories,  for  dyspnoea  has  been  given,  and  in- 
deed formerly  used  to  be  given  by  myself,  as  the  chief  indication  of  the 
necessity  of  paracentesis.  I  was  singularly  mistaken  as  to  its  value,  as  I 
shall  have  occasion  to  tell  you  in  the  course  of  these  lectures.  To  wait  for 
the  dyspnoea,  as  has  been  recommended,  and  as  was  formerly  laid  down  by 
me  as  the  rule,  is  to  run  the  risk  of  allowing  the  time  for  operating  to  pass, 
and  of  letting  the  patient  die,  as  I  have  done.  It  is  above  all  things  im- 
portant to  ascertain  the  extent  of  the  effusion. .  Upon  this  point,  ausculta- 
tion and  percussion  furnish  us  with  information  in  which  we  can  place 
implicit  reliance.  The  chest  must  be  examined  daily  by  these  means ;  and 
when  the  progress  of  the  hydrothorax  is  watched  in  this  way,  and  is  seen 
to  be  increasing  very  rapidly,  the  indication  to  operate  is  peremptory,  what- 
ever may  be  the  degree  in  which  dyspnoea  exists — whether  there  be  great 
difficulty  in  breathing,  or  whether  there  be  no  difficulty  at  all.  It  was  this 
consideration  which  constrained  me  to  operate  at  my  first  visit  without  any 
waiting,  in  the  case  of  our  patient  in  bed  12,  St.  Bernard's  Ward. 

On  the  evening  of  that  clay,  as  I  have  already  said,  Dr.  Beylard  had  still 
found  resonance  in  the  infraspinous  fossa,  and  in  a  space  from  four  to  five 
centimetres  under  the  clavicle.  Next  morning,  the  dulness  was  absolute 
everywhere.  The  effusion,  therefore,  had  made  great  progress  within  fifteen 
hours.  It  was  estimated  that  half  a  litre  of  liquid  was  secreted  by  the 
pleura  between  morning  and  evening.  Moreover,  the  displacement  of 
organs  testified  to  this  increase. 

The  heart  was  not  in  its  natural  position  ;  the  apex  was  felt  to  beat  under 
and  near  the  right  edge  of  the  sternum,  as  was  easily  ascertained  by  the 
aid  of  the  stethoscope  and  pleximeter.  That  I  might  eliminate  every 
source  of  error,  and  not  be  influenced  by  the  sense  of  sight,  I  percussed  the 
patient  with  the  eyes  shut.  Proceeding  thus,  I  limited  the  dulness,  begin- 
ning at  the  right,  to  three  centimetres  beyond  the  median  line  :  the  medias- 
tinum and  heart,  therefore,  were  considerably  displaced,  and  pushed  to  the 
right ;  on  percussing  from  above  downwards,  I  found  dulness  extending 
from  the  border  of  the  false  ribs,  where  I  discovered  that  the  spleen  was 
out  of  its  normal  situation,  showing  that  the  diaphragm  was  squeezed  up. 

The  great  amount  of  effusion,  and  its  rapid  progress  within  a  short  space 
of  time,  convinced  me  that  the  operation  was  urgent,  and  could  only  he 
delayed  at  the  risk  of  the  patient  dying  before  next  day.  I  performed 
paracentesis  of  the  chest  according  to  the  plan  I  have  described  to  you,  and 
drew  off  2000  grammes  (2  litres),  of  perfectly  clear  yellowish  serosity.  As 
the  fluid  was  being  evacuated,  the  patient  experienced  a  measure  of  com- 
fort which  was  a  great  contrast  to  the  feelings  of  distress  of  which  she  had 
previously  been  complaining.  The  vaulted  form  of  the  chest  was  gone ; 
and  with  the  aid  of  the  pleximeter,  I  could  follow  the  movements  of  the 
heart,  and  perceive  that  its  apex  was  again  in  its  proper  situation  near  the 


568  PLEURISY:     PARACENTESIS    OF    THE    CHEST. 

left  nipple.     The  spleen  too  had  retreated  to  its  natural  position  under  the 
false  ribs. 

After  the  operation,  which,  as  the  woman  herself  stated,  was  not  at  all 
painful,  the  pulse,  formerly  weak  and  irregular,  regained  its  power  and 
regularity.  The  patient  ceased  to  complain  of  a  feeling  of  extreme  weak- 
ness which  had  prevented  her  from  sitting  up  through  fear  of  syncope. 

All  the  effused  fluid,  however,  had  not  been  evacuated:  there  was  still 
dulness  as  high  up  as  the  nipple,  but  respiration  was  heard  in  every  part  of 
the  chest.  At  a  point  where  a  few  minutes  previously  no  sound  was  audi- 
ble, we  now  heard  blowing,  vocal  resonance,  and  segophony. 

The  absorption  of  the  fluid  took  place  gradually,  and  during  some 
following  days  nothing  noteworthy  occurred.  The  general  condition  of  the 
patient  went  on  improving :  by  the  15th  May,  resolution  of  the  pleurisy 
was  complete,  and  recovery  was  sufficiently  perfect  to  allow  her  to  leave 
the  hospital  at  her  own  request.  However,  on  percussing  the  chest,  I  still 
found  dulness,  or  a  hardness  of  sound  from  the  infraspinous  fossa  down  to 
the  lower  part  of  the  chest.  This  dulness  remains  a  long  time  after  the 
most  ordinary  pleurisy,  being  caused  by  the  presence  of  false  membranes, 
which  require  a  certain  time  for  absorption.  On  auscultation,  I  perceived 
the  vesicular  murmur  everywhere,  but  it  was  accompanied  by  coarse  and 
subcrepitant  mucous  rales. 

Gentlemen,  similar  cases  will  no  doubt  occasionally  come  under  our 
observation  :  but  I  could  not  allow  this  opportunity  to  pass  without  speak- 
ing to  you  of  paracentesis  of  the  chest  in  the  consecutive  effusion  of 
pleurisy ;  and  with  your  permission,  I  propose  to  devote  several  lectures  to 
the  development  of  this  grave  and  important  subject. 

It  will  be  granted,  I  trust,  that  I  seldom  speak  of  myself.  Indeed, 
generally,  I  attach  very  little  value  to  questions  of  priority.  I  am  entitled 
therefore,  once,  in  passing,  to  lay  claim  to  as  much  as  belongs  to  me,  in 
respect  of  paracentesis  of  the  chest.  I  make  no  pretension  to  being  the 
originator  of  the  practice :  I  have  not  invented  an  instrument  for  the  more 
easy  performance  of  the  operation,  nor  have  I  recommended  any  operative 
proceeding  which  was  not  previously  well  known:  but  I  conceive  that,  if 
not  the  first,  I  was  at  least  among  the  first  to  point  out  in  a  precise  manner 
the  necessity  of  resorting  to  paracentesis  in  pleurisies  followed  by  a  great 
amount  of  effusion.  I  established  with  precision — perhaps  with  more  pre- 
cision than  had  been  previously  attained — the  indications  for  operating; 
and  I  believe  I  popularized  the  method  which  is  now  generally  adopted, 
thus  entitling  me  to  be  looked  upon  as  having  somewhat  contributed  to  the 
progress  of  the  therapeutics  of  pleurisy. 

Let  me  tell  you,  gentlemen,  how  I  was  led  to  inculcate  the  necessity  of 
surgically  interposing  in  the  treatment  of  extensive  hydrothorax.  In  1832, 
a  woman  aged  50  was  admitted  to  the  Hotel-Dieu,  and  became  a  patient 
in  these  wards,  of  which  I  then  had  charge  jointly  with  Dr.  Kecamier. 
For  five  day-,  .-lie  had  been  suffering  from  acute  pleurisy.  The  breathing 
was  exceedingly  oppressed :  on  the  left  side,  there  was  complete  dulness: 
the  heart  was  pushed  over  to  the  rigb.1  side:  the  ribs  were  far  apart.  A 
large  blister  was  applied  to  the  chest:  digitalis  was  administered:  in  a 
word,  active  treatment  was  instituted.  The  woman  died  on  the  day  follow- 
ing that  on  which  .-he    was  admitted   to   the  hospital.      At    the   autopsy,  we 

found  the  left  pleura  distended  by  an  enormous  quantity  of  limpid  scrum, 
in  which  fibrinous  Hakes  were  Gloating.  The  Lung  was  squeezed  upagainsl 
the  vertebra]  column;  ami  both  the  pulmonary  ami  costal  portions  of  the 
pleura  were  slightly  coated  with  false  membrane.    We  found  no  tubercular 

products,  noi-  any  other  serious  lesion. 


PLEURISY:     PARACENTESIS    OF    THE    CHEST.  569 

This  ease  was  a  direct  contradiction  to  what  I  then  believed,  in  common 
with  the  majority  of  authors,  as  to  the  small  degree  of  danger  attaching  to 
an  attack  of  pleurisy:  more  extended  experience  has  convinced  me  how 
erroneous  were  the  ideas  entertained  on  that  point.  Other  unfortunate 
cases  observed  by  me  and  others  have  negatived  the  law  laid  down  by  Dr. 
Louis,  adopted  by  his  pupils,  and  re-echoed  by  numerous  physicians,  to  the 
effect,  that  pleurisy  is  never  an  immediate  cause  of  death — a  law,  be  it 
noted,  founded  on  a  series  of  150  cases  of  simple  pleurisy  which  terminated 
in  recovery. 

One  of  my  pupils,  Dr.  Lacaze  du  Thiers,*  has  collected  a  number  of 
cases,  some  communicated  by  me  and  others  derived  from  different  sources, 
which  absolutely  demonstrate  that,  notwithstanding  the  famous  law  of 
Louis,  it  is  possible  to  die,  and  to  die  suddenly,  from  acute  pleuritic  effusion. 
Very  recently,  my  friend  Dr.  Lasegue  saw  a  young  physician  die  from  this 
cause,  at  the  very  moment  that  he  was  about  to  make  the  puncture. 

On  7th  April",  1843,  I  received  into  bed  31  of  St.  Anne's  Ward  of  the 
Necker  Hospital  a  woman  of  42  years  of  age,  with  paralysis  of  the  inferior 
extremities,  bladder,  and  rectum.  The  intellectual  faculties  were  unim- 
paired. The  paralysis,  which  did  not  affect  the  superior  extremities,  had 
set  in  suddenly  three  years  previously,  and  had  not  since  that  time  become 
modified. 

Ten  days  before  admission,  this  woman  was  seized  with  stitch  in  the  side, 
cough,  dyspnoea,  and  fever.  On  examining  the  chest,  I  at  once  detected 
pleurisy,  with  effusion  on  the  right  side.  Dulness  extended  up  to  just 
below  the  clavicle  :  a?gophonic  resonance  of  the  voice  and  bronchial  blowing 
were  audible.  The  cough  was  dry.  Some  relief  followed  a  bleeding  Avhich 
I  had  ordered,  but  the  oppression  of  breathing  continued  very  urgent. 
Next  day,  the  orthopnoea  assumed  very  great  intensity.  The  pulse  became 
small  and  wretched  ;  and  finally,  death  took  place,  without  a  struggle, 
twelve  days  from  the  beginning  of  the  disease. 

I  shall  say  nothing  of  the  lesions  of  the  nervous  system,  which  were  not 
at  all  of  a  severe  character.  In  the  right  pleura,  there  was  an  enormous 
effusion  of  purely  serous  character :  the  lung,  pressed  against  the  vertebral 
column,  was  shrivelled  and  covered  with  soft  false  membrane,  which  had  a 
reticulated  appearance :  some  fibrinous  flakes  were  floating  in  the  effused 
serosity. 

The  occurrence  of  this  case  of  sudden  death,  from  acute  pleurisy  with 
profuse  effusion,  recalled  to  my  recollection  that  which  I  had  observed 
eleven  years  previously  in  the  wards  of  Dr.  Recamier.  It  set  me  to  think. 
I  asked  myself,  whether  the  fatal  issue  might  not  have  been  prevented  in 
both  these  cases  by  rapidly  disembarrassing  the  chest  of  the  fluid  which  it 
contained,  and  to  the  presence  of  which  the  untoward  symptoms  were  due. 
I  asked  myself,  whether  under  such  circumstances  paracentesis  was  not  dis- 
tinctly indicated. 

In  the  same  year,  and  at  an  interval  of  exactly  a  month — on  8th  May, 
1843 — a  seamstress,  thirty  years  of  age,  was  admitted  to  St.  Theresa's  "Ward, 
bed  8,  for  pleurisy  without  effusion :  she  too  was  carried  off  in  consequence 
of  paracentesis  not  having  been  resorted  to.  This  woman  had  been  deliv- 
ered at  the  Maternity  Hospital  on  the  19th  of  April,  and  had  left  that  insti- 
tution, in  good  health,  on  the  27th,  except  that  she  had  a  slight  cough, 
which  had  existed  for  four  days.  Next  day,  the  28th,  she  fell  ill,  in  conse- 
quence, perhaps,  of  the  imprudences  to  which  these  unfortunate  puerperal 

*  Lacaze  du  Thiers  :  De  la  Paracentese  de  la  Poitrine  et  des  Epanchements 
Pleure'tiques  qui  necessitcnt  son  Emploi.      [These  de  Paris,  1851.] 


570  pleurisy:   paracentesis  of  the  chest. 

women  so  frequently  expose  themselves.  On  the  same  day,  the  28th,  she 
had  fever,  slight  oppression,  and  an  increase  of  cough.  These  symptoms 
increased  up  to  the  8th  May,  when,  along  with  her  infant,  she  was  admitted 
to  my  ward  for  nursing  women  in  the  Necker  Hospital.  The  lochial  dis- 
charge, which  had  ceased  for  some  days  after  the  fever  set  in,  was  not  long 
in  reappearing,  and  at  the  date  of  admission,  was  flowing  in  a  normal  man- 
ner :  the  secretion  of  milk  was  scanty. 

On  the  9th  May,  the  twelfth  day  of  the  disease,  at  my  visit  in  the  morn- 
ing, I  dictated  the  following  report:  "Oppression,  without  orthopnoea  : 
countenance  somewhat  anxious :  a  dry  but  not  frequent  cough  :  expectora- 
tion frothy  and  scanty,  and  having  the  appearance  of  saliva.  Complete 
dulness  on  the  left  side  of  the  chest  as  high  up  as  the  lower  margin  of  the 
clavicle:  a  considerable  arched  appearance  of  the  chest  in  front:  respiratory 
sound  absent,  but  there  can,  however,  be  heard  a  distant,  very  feeble  mur- 
mur, without  segophony  and  without  vocal  resonance.  On  the  right  side, 
respiration  is  puerile."  The  heart  was  noted  as  being  beyond  the  median 
line.  I  ordered  four  basins  of  blood  \_quatre  palettes]*  to  be  taken  from  the 
arm,  and  put  her  on  strictly  low  diet,  broth  only  being  allowed.  She  was 
recommended  to  drink  very  little. 

Next  day,  there  was  no  change  in  the  condition  of  the  patient.  It  was 
observed,  that  the  blood  drawn  on  the  previous  evening  was  very  much 
cupped.     I  ordered  the  treatment  to  be  continued. 

Between  the  11th  and  17th  May,  there  was  a  slight  amelioration,  which, 
however,  was  soon  succeeded  by  an  exacerbation  of  the  malady.  There  was 
a  tendency  to  syncope.  Two  flying  blisters  were  applied  to  the  affected 
side,  at  the  interval  of  a  few  days;  and  diuretics  were  administered. 

On  the  17th,  the  state  of  the  patient  was  manifestly  worse.  She  lay  on 
her  back,  without  pillows,  and  did  not  seem  to  have  any  oppression:  never- 
the  less,  her  countenance  was  pale  and  anxious,  and  her  eyes  wide  open. 
Her  respiration  was  feeble  and  imperfect:  her  pulse  was  miserable:  her  in- 
tellectual faculties,  however,  were  unaffected.  It  seemed  as  if  she  were 
dying,  suffocated  by  a  power  against  which  she  had  ceased  to  struggle. 

The  two  cases  which  I  have  just  related  to  you  presented  themselves  to 
my  mind:  I  saw  that  my  patient  was  in  similar  peril,  and  paracentesis  sug- 
gested itself.  But  as  it  was  a  somewhat  unusual  proceeding  to  resort  to 
this  operation  at  the  twentieth  day  of  a  pleuritic  attack,  as  the  operation 
was  at  that  time  loudly  condemned  in  acute  cases  of  effusion  by  all  French 
physicians,  and  indeed  in  all  cases  of  hydrothorax;  as  the  oppression  of  the 
breathing  did  not  seem  to  me  to  be  very  great,  I  yielded  to  the  culpable 
weakness  of.preferring  to  wait:  in  fact,  I  wished  to  avoid  the  imputation  of 
rashness.  I  directed  my  interne  to  watch  the  patient,  and  to  puncture  the 
chest  in  accordance  with  a  plan  we  agreed  upon,  should  life  seem  in  ex- 
treme jeopardy.  My  pupil  saw  the  patient  at  seven  in  the  evening,  for  the 
last  time.  She  did  not  then  appear  to  him  to  be  in  a  worse  slate  than  in 
the  morning:  believing  that  paracentesis  might  be  delayed,  he  Left  her  for 
a  little.     Within  an  hour,  the  unfortunate  woman  died  without  a  struggle. 

At  the  autopsy  we  found  that  the  heart  was  pushed  quite  to  the  righl 
side,  and    that    the   left    pleura   was  distended   by  an  enormous  quantity    of 

fluid,  which  we  estimated  at  not  less  than  four  litres.  This  Berosity  was 
limpid  in  the  upper  part  of  the  chest,  but  in  the  depending  pan-  it  was 
seropurulent :  the  lung  was  shrivelled,  and  was  squeezed  up  against  the 
vertebral  column.     At   the  summit   ii   was  closely  adherent   t<>  the  costal 

*  A  "paleth  "  is  a  basin  used  for  receiving  Meed  taken  by  venesection.  It  con- 
tains '■>  grammes,  /'.  c,  81  ft.  ounces. — Tka  nslatob. 


PLEURISY:     PARACENTESIS    OF    THE    CHEST.  571 

pleura,  and  at  that  point  there  was  a  cicatrix  consequent  upon  softened 
tubercle.  In  no  other  situation  did  we  find  any  appreciable  organic  altera- 
tion. 

I  was,  as  you  may  suppose,  shocked  by  the  death  of  this  woman;  and, 
too  late  for  her,  I  perceived  the  necessity  of  having  recourse  to  paracentesis 
at  the  earliest  possible  opportunity  in  similar  cases.  I  had  not  long  to  wait 
for  an  occasion  to  give  practical  effect  to  this  conviction. 

In  the  following  September  I  went  to  Tours  to  see  my  mother,  who  was 
dangerously  ill.  During  my  absence  I  had  been  sent  for  by  my  excellent 
friend,  M.  Michel  Masson,  the  dramatic  author,  with  whose  name  you  are 
familiar,  to  see  his  daughter.  She  was  a  young  lady  of  sixteen,  who  gen- 
erally enjoyed  good  health,  excepting  that  she  had  great  nervous  irritability. 
During  the  ten  years  that  I  had  been  the  family  physician  I  had  hardly 
once  been  consulted  regarding  her. 

On  Sunday,  September  3d,  1843,  she  had  fever  and  loss  of  appetite.  On 
the  5th  she  took  to  her  bed.  I  did  not  see  her  till  the  8th.  I  then  observed 
that  the  skin  was  very  pale,  and  that  there  was  considerable  fever:  she  had 
a  little  dyspnoea,  but  neither  cough  nor  expectoration:  there  was  no  symp- 
toms of  any  gastric  affection.  On  exploring  the  chest  I  found  that  there 
was  enormous  effusion  in  the  left  pleura,  ascending  as  high  as  the  clavicle. 
Everywhere  complete  dulness  existed;  and  in  no  situation  could  I  hear  the 
respiratory  murmur,  blowing,  or  segophony.  The  heart  was  twisted  to  the 
right,  and  occupied  the  median  line.  I  bled  her  from  the  arm,  prescribed 
calomel,  and  recommended  her  to  drink  sparingly. 

On  Monday,  September  11th,  the  eighth  day  of  the  attack,  there  was  a 
great  increase  in  the  severity  of  the  symptoms.  The  skin  was  cold,  and  the 
face  pale.  On  account  of  the  orthopnoea,  the  young  lady  was  obliged  to  sit 
up  in  bed  supported  by  pillows.  She  had  a  tendency  to  syncope,  and 
groaned  without  ceasing.  I  applied  a  large  blister  to  the  posterior  aspect 
of  the  chest. 

I  resolved  to  perform  paracentesis;  and  as  the  indication  to  operate  was 
urgent,  I  did  not  wish  to  have  a  consultation,  fearing,  on  the  one  hand,  that 
a  meeting  of  doctors  upon  her  case  might  alarm  the  patient;  and,  on  the 
other,  that  the  conflict  of  opinions,  certain  to  arise,  might  lead  the  family 
to  fatal  indecision.  Consequently,  when  I  arrived  on  the  Tuesday  morning 
— the  ninth  day  of  the  illness — I  was  provided  with  the  necessary  instru- 
ments, and  perfectly  determined  to  fulfil  the  commands  of  duty,  without 
making  the  slightest  parade,  just  as  if  I  were  about  to  do  the  simplest  thing- 
imaginable.  I  found  the  patient  at  the  brink  of  death,  and  reproached 
myself  for  having  on  the  previous  evening  postponed  a  proceeding  which 
had  become  so  peremptory  as  to  admit  of  no  delay  whatever. 

I  performed  the  operation  in  a  way  which  I  shall  point  out  to  you  when 
I  come  to  speak  of  the  manual  operation  of  paracentesis,  which  is  a  very 
simple  affair.  I  withdrew  about  800  grammes  [between  one  and  two  pints] 
of  transparent  serosity,  having  a  beautiful  amber  color.  It  retained  its 
transparency  till  next  day,  but  there  was  visible  in  it  a  sort  of  soft,  shreddy 
tissue,  evidently  formed  of  fibrin  condensed  by  the  cold.  Although  I  could 
easily  have  withdrawn  a  larger  quantity  of  the  fluid,  I  did  not  wish  to  do 
so,  being  satisfied  with  having  removed  the  excess  which  rendered  the  effu- 
sion mortal,  so  reducing  the  case  to  simple  pleurisy,  curable  by  ordinary 
means. 

AVhen  the  operation  was  completed,  the  young  lady  seemed  to  return  to 
life:  she  breathed  easily,  had  no  longer  an  anxious  countenance,  and  her 
pulse  had  regained  some  degree  of  volume.  The  lungs  and  heart  had  re- 
turned to  nearly  their  normal  position :  the  respiratory  murmur  was  once 


572      •  PLEURISY:     PARACENTESIS    OF    THE    CHEST. 

more  audible:  there  was  a  little  tympanic  resonance  in  front,  at  the  upper 
part  of  the  chest,  which,  at  the  time,  I  thought  was  attributable  to  the 
entrance  of  some  bubbles  of  air  during  the  operation.  I  was  not  then 
acquainted  with  the  exaggerated  resonance  observable  in  the  majority  of 
pleuritic  cases — that  peculiar  resonance  which,  at  a  later  date,  Skoda  dis- 
covered and  made  known.  During  the  night  which  followed  the  operation, 
the  patient  slept  six  hours. 

Next  morning,  she  was  in  a  very  nervous  state,  but  respiration  was  easy: 
she  spoke  fluently,  and  made  use  of  long  phrases  without  taking  breath. 
Her  countenance  was  calm.     The  skin  was  rather  hot,  and  the  pulse  112. 

On  the  second  night  after  the  operation,  she  slept  eleven  hours.  There 
was  a  notable  diminution  in  the  quantity  of  effusion  in  the  chest:  the  heart 
was  more  and  more  resuming  its  place  on  the  left,  although  it  was  still 
beyond  the  median  line.  Anteriorly,  the  dulness  did  not  rise  higher  than 
the  fourth  rib. 

The  subsequent  history,  I  shall  rapidly  sum  up.  Under  the  influence  of 
flying  blisters  applied  to  the  chest,  diuretic  drinks,  and  digitalis,  improve- 
ment went  on  rapidly.  On  28th  September,  sixteen  days  after  the  opera- 
tion, the  pulse  was  80:  she  had  a  decided  relish  for  her  food:  the  menstrual 
flux  came  at  its  proper  time,  but  not  in  normal  abundance.  From  that 
time,  all  the  morbid  symptoms  disappeared :  respiration  became  natural, 
and  the  patient  entered  upon  a  convalescence  which  had  a  favorable  issue. 

This  case  taught  me  a  great  lesson.  It  prevented  me  from  having  any 
hesitation  in  acting  in  the  same  way  under  similar  circumstances.  Having 
had  three  similar  cases  of  success,  I  hastened  to  publish  them.  They  formed 
the  subject  of  a  memoir  which  was  read  to  the  Academy  of  Medicine  in 
1843 :  during  the  following  year,  I  communicated  a  second  memoir  to  the 
Academy  on  the  same  subject.*  In  1846,  the  duty  of  reporting  on  these 
two  memoirs  was  intrusted  to  my  honorable  colleague  Dr.  Bricheteau,  in 
whose  presence  I  performed  paracentesis  of  the  chest  upon  a  girl  of  fourteen 
years  of  age,  who  made  a  rapid  recovery.  In  the  report  of  this  excellent 
practitioner,  which  is  a  real  masterpiece  of  erudition  and  criticism,  the  con- 
clusions drawn  by  me  are  adopted  with  very  slight  modifications.  The 
report  hardly  gave  rise  to  any  objections,  so  that  the  discussion  upon  it 
attracted  no  attention. 

I  now  more  than  ever  followed  out  my  views  in  this  matter:  successes 
were  multiplying,  and  encouragiug  me  to  pursue  the  same  course,  when,  in 
1850,  having  asked  my  colleagues  of  the  Medical  Society  of  the  Hospitals 
to  give  me  their  opinion  upon  a  case  of  death  following  paracentesis  of  the 
chest,  and  information  upon  a  peculiarity  in  the  case,  I  was  led  to  explain 
my  views  on  the  general  question  of  paracentesis.  The  controversy  was 
animated;  audi  found  myself  confronted  by  as  violent  an  opposition  as 
that  which  I  encountered  when  I  published  my  first  eases  of  tracheotomy. 

Ill-natured  insinuations  were  not  wanting  upon  that  occasion.  When  I 
broughl  forward  cases  of  children  cured  by  tracheotomy,  I  was  told  that 
they  had  never  had  croup ;  thai  only  those  children  had  had  croup  whom 
1  had  failed  to  save:  1  was  even  caluminated.  According  to  mv  custom,  1 
made  no  reply.  Inlliioncod  only  by  an  approving  conscience.  I  continued 
to  pursue  the  practice,  hoping  that  truth  would,  sooner  or  later,  carry  the 
day.  In  respect  of  tracheotomy,  I  attained  my  objed  ;  for  that  operation 
has- for  a  long  time  been  generally  acknowledged  as  indicated  in  the  cir- 
cumstances in  which  I  declared  it  to  he  necessary.  Paracentesis  ol'the 
chest  was  not   met   by  the  same  objections,  but,  nevertheless,  encountered 


Bulletin  de  L'Academie  de  Mi'-docim-,  t.  ix,  p.  i:'.s ;  Ibid.,  t.  \,  p.  .".IT. 


PLEURISY:     PARACENTESIS    OF    THE    CHEST.  573 

many  opponents.     When,  however,  it  became  known  that  I  had  operated 

in  from  fifteen  to  twenty  cases,  in  two  instances  among  others  upon  Parisian 
physicians,  without  having  had  one  failure  to  deplore ;  when  many  of  my 
fellow-practitioners  in  the  hospitals  and  in  the  town  (my  youthful  col- 
leagues be  it  observed,  for  the  elders  hardly  like  to  follow  the  example  of 
juniors),  when,  I  say,  many  of  my  colleagues  had  also  operated  successfully, 
paracentesis  was  proclaimed  as  a  good  means  of  treating  acute  pleurisies 
accompanied  by  profuse  effusion,  just  as  tracheotomy  had  ultimately  been 
accepted  in  the  treatment  of  croup. 

Far  be  it  from  me,  gentlemen,  to  appropriate  to  myself  the  honor  of  the 
discovery.  Paracentesis  of  the  chest  has  been  practiced  from  very  remote 
times  ;  but,  exposed  to  varying  fortunes  like  every  other  therapeutic  measure, 
it  was  all  but  abandoned,  or  at  least  was  reserved  for  exceptional  cases.  It 
was  resorted  to  distrustfully,  and  then  only  when  imminent  peril  justified 
extreme  daring.  If  it  have  now  taken  that  place  which  it  ought  always  to 
maintain,  if  it  be  now  mentioned  among  modes  of  treatment  which  have 
the  advantage  of  being  free  from  danger,  I  conceive  that  I  have  contributed 
to  bring  about  this  change  of  opinion  by  my  works,  by  the  indications  for 
operating  which  I  have  furnished,  and  in  a  special  manner,  let  me  add,  by 
the  success  which  has  attended  my  practice. 

Before  I  point  out  to  you  the  circumstances  in  which  this  method  of  sur- 
gical interference  is  indicated,  allow  me  briefly  to  recapitulate  the  history 
of  paracentesis  of  the  chest,  following  it  in  succession  through  its  different 
phases.  I  cannot  explain  to  you  in  any  other  way  why  an  operation,  never 
before  adopted  as  an  ordinary  practice,  is  at  present  performed  in  all  places, 
and  by  all  practitioners. 

The  earliest  data  relating  to  puncture  of  the  chest  are  as  old  as  the  school 
of  Hippocrates.  The  operative  procedure  indicated  in  his  times  is  followed 
in  the  present  day.  There  are  two  modes  of  operating :  we  either  open  into 
one  of  the  intercostal  spaces,  or  we  perforate  a  rib.  The  intercostal  space 
may  be  opened  by  actual  cautery  or  bistoury.  Whatever  method  is  selected, 
it  is  essential  that  the  wound  remain  open  till  the  fluid  is  entirely  evacuated, 
and  till  there  is  no  tendency  to  more  effusion.  If  the  opening  should 
have  a  tendencv  to  close,  this  must  be  prevented  by  the  introduction  of  a 
metallic  sound. 

Such  is  the  operative  basis  upon  which  surgeons  have  proceeded  since  the 
time  of  Hippocrates  ;  and  it  is  not  uninteresting  to  see  how  little  they  have 
added  to  the  old  traditions.  Galen  simply  repeated  the  rules  laid  down  by 
Hippocrates :  Celsus  did  not  describe  the  operation  very  happily ;  and 
paracentesis,  almost  forgotten  by  the  writer  who  for  so  long  a  period  was 
the  sole  authority  on  the  subject,  fell  into  discredit  among  the  Greeks  and 
Romans,  and  was  not  revived  by  the  Arabs. 

During  the  middle  ages,  it  was  discussed,  whether  it  were  better  to  make 
the  opening  into  the  chest  by  steel  or  fire ;  but  it  was  scarcely  admitted  that 
there  was  any  cases  except  those  of  surgical  lesions  in  which  paracentesis 
ought  to  be  performed. 

About  the  sixteenth  century,  trepanning  the  ribs  was  revived,  after  having 
been  almost  abandoned.  About  the  same  time,  detersive  injections,  which 
had  been  recommended  by  Galen  and  Rhases,  were  again  advocated  as  a 
necessary  element  in  the  treatment.  We  find,  however,  that  in  those  times, 
the  operation  was  seldom  tried,  and  that,  even  in  extreme  cases,  it  was  gen- 
erally rejected  by  the  greatest  surgeons.  Fabricius  of  Acquapendente,  for 
example,  regretted  that  it  had  fallen  into  desuetude.  A  more  attentive 
study  of  facts,  however,  and  a  less  servile  obedience  to  tradition,  led  to  some 
important  observations. 


574  PLEURISY:     PARACENTESIS    OP    THE    CHEST. 

It  was  remarked  that  in  penetrating  wounds  of  the  chest,  recovery  seemed 
to  take  place  most  quickly,  when  the  wound  was  closed  early  ;  and  it  was 
then  asked,  whether  it  would  not  be  expedient  to  close  the  opening  made 
in  paracentesis  for  empyema,  in  place  of  leaving  it  patent  for  an  indefinite 
period. 

From  the  seventeenth  to  the  eighteenth  century,  the  operation  of  paracen- 
tesis was  the  topic  of  numerous  surgical  treatises.  In  1658,  Bontius  for  the 
first  time  took  up  in  a  precise  manner  the  subject  of  the  introduction  of  air 
into  the  chest,  which  till  then  had  been  hinted  at,  rather  than  discussed. 
He  declared  that  there  was  nothing  to  dread  in  the  coutact  of  air,  and  con- 
sidered injections  as  a  perfectly  sufficient  means  of  combating  the  conse- 
quences which  were  dreaded.  Bartholin  maintained  the  opposite  opinion  : 
he  insisted  that  the  opening  ought  to  be  closed  with  the  least  possible  delay, 
to  prevent  at  all  hazards  contact  with  the  air.  The  indication  for  the 
operation  was  then  laid  down ;  but  two  centuries  elapsed  before  a  satisfac- 
tory manner  of  fulfilling  it  was  attained. 

The  more  that  attention  was  directed  to  the  question  of  the  admission  of 
air,  the  more  was  the  manner  of  operating  modified.  The  fluid  was  evacu- 
ated by  aspiration  and  suction :  this  practice  was  at  first  very  timidly  pur- 
sued, in  accordance  with  Scultet's  example ;  but  it  became  afterwards  in 
vogue  with  the  masters  of  surgical  art. 

Surgeons  had  now  entered  upon  a  new  and  very  propitious  path.  In 
place  of  discussing  theoretical  probabilities,  they  proceeded  to  direct  exami- 
nation of  facts.  As  cases  of  paracentesis  were  still  of  rare  occurrence,  they 
based  their  observations  on  examination  of  wounds  of  the  chest.  They  thus, 
from  considering  the  small  number  of  untoward  occurrences  which  such 
accidents  lead  to,  became  less  distrustful  of  puncturing  the  chest,  and  were 
even  led  to  believe  in  the  harmlessness  of  the  operation. 

As  a  consequence  of  this  tendency,  felt  rather  than  expressed,  physicians 
began  to  study  the  question  of  puncturing  the  chest  in  hydrothorax.  In 
1624,  Gerome  Goulu  alleged  that  he  succeeded  more  frequently  in  hydro- 
thorax  than  in  abdominal  paracentesis  in  ascites.  Twenty  years  later,  wo 
read  in  the  writings  of  Zacutus  Lusitanus  that  paracentesis  was  as  much 
indicated  in  cases  of  serous  effusion  into  the  chest  as  in  cases  of  empyema, 
if  puncture  was  the  only  means  of  evacuating  the  fluid.  Some  time  after- 
wards, this  practice  was  put  in  force  by  Willis ;  Lower  also  mentions  a 
case;  and  subsequent  authors  quoted  these  cases  as  an  encouragement  to 
the  performance  of  paracentesis  of  the  chest  for  the  removal  of  Berous  eflu- 
sion. 

About  the  middle  of  the  eighteenth  century,  when  perforation  by  the 
actual  cautery,  which  till  then  had  its  partisans,  was  abandoned,  it  was 
proposed  to  substitute  for  the  bistoury,  a  trocar  such  as  was  employed  in 
abdominal  paracentesis.  In  1765,  Lurde  recommended  the  use  o\'  tins  in- 
strument, which,  however,  had  been  proposed  nearly  a  century  before  by 
Drouin.  Limit's  recommendation  was  timidly  given,  through  the  fear 
which  he  had,  that  in  using  the  trocar  t here  was  a  risk  of  wounding  the 
lung.  He  advised  the  operator  to  close  the  eanula  with  the  finger  at  each 
inspiration,  leaving  it  open  during  expiration,  so  that  the  entrance  of  air 
mighl  he  prevented.  Lurde's  recommendation  to  employ  the  trocar  was 
not  80  well  received  as  mighl   he  supposed;  and  among  its  adversaries  were 

Choparl  and    Desault.     The  use  of  the  trocar  was  alleged  to  he  a  coarse 

mode   of  proceeding,  ami  to    involve  the    risk    of  wounding   the  interco.Ma  1 

artery  and  the  lung.  More  than  a  hundred  years  elapsed  before  the  sug- 
gestion of  Drouin  found  support  ;  and  we  can  still  Bee  with  what  difficulty 
it  obtained  adherents,  notwithstanding  the  future  which  was  in  store  for  it. 


pleurisy:   paracentesis  of  the  chest.  575 

Finally,  in  ISO*,  Audouard  raised  anew  a  question,  considered  as  defi- 
nitely settled,  attacking  a  universally  admitted  conclusion.  From  the  time 
that  paracentesis  was  first  practiced,  the  rule  laid  down  was  to  allow  the 
fluid  to  flow  only  little  by  little.  On  the  first  day,  a  portion  was  drawn 
off;  on  each  succeeding  day,  the  evacuation  of  a  small  additional  quantity 
was  promoted.  This  precept  originated  in  the  conviction,  that  if  the  fluid 
escaped  suddenly,  the  result  would  be  a  vacuum  in  the  chesl  causing  the 
death  of  the  patient.  This  hypothesis,  afterwards  admitted  to  be  unsatis- 
factory, was  replaced  by  another  explanation  ;  but  the  rule  remained. 
Audouard  maintained  and  proved  that  even  the  sudden  evacuation  of  the 
fluid  is  not  attended  by  the  drawbacks  which  had  been  supposed  to  exist. 

Between  1808  and  1843,  when  I  published  my  first  work  on  the  subject, 
the  manner  of  performing  the  operation  had  scarcely  undergone  any  modi- 
fications, suggested  changes  not  having  been  sanctioned  by  experience. 
Certain  facts,  however,  had  been  ascertained  :  it  had  been  found  that  the 
fluid  might  be  evacuated  rapidly,  and  at  one  time ;  also,  that  while  it  was 
incumbent  on  the  operator  to  prevent  as  much  as  possible  the  entrance  of 
air,  there  need  not  be  much  alarm  as  to  the  deleterious  consequences  of 
such  an  occurrence.  The  soundness  of  these  two  principles  being  admitted, 
it  followed  that  the  trocar  was  considered  preferable  to  the  bistoury ;  that 
perforation  of  the  ribs  ceased  to  be  practiced  ;  and  that  various  plugs  were 
invented  as  substitutes  for  the  finger,  which  Lurde  recommended  to  be 
placed  at  the  external  orifice  of  the  canula. 

Every  apparatus  constructed  for  adaptation  to  the  trocar,  with  the  view 
of  preventing  the  introduction  of  air  and  leaving  free  passage  to  the  fluid, 
was  made  on  the  principle  announced  almost  simultaneously  by  Schuh  and 
Reybarb,  but  which  has  been  especially  elucidated  by  the  former.  The 
apparatus  of  Schuh,  a  complex  machine  composed  of  a  system  of  plugs 
and  reservoirs  difficult  to  work,  has  been  abandoned  by  its  inventor.  The 
simplicity  of  the  trocar  devised  by  Reybarb  has  led  to  its  adoption  by  all 
operators.  Its  peculiarity  consists,  as  you  know,  gentlemen,  in  arming 
the  free  extremity  of  the  canula  with  a  piece  of  goldbeater's  skin,  which, 
being  rolled  round  the  instrument,  is  then  softened  by  water.  The  gold- 
beater's skin  thus  adjusted,  acts  as  a  plug,  and  has  the  advantage  over 
every  other  mechanical  contrivance  of  requiring  neither  precision  nor  re- 
pairs.* 

In  summing  up  what  has  been  said  regarding  the  operative  proceeding 
itself,  you  perceive  that  a  certain  number  of  desiderata  have  been  pointed 
out ;  and  that  all  of  them  have  now  been  so  well  supplied,  that  there  is 
not  much  scope  for  future  improvement.  You  perceive  from  what  has  been 
said,  that  even  at  the  time  when  paracentesis  of  the  chest  was  performed 
under  conditions  and  with  instruments  far  from  favorable,  it  took  its  place 
among  the  least  delicate  operations  of  surgery. 

Nevertheless,  puncturing  the  chest  continued  to  be  looked  upon  as  one 
of  those  bold  measures  only  sanctioned  by  the  existence  of  danger  of  a  cer- 
tain urgency.  The  cause  of  this  timidity  arose  from  insufficient  knowledge 
of  the  indications  for  operating,  and  not  from  any  imperfection  in  the  mode 
of  performing  the  operation. 

It  is  impossible  for  any  therapeutical  means  to  be  regarded  with  general 
favor-,  be  it  a  medicine  or  a  surgical  operation,  unless  it  be  suited  to  a  de- 
terminate exigency.  A  remedy  will  remain  unemployed,  so  long  as  the 
circumstances  which  demand  its  employment  are  imperfectly  known.  Or 
at  most,  an  experimentalist  tries  it  at  a  time,  in  a  sort  of  haphazard  way, 

*  Gaujot  :  Arsenal  de  la  Chirurgie  Contemporaine.     Paris,  18G7. 


576  PLEURISY:     PARACENTESIS    OF    THE    CHEST. 

and  announces  a  successful  result :  others,  who  attempt  to  follow  in  the 
same  direction,  either  use  the  remedy  too  timidly  or  too  indiscriminately, 
thus  discrediting  it,  and  causing  it  to  fall  into  oblivion.  Such  has  been 
the  fate  of  paracentesis  of  the  chest.  It  is  not  surprising  that  De  Haen 
should  have  asked  in  reference  to  hydrothorax  :  "  Our  ita  laudato,  paracen- 
tesis sive  ut  primum  sive  saltern  ut  alteram  adhibendum  auxilium  spatio  XXIII 
seculorum  theoretice  commendetur  et  vix  unquam  instituto  legaturt" 

I  have  now  rapidly  sketched  the  history  of  the  operation  ;  but  to  make 
this  history  practically  instructive  to  you,  I  must  state  the  indications  for 
resorting  to  paracentesis. 

When  Hippocrates  recommended  tapping  of  the  chest,  he  distinctly  in- 
dicated the  intention  of  the  operation — the  evacuation  of  fluid  contained 
in  the  thoracic  cavity ;  but  he  did  not  furnish  signs  sufficiently  precise  to 
enable  effusion  to  be  detected  during  life.  His  description  of  symptoms  is 
applicable  to  affections  of  very  different  kinds ;  it  comprises,  along  with 
dropsy  of  the  chest,  hemorrhagic  and  purulent  effusions,  and  in  particular 
hydro-pneumothorax.  Thus,  the  beautiful  experiment  of  succussion,  which 
still  holds  its  place  among  the  most  valuable  physical  signs,  is  given  as  an 
absolute  criterion.  It  had  been  perceived  that  the  local  phenomena  were 
deficient  in  precision,  and  by  way  of  supplementing  them,  a  number  of 
general  phenomena,  still  more  deceptive,  were  added.  It  is  curious  to  see, 
that  at  the  commencement  of  the  nineteenth  century,  the  diagnosis  of  effu- 
sion into  the  pleura  had  not  gained  anything  in  respect  of  exactitude.  The 
Hippocratic  description,  invariably  reproduced  by  all  succeeding  authors,  is 
repeated  by  Mursinna,  who,  however,  in  1811,  had  operated  four  times,  and 
twice  successfully,  guided  only  by  these  untrustworthy  data.  In  his  re- 
markable dissertation,  the  German  surgeon  insisted  that  the  sound  caused 
by  succussion  was  an  indispensable  element  in  the  diagnosis.  He  speaks 
of  (Edema  of  the  inferior  extremities  and  scrotum  as  a  symptom  almost  in- 
variably present ;  and  adds,  without  making  more  direct  reference  to  the 
discovery  of  his  fellow-countryman  Avenbriigger,  a  statement  to  the  effect, 
that  a  dull  sound  of  a  very  peculiar  character  is  sometimes  heard  on  per- 
cussion. No  one  has  shown  more  clearly  than  De  Haen,  the  inadequacy  of 
the  diagnostics.  His  monograph  on  hydrothorax  is  in  fact  an  elaborate 
criticism  upon  the  phenomena  which  his  predecessors  had  indicated  as 
characteristic:  "Suspicio  morbi  duntaxat  est  eague  cum  aliorum  morbis  signia 
ita  intricate,,  ut  certi  quid  concludi  nequeat."  He  elsewhere  insists  upon  the 
deceptions  which  beset  physicians:  "  Subdolus  hie  morbus  raro  dum  curabUis 
est  cognoscitur." 

The  result  of  this  diagnostic  uncertainty,  which  was  Hit  and  proclaimed 
by  all  good  observers,  was  the  restriction  of  paracentesis  of  the  dust  to 
rases  extremely  limited  in  number,  and  belonging  to  die  domain  of  surgery. 
It  was  thought  accessary  to  wait  till  the  chest  was  enormously  distended. 
till  an  intercostal  space  was  visibly  elevated  by  the  tension  caused  by  the 
pus  Beeking  to  make  an  exit  for  itself;  and,  generally  speaking,  the  rule 
was  to  operate  only  in  traumatic  cases. 

Nevertheless,  in  spite  of  so  many  reasons  for  abstaining  from  operating, 

and  though  there  was  very  little  actual  experience  to  appeal  to,  there  was 
not  wanting  on  the  part  of  physicians  belief  in    favorable   results,  and   the 

hope  of  success.  They  asked  themselves  the  reason  for  delaying  the  opera- 
tion to  so  advanced  a  stage  of  the  case:  they  were  convinced  by  reasoning 
rather  than  by  facts — but  they  were  convinced.     This  remark  is  applicable 

to  more  than  one  writer.      So  far   back    as    1624,  Qoulu,  as  I  have  alivad\ 

stated,  alleged  thai  paracentesis  of  the  chesl  in  hydrothorax  was  more  fre- 
quently successful  than  paracentesis  of  the  abdomen    in  ascites:  "  AV// 'i 


PLEURISY:     PARACENTESIS    OF    THE    CHEST.  577 

in  thoracis  quam  in  abdominis  hydrope,  paracentesis  tutior."  Such  is  the  con- 
clusion of  his  dissertation.     In  1774,  Majault  took  up  the  s: i  thesis,  and 

thus  summed  up  his  views :  "  Ergo  hydropi  pa-tori*  ]><traauit<-*i*.'n  Do 
Haeu,  too,  had  said  :  "  Ut  si  hydro])*  j/n-tori*  cognosced ur  mature,  nil  est 
paracentesi  tutius." 

The  great  discovery  of  Laennec  changed  the  aspect  of  the  question  :  in 
the  room  of  confused  and  inextricable  symptoms,  auscultation  substituted 
the  simple  and  positive  elements  of  diagnosis.  Effusions  into  the  chest 
were  henceforth  considered  to  be  among  the  diseases  which  were  most  acces- 
sible to  the  investigation  of  the  physician.  From  that  moment — the  ob- 
scurity being  apparently  dispelled — the  desire  so  often  expressed  of  extend- 
ing the  practice  of  paracentesis  of  the  chest  seemed  about  to  be  realized. 
It,  however,  happened  otherwise.  Laennec,  with  his  usual  sagacity,  had 
defined  all  the  indications  of  the  operation.  He  recommended  its  perform- 
ance in  cases  of  acute  pleurisy  with  effusion,  in  which  the  effusion,  from 
the  first  very  profuse,  increases  so  rapidly,  that  at  the  end  of  some  days  it 
produces  a  general  or  local  condition  of  great  seriousness,  possibly  threat- 
ening suffocation,  and  constituting  whas  has  received  the  name  of  acute 
empyema.  He  also  recommended  it  as  a  last  resource  in  chronic  pleurisy, 
when  every  means  had  failed  to  promote  absorption  of  the  fluid  ;  but  he 
added  :  "  The  operation  for  empyema  is  seldom  successful."  That  depends 
on  several  causes,  all  of  which  have  not  been  equally  well  appreciated. 
With  the  exception  of  particular  conditions  of  organs  contraindicating 
paracentesis,  the  condition  which  Laennec  considered  as  most  opposed  to 
success  was  flattening  and  loss  of  elasticity  of  the  lung,  from  its  being 
covered  by  false  membrane.  Hence,  he  thought  that  there  is  a  better 
chance  of  success  in  acute  than  in  chronic  empyema.  The  usual  mode  of 
operating  did  not  appear  to  him  to  be  susceptible  of  much  improvement; 
and  though  he  dwelt  upon  the  danger  resulting  from  the  introduction  of 
air,  he  does  not  seem  to  have  inquired  into  the  means  of  preventing  this 
occurrence.  "  Puncture  with  the  trocar,"  says  Laennec,  "  in  an  intercostal 
space,  was  several  times  tried  ;  Morand  among  others  had  recourse  to  it 
several  times.  My  friend  Professor  Recamier  employed  it  several  times, 
making  use  of  a  very  small  trocar.  I  have  myself  often  had  recourse  to 
it,  but  have  never  obtained  by  it  permanent  success."  Three  pages  farther 
on,  Laennec  expresses  the  conviction  that ""  the  operation  for  empyema 
will  become  much  more  common  and  much  more  useful,  in  proportion  to 
the  diffusion  of  the  employment  of  mediate  auscultation." 

As  you  perceive,  gentlemen,  Laennec  does  not  by  any  means  enunciate 
his  opinion  in  a  decided  manner  :  he  raises  with  one  hand  that  which  he 
pulls  down  with  the  other.  While  he  promises  fortunate  results  from  the 
diagnostic  means  with  which  he  endowed  science,  he  speaks  doubtingly  of 
the  successful  results  of  paracentesis.  He  only  cites  unsuccessful  cases,  and 
lays  stress  on  the  anatomical  conditions,  only  that  he  may  bring  out  into 
stronger  relief  those  which  appeared  to  him  to  be  the  most  unfavorable. 
Distrust,  though  tempered  by  the  expression  of  better  hopes  for  the  future, 
was  too  distinctly  shown  by  Laennec  to  encourage  new  attempts.  What 
was  the  consequence?  When  ten  years  later,  in  1835,  the  question  of  para- 
centesis was  brought  before  the  Academy  of  Medicine,  upon  the  occasion 
of  Dr.  Faure's  memoir  being  read,  the  discussion  was  confused  and  misty, 
opinions  of  a  contradictory  character  being  stated  :  on  all  sides,  proofs  were 
wanting  :  and  prolonged  debates  terminated  without  any  conclusion  being 
arrived  at.* 

*  Bulletin  de  l'Academie  de  Medecine,  1838,  t.  i,  p.  62. 
vol.  i.— 37 


578  PLEURISY:     PARACENTESIS    OF    THE    CHEST. 

There  was  a  disposition  to  follow  the  authority  of  Laennec  in  France, 
the  country  in  which  auscultation  was  discovered,  and  an  inclination  to 
dispute  the  efficacy  of  paracentesis  in  the  different  forms  of  effusion  into 
the  chest  which  physicians  are  called  upon  to  treat ;  and  surgeons  continued 
to  eraplov  it  only  in  traumatic  effusiou.  But  in  foreign  countries,  the  new 
means  of  diagnosis  excited  better  hopes  from  the  operation. 

In  1834,  Becker  published,  at  Berlin,  a  monograph  on  chronic  pleurisy, 
in  which,  after  having  explained  how  the  progress  of  thoracic  examination 
had  enabled  the  operation  to  be  better  applied,  he  detailed  five  cas 
chronic  pleurisy  in  which  paracentesis  was  performed  at  the  request  of  Dief- 
fenbach ;  and  upon  his  title-page,  he  placed  these  words  "  Melius  est  aneeps 
remedium  quam  n  uUum."  In  1835,  Thomas  Davies  set  himself  after  a  some- 
what awkward  fashion  to  refute  the  opinion  of  Laennec,  whom  he  repre- 
sented as  utterly  denying  the  utility  of  the  operation.  In  opposition  to  the 
opinion  of  the  French  physician,  he  declared  that  paracentesis  is  useless  in 
pneumothorax,  but  that  it  renders  very  marked  benefits  in  cases  of  hydro- 
thorax  and  empyema,  particularly  in  children.  His  plan  was  to  make  the 
puncture  in  the  intercostal  space  with  a  small  trocar,  without  using  any 
accessory  apparatus  to  prevent  the  entrance  of  air.  He  recommended — 
and  the  recommendation  has  been  long  followed  in  England — that  the 
operation  should  be  preceded  by  an  exploratory  puncture  with  a  needle, 
to  ascertain  the  nature  of  the  effused  fluid  and  its  degree  of  consistence,  as 
well  as  other  points,  such  as  the  presence  or  absence  of  false  membranes. 

The  support  given  by  Thomas  Davies  to  an  operation  then  so  little  in 
favor  was  not  without  a  good  effect.  His  opinion  was  ignored  in  France, 
but  had  many  advocates  in  his  own  country,  where  Davies  became  an 
authority  with  all  who  made  new  trials  of  the  operation  :  the  feeling  in  its 
favor,  however,  was  not  a  general  conviction.  While  some  performed  the 
operation,  and  lauded  its  results,  there  were  others  who  abstained  from 
having  recourse  to  it,  and  were  not  remiss  in  arguing  against  it.  Stokes,* 
and  afterwards  Watson,  insisted  upon  the  evils  resulting  from  paracentesis, 
which  they  alleged  converted  a  serous  into  a  suppurative  inflammation — 
a  false  doctrine,  which  has  been  recently  revived.  Holding  these  views, 
they  maintained  that  the  operation  ought  not  to  be  performed,  unless  the 
life  of  the  patient  was  in  imminent  peril. 

In  Germany,  however,  confidence  was  sustained.  Schuh  of  Vienna  gave 
in  his  adhesion  to  the  doctrines  of  Becker.  In  1839,  Schuh,  in  his  "  I>i-- 
sertation  on  the  Influence  which  Auscultation  and  Percussion  are  entitled 
to  exercise  on  Practical  Surgery,"  declares  that  paracentesis  is  a  radical 
cure  in  cases  of  chronic  thoracic  effusion,  whether  the  effusion  has  or  has 
nor  followed  an  acute  attack.  In  that  work,  he  lays  down  the  principles 
which  three  years  later  lie  applied  in  practice. 

Such,  gentlemen,  was  the  state  of  the  controversy  upon  this  question  in 
therapeutic-,  when  I  contributed  my  own  researches  to  its  elucidation. 
Contradictory  opinion-  were  maintained  with  equal  keenness  on  both  sides. 
Dr.  Eteybard  had  already  published  an  account  of  his  ingenious  instru- 
ment ;f  hut  being  more  occupied  with  the  mode  of  operating,  than  with 
the  indications  for  operating,  lie  added  nothing  to  what  had  already  been 
taughl  on  the  subject.  lie  admits  that  he  had  had  few  opportunities  of  per- 
sonally applying  his  method  in  practice,  and  from  want   of  cases  i"  appeal 

*  Btok  ecg     Die  ases  of  the  Chest :   Dublin. 

;    Ki  ■,  1. 1  i;i.  :    Memoire  Bur  Les  Epanchements  dans  La  Poitrine,  el  sur  un  Nouveau 
16  Operatoire  pour  retirer  les  fiuides  epancbes  sans  laisser,  penetrer  l'a 
terieur  dana  le  thorax.     \Qa    "•    kfii         •,  for  January,  1841.] 


PLEURISY:     PARACENTESIS    OP    THE    CHEST.  579 

to,  he  supposed  that  dropsical  effusions  into  the  chest,  generally  caused  l>y 
an  inflammation  of  the  pleura,  ought  to  be  cured  by  asingle  tapping.  The 
remainder  of  his  exceedingly  interesting  dissertation  is  specially  devoted  to 
wounds  of  the  chest. 

Towards  the  end  of  1841,  two  professors  of  the  Vienna  School  of  Medicine, 
Schuh*  and  Skoda  published  an  important  work  on  this  therapeutical 
subject.  As  I  formerly  mentioned,  Schuh  had  already,  on  theoretical 
grounds,  lauded  the  good  effects  of  paracentesis  of  the  chest.  Their  mono- 
graph, which  has  become  a  classical  work  in  Germany,  deserves  to  occupy 
a  distinguished  place  in  the  history  of  paracentesis  of  the  chest.  They 
begin  by  laying  down  the  principle  that  recovery  from  pleurisy  generally 
takes  place  when  the  effusion  is  not  excessive  in  quantity,  and  when  the 
case  is  without  complications.  Even  when  the  effusion  is  profuse,  they  say 
that  nature  will,  when  aided  by  known  means,  accomplish  a  cure;  but  that 
the  time  required  will  extend  to  months,  or  it  may  be  to  years.  The  evils 
which  follow  pleurisy  are  deformity  of  the  chest,  anaemia  and  its  worst  con- 
sequences, viz.,  syncope,  sudden  death,  formation  of  tubercle,  and  hyper- 
trophy with  dilatation  of  the  right  side  of  the  heart. 

If  the  effusion  be  to  the  extent  of  several  pounds,  and  the  fever  have 
ceased,  paracentesis  is  indicated,  provided  there  has  been  no  amelioration 
of  symptoms  for  three  weeks  :  the  operation  will  prove  either  a  radical  cure 
or  a  palliative. 

Both  authors  set  themselves  to  refute  the  arguments  adduced  against 
paracentesis,  and  to  explain  in  detail  the  different  stages  of  the  operation. 
They  recommended  that  the  whole  of  the  fluid  should  not  be  withdrawn  at 
once,  being  afraid  that  the  sudden  expansion  of  the  lung,  and  replacement 
of  organs  pushed  out  of  place  by  the  effusion,  might  be  productive  of  in- 
jurious consequences.     This  fear  is  chimerical,  as  I  shall  show  you. 

The  work  of  Schuh,  though  supported  by  the  authority  of  Skoda,  did  not, 
even  in  Germany,  meet  with  the  approbation  which  it  deserved.  In  foreign 
countries,  it  remained  unknown ;  and  I  have  not  once  seen  it  quoted  by 
French  or  English  experimenters. 

Almost  about  the  same  time,  just  as  if,  in  the  history  of  this  operation,  it 
was  fated  that  every  hope  of  success  should  be  counterbalanced  and  con- 
tradicted, Hope  dictated  his  "Notes  on  the  Treatment  of  Chronic  Pleurisy," 
which  were  published  in  the  Medico-Chirurgical  Review  (of  London),  in 
1841.  He  therein  endeavored  to  prove  that  pleuritic  effusions  did  not  require 
the  aid  of  surgery,  and  that  the  resources  of  the  materia  medica  were  always 
sufficient  for  their  treatment.  Concurring  with  the  physicians  who,  upon 
the  occasion  of  the  discussion  before  the  Academy  of  Medicine,  maintained 
that  pleurisy  is  never  fatal,  concurring  also  with  Stokes  and  Watson,  Hope 
declared  that  the  want  of  success  in  the  treatment  arose  from  the  timidity 
with  which  the  remedies  were  administered.  He  spoke  very  strongly  in 
favor  of  the  plan  of  pushing  resolutely  mercurial  medicines,  and  giving  a 
sustaining  diet  embracing  animal  food,  even  when  there  existed  fever;  and 
he  recommended  certain  diuretics.  He  details  thirty-three  cases  of  chronic 
pleurisy  cured  by  this  plan  of  treatment. 

The  discussions  excited  by  these  writings  were  not  very  numerous,  and 
were  soon  forgotten.  Attention  was  not  fixed  upon  the  indications,  upon 
the  advantages  or  danger  of  paracentesis ;  and  what  appeared  at  that  date 
in  the  medical  periodicals  w7as  only  an  occasional  report  of  cases  in  which 
the  operation  was  performed,  both  the  nature  of  the  cases  and  the  results 
being  very  various. 

*  Schuh:  Medicinische  Jahrbucher  der  k.  k.  Oesterreich.  Staates.     Wien,  1841. 


5S0  pleurisy:   paracentesis  of  the  chest. 

In  1844,  my  memoir,  read  before  the  Academy,  by  awakening  a  fresh 
interest  in  the  subject,  called  forth  new  researches.  In  England,  a  similar 
impulse  was  given  to  inquiry.  It  now  began  to  be  felt,  that  there  was  a 
sufficiently  solid  basis  for  inquiry,  and  that  consequently,  leaving  aside 
hypothesis,  facts  might  be  appealed  to.  In  this  spirit  were  conceived  two 
monographs,  which  close  the  list  of  English  publications  of  any  importance 
upon  "tapping  the  chest.  I  refer  to  the  work  of  Hamilton  Roe  "  On  Para- 
centesis of  the  Chest  in  Empyema  and  Inflammatory  Hydrothorax,  "  *  and 
to  the  writings  of  Hughes,  f  Roe  laid  down  excellent  precepts,  and  con- 
sidered the  results  of  experience  as  very  satisfactory.  He  was  not  afraid  of 
syncope,  which  according  to  the  views  of  objectors,  threatened  the  life  of 
the  patient  immediately  after  the  operation;  nor  was  he  afraid  of  the  en- 
trance of  air,  against  which  he  took  no  manner  of  precaution.  The  mode 
of  operating  which  he  recommended  was  exceedingly  simple :  he  reduced 
the  operation  to  a  mere  puncture  in  an  intercostal  space  with  a  trocar  of 
medium  size. 

Perhaps,  gentlemen,  you  may  have  thought  that,  considering  the  nature 
of  the  instruction  which  it  is  my  duty  to  give,  I  have  gone  too  minutejy 
into  this  historical  sketch  of  paracentesis  of  the  chest ;  I  wished  to  go  fully 
into  the  matter,  because  I  desired  to  show  how  this  operation,  though  recog- 
nized in  the  very  infancy  of  medicine,  had  had  difficulty  in  establishing 
itself  in  the  domain  of  therapeutics,  and  that  its  doing  so  at  last  was  in 
consequence  of  the  indications  having  been  established  in  that  precise  form 
in  which  they  now  exist. 

I  propose  in  my  next  lecture  to  go  into  the  essentially  practical  parts  of 
the  subject. 


(Xrcumstances  which  render  Paracentesis  of  the  Chest  necessary. — Pleurisy 
may  be  fatal. — Profuse  Effusion  may  cause  Sudden  Death. — If  may  occa- 
sion Death  by  Asphyxia. —  On  the  other  hand,  Paracentesis  may  accom- 
plish fin  Immediate  Oure:  when  this  takes  place,  tin  Temperaturi  of  the 
Body  at  once  becomes  normal. —  The  Continuance  of  ilie  Effusion  in  the 
Chest  hi"!/  occasion  Hectic  Fever. —  TheEffusion  may  become  Purulent. — 
Traumatic  Pleurisy. — Pleurisy  may  occasion  dt  vt  lopnu  nt  >>j'fli>:  Tn1»  rcular 
Diathesis. — Latent  Pleurisy  is  <i  frequent  manifestation  of  this  Diathesis, 
trhfth'-r  ihe  Eft'n.<init  miuiiii  Serous,  or  become  Purulent,  as  usually  occurs. 
— Paracentesis  is  also  useful  when  there  exists  Hydropneumothoraz, — 
( 'ancerous  Pit  urii 

Gentlemen:  To  justify  paracentesis  of  the  chest  in  pleurisy  with  a  great 
amount  of  effusion,  it  is  firsl  of  all  essentia]  to  establish,  in  opposition  to 
tin-  opinion  of  Dr.  Louis,  thai  pleurisy  sometimes  terminates  in  death. 

Tin-  disease  may  prove  fatal  from  the  immediate  effect  of  excessive 
effusion. 

Death  may  also  1»\  in  an  indirect  manner,  the  result  of  pleurisy  becom- 
ing the  starting-point  of  affections  under  which  individuals  sink  sooner  or 
later.  For  example,  the  mere  continued  existence  of  effusion,  whether  the 
fluid  in  lie  cavity  of  the  pleura  remain  .-irons  or  degenerate  into  pus,  will 

*  Hamilton   Roe:  Transactions  of  the  Medical  and  Chirurgical  Society  of  Lon- 
don: 1844. 
f  lluoin       •■    .     Hospital  Reports,  1844:  and  London  Medical  Gazette,  1848, 


pleurisy:   paracentesis  of  the  chest.  581 

cause  continued  fever,  luetic  fever,  by  which  the  patients  will  become  ex- 
hausted. Let  me  add,  that  from  the  special  nature  of  the  inflammation 
which  gives  rise  to  the  effusion,  the  effusion  is  often  purulent  from  the 
very  first. 

Moreover,  a  persistent  determination  towards  the  thoracic  viscera  is  cal- 
culated to  lead  to  the  development  of  the  tubercular  diathesis  in  predisposed 
persons. 

Finally,  the  longer  a  pleurisy  continues,  the  less  curable  is  it,  as  the  lung 
contracts  adhesions  in  protracted  cases  which  permanently  prevent  it  resum- 
ing its  place  in  the  thoracic  cavity,  and  discharging  its  functions. 

Let  me  pass  before  you  in  review  the  different  propositions,  now  generally 
admitted  to  be  true;  and  to  which  general  recognition,  I  have  perhaps  con- 
tributed. 

Pleurisy  may  prove  fatal  from  the  quantity  of  the  effusion  being  very  great. 

This  is  a  point  which  I  have  already  established  in  my  last  lecture.  I 
established  it,  not  only  by  appealing  to  cases  which  had  come  under  my 
own  personal  observation,  but  also  by  referring  to  others  which  had  been 
observed  by  physicians  altogether  reliable,  among  whom  I  may  mention 
Chomel,  Bricheteau,  and  my  friend  Dr.  Pidoux. 

Among  other  additional  examples  which  I  could  lay  before  you,  let  me 
present  to  you  the  following  history,  all  the  details  of  which  I  have  care- 
fully collected. 

On  17th  August,  1847,  I  was  requested  to  see,  in  consultation,  a  man 
aged  44,  who  had  been  ill  for  six  weeks.  Up  to  the  date  of  his  attack,  he 
had  always  had  good  health.  On  3d  July,  he  was  seized  with  symptoms 
of  inflammatory  fever,  the  result  of  a  chill,  commonly  called  a  coup  defroid. 
He  continued  to  walk  daily  from  his  residence  at  the  Barriere  Blanche  to 
the  War  Office  in  the  Rue  Saint-Dominique,  where  he  was  a  clerk.  In  the 
evening,  on  returning  from  his  office,  he  always  complained  of  fatigue,  then 
of  a  feeling  of  oppression,  which  increased  clay  by  day,  and  which  he  com- 
pared to  a  military  stock  [liausse-eol]  painfully  compressing  the  upper  part 
of  the  chest.  On  26th  July,  he  was  obliged  to  give  in.  The  dyspnoea,  the 
feeling  of  constraint  of  the  chest,  and  the  general  debility  went  on  increas- 
ing :  consequently,  he  took  to  his  bed,  and  sent  for  his  medical  attendant. 
At  that  time,  he  was  coughing  a  little.  The  physician  who  was  called  in 
informed  me  that  he  found  him  in  a  feverish  state,  with  rusty  sputa,  but 
■without  dulness  of  the  chest  on  percussion.  He  was  bled  :  but  as  the 
bleeding  was  followed  by  syncope,  the  physician  was  afraid  to  repeat  it.  A 
plan  of  treatment  was  then  commenced  intended  to  produce  revulsion  from 
the  lungs  to  the  skin  and  intestinal  canal ;  while,  at  the  same  time,  there 
were  administered  opiated  potions  to  subdue  the  cough.  It  was  not  till  the 
eighth  or  tenth  day  of  the  attack,  that  incipient  dulness  was  detected  on 
the  left  side :  the  dulness  existed  throughout  the  entire  left  side  of  the 
chest,  both  before  and  behind.  The  treatment  was  then  changed  to  blister- 
ing the  chest,  and  administering  diuretics.  The  severity  of  the  symptoms 
increased :  the  debility  and  the  fever  became  more  menacing.  There  was 
delirium  during  the  night,  and  profuse  sweating  which  weakened  the 
patient :  but  the  oppression  of  the  breathiug  was  only  marked  in  a  moder- 
ate degree.  As,  however,  matters  were  going  on  from  bad  to  worse,  they 
did  me  the  honor  to  call  me  in. 

The  following  is  an  account  of  the  state  in  which  I  found  the  patient. 
The  pulse  was  100,  soft,  and  easily  compressed:  there  was  sweating,  which 
was  constant,  passive,  and  warm:  the  skin  was  rather  hot:  the  face  was 
flushed,  the  eye  expressionless,  and  the  brain  "  empty,"  to  use  a  vulgar 
phrase.     There  was  no  cough,  and  the  respirations  were  25  in  a  minute. 


582  pleurisy:   paracentesis  of  the  chest. 

The  patient  was  lying  in  the  horizontal  position :  on  ray  arrival,  he  sat  up 
in  bed,  and  made  no  complaint,  except  that  he  suffered  from  fever,  and 
wasting  sweats,  to  use  his  own  expression  \_des  sueurs  qui  le  minenf].  He 
only  made  one  request,  which  was,  that  the  fever  might  be  cut  short :  he 
made  no  mention  of  oppressed  breathing,  cough,  or  stitch  in  the  side.  He 
passed  his  urine  and  stools  involuntarily.  His  countenance  and  appearance 
suggested  the  idea  of  a  person  suffering  from  typhoid  fever,  but  with  this 
difference,  that  the  mucous  membrane  of  the  mouth  was  in  a  normal  state. 

On  examining  the  chest,  I  found  complete  dulness  on  the  left  side  from 
summit  to  base,  in  front  and  behind,  extending  to  the  subclavicular  and 
infraspinous  fossae :  everywhere,  auscultation  revealed  the  absence  of  all 
sounds,  vocal  or  respiratory,  normal  or  morbid.  On  this  side,  the  thoracic 
walls  did  not  vibrate  under  the  hand  when  the  patient  spoke.  On  the 
right,  there  existed  normal  resonance  and  supplementary  respiration.  There 
was  no  enlargement  of  the  intercostal  spaces,  and  the  chest  did  not  seem  to 
be  distended  on  the  affected  side.  The  effusion  extended  laterally  to  the 
middle  of  the  sternum :  exactly  at  this  point,  and  not  in  its  natural  position, 
the  pulsation  of  the  heart  was  felt. 

Looking  to  the  great  amount  of  the  effusion,  and  notwithstanding  the 
slightness  of  the  dyspnoea,  I  was  of  opinion  that  any  attempt  to  promote 
absorption  would  be  useless  and  even  injurious,  inasmuch  as  it  would  delay 
the  tapping,  the  only  efficacious  treatment  which  could  be  employed. 

However,  to  enable  the  patient  to  wait  till  the  following  day  (it  was  then 
three  in  the  afternoon),  I  prescribed  (in  place  of  the  strict  low  diet  on  which 
he  had  been  placed)  two  cups  of  milk  and  meat  broth,  a  slightly  stimulat- 
ing potion,  and  thirty  centigrammes  of  the  sulphate  of  quinine.  But  at 
eight  o'clock  next  morning,  the  patient  died,  after  some  hours  of  dreadful 
agouy,  repeated  faintings,  delirium,  but  no  great  amount  of  dyspnoea. 
After  death,  percussion  of  the  chest  gave  results  similar  to  those  of  the 
previous  evening. 

These  unfortunate  cases,  more  of  which  might  be  cited,  speak  too  plainly 
to  allow  any  one  to  deny  that  simple  pleuritic  effusion,  may  from  mere 
quantity,  cause  death.     We  shall  afterwards  see  how  this  occurs. 

Enormous  effusion  may  arise  from  simple  acute  pleurisy ;  and  I  do  not 
believe  that  as  yet  any  clinical  observer  has  discovered  signs  by  which  to 
determine  whether  an  attack  of  pleurisy  is  or  is  not  to  be  followed  by 
extensive  effusion.  There  can,  however,  be  no  doubt  that  Dr.  Pidoux  made 
a  correct  remark  when  he  said,  that  "very  profuse  effusion  generally 
supervenes  in  a  peculiar  form  of  pleurisy,  quite  different  from  ordinary 
pleurisy."* 

It  is  usual  to  distinguish  two  stages  in  pleurisy.  The  first  is  peculiarly 
the  iiijhmniHilori/  sluc/c,  characterized  by  anatomical  changes  described  in 
your  text-books,  and  during  the  progress  of  which  occur  in  a  marked  man- 
ner the  ordinary  phenomena  of  inflammatory  fever,  with  the  violent  si  itch 
in  the  side,  and  the  dry  pleuritic  cough.  This  stage  is  of  short  duration  : 
and  sonic,  indeed — anion;/  whom  is  LaenneC-  have  denied  that  it  is  at  all 
distinct  from  the  sec I.  The  second  is  the  stage  of  effusion:  in  it  the  in- 
flammatory element  appears  to  be  relatively  feebler,  bul  continues  during 
a  period  to  which  it  is  difficult  to  assign  the  limits;  and  afterwards  the 
effused  products  undergo  transformations,  and  originate  false  membranes. 

As  an  exception  to  the  general  rule,  the  inflammatory  elemenl  is  some- 
times very  slightly  marked      if  we  judge  by  the  mildness  of  the  local    and 

general  Bymptoms — though  the  amount  of  the  effusion  is  considerable. 


*Pidoux:    M'ni.nr.'  -in-  le  Prognostic  do  In  l'leurisie  Latente,  A:<\     Paris,  I860. 


PLEURISY:     PARACENTESIS    OF    THE    CHEST.  583 

This  is  not  peculiar  to  the  pleura, being  likewise  observed  in  other  serous 
membranes.     Observe  what  takes  place  in  the  synovial   membranes.     In 

certain  forms  of  articular  rheumatism  the  phlegmasia,  characterized  by 
intensity  of  local  pain  ami  general  reaction,  is  very  violent,  although  the 
effusion  into  the  joint  is  inconsiderable:  in  other  cases  the  effusion,  although 

proportionate  to  the  intensity  of  the  inflammation,  yields  as  rapidly  as  the 
phlegmasia  itself:  finally,  there  are  cases,  unfortunately  only  too  common, 
in  which  there  is  almost  no  inflammatory  action,  although  there  is  an  enor- 
mous synovial  exudation,  remaining  for  months,  notwithstanding  the  use  of 
the  most  energetic  therapeutic  measures.  A  similar  occurrence  is  observed 
in  peritonitis,  in  which  the  ascitic  effusion  is  never  greater  than  in  cases  in 
which  the  phlegmasia  of  the  serous  membrane  has  seemed  to  be  exceedingly 
slight.  Of  this  you  have  recently  seen  an  example  in  a  young  woman  in 
Si.  Bernard's  Ward,  who  had  hydropcritonitis  for  several  months. 

Acute  hydrothorax,  that  particular  form  of  pleurisy  of  which  I  now  speak, 
is  evidently,  in  general,  associated  with  a  special  state  of  the  system,  a  sort 
of  serous  diathesis,  which  may  either  show7  itself  only  by  effusion  into  the 
pleura,  or  which  may  simultaneously  manifest  itself  by  effusion  into  other 
serous  cavities. 

Some  of  you  no  doubt  remember  the  case  of  a  man,  sent  to  us  by  Profes- 
sor Rostan,  who  died  in  our  wards  from  double  pneumonia  complicated  with 
peritonitis.  This  patient  entered  the  wards  of  my  honorable  colleague  with 
extensive  pleuritic  effusion  requiring  paracentesis.  At  the  request  of  Pro- 
fessor Rostan  I  performed  the  operation :  a  perfectly  transparent  serous 
fluid  was  withdrawn.  The  effusion  having  been  reproduced,  a  second  opera- 
tion was  performed,  wrhen  again  the  fluid  was  purely  serous.  Again  there 
was  a  return  of  the  effusion.  The  patient  then  came  into  my  wards.  He 
had  at  that  time  double  pleurisy,  and  also  subacute  peritonitis,  accompanied 
by  considerable  ascitic  effusion. 

There  was  evidently  in  this  individual  a  peculiar  tendency  to  inflamma- 
tion of  the  serous  membranes. 

At  the  autopsy  we  found  the  surface  of  the  peritoneum  covered  with  small 
granulations,  which  gave  it  the  appearance  of  the  skin  of  a  plucked  bird. 
The  granulations  had  none  of  the  characters  of  tuberculous  products,  of 
which  no  traces  were  found  in  any  organ. 

Latent  pleurisy  is  a  subject  on  which  I  have  now  a  word  to  say. 

In  consequence  of  a  chill,  oi',  it  may  be,  even  without  any  appreciable 
determining  cause,  an  individual  is  seized  with  rigors,  general  uneasiness, 
loss  of  appetite,  pains  in  the  back  and  limbs,  and  feverishness :  he  feels  a 
slight  stitch  in  the  side,  or  perhaps  he  has  no  pain  in  the  side:  for  a  few 
days  he  has  a  short  dry  cough.  These  first  symptoms  continue  a  very  short 
time,  and  are  so  soon  forgotten  by  the  patient  that  he  makes  no  reference 
to  them,  unless  you  recall  them  to  his  recollection.  The  disease  has,  never- 
theless, pursued  its  slow  course:  the  patient  feels  that  he  does  not  breathe 
freely,  and  that  he  pants  on  making  the  least  movement:  the  dyspnoea  is 
so  great  that  he  cannot  lie  on  the  sound  side,  or  perhaps  he  finds  it  impos- 
sible to  remain  in  the  recumbent  position:  there  is  orthopncea:  possibly  the 
dyspnoea  is  so  slight  that  the  patient  is  found  lying  flat  on  his  back,  and 
the  oppression  of  the  breathing  may  be  much  more  appreciable  by  the  phy- 
sician than  by  the  patient.  On  examining  the  chest  with  the  pleximeter 
and  the  stethoscope,  you  discover  that  there  is  effusion — sometimes  enormous 
effusion — by  which  the  heart,  spleen,  and  liver  are  compressed  and  dis- 
placed, by  which  the  chest  is  deformed  in  consequence  of  great  distension 
of  the  affected  side.     These  extensive  effusions  lead  to  very  serious  dangers. 

Sudden  death  may  be  one  of  the  consequences.  It  is  not  unusual,  I  repeat, 


584  PLEURISY:     PARACENTESIS    OF    THE    CHEST. 

for  persons  with  extensive  pleuritic  effusion  to  siuk  all  at  once,  without 
having  had  the  breathing  much  oppressed,  at  any  time,  and  without  ever 
having  had  a  threatening  of  suffocation.  Death  takes  place  from  syncope. 
In  corroboration  of  this  statement,  I  appeal  to  the  cases,  published  by  my 
professional  brethren,  of  sudden  death  occurring  under  such  conditions  as 
I  have  now  described.  I  could  also  adduce  several  similar  cases  which 
have  occurred  in  my  own  practice.  The  mortal  faintings  are  explained  by 
the  great  displacement  of  the  heart  occasioned  by  the  mass  of  effused  fluid. 
The  heart,  as  I  have  told  you,  is  forced  out  of  its  natural  place :  the  aorta 
and  large  vessels  are  twisted  in  such  a  way  as  to  impede  greatly  the  current 
of  the  blood,  so  that  under  the  influence  of  an  exciting  cause,  such  as  the 
more  or  less  abrupt  movement  of  the  body,  the  circulation  is  brought  to  a 
complete  standstill.  Perhaps  also,  death  is  sometimes  induced  by  the  forma- 
tion of  clots  in  the  heart  and  large  vessels,  which  is  liable  to  occur  from 
the  circulation  of  the  blood  being  impeded. 

This  opinion,  which  I  announced  long  ago,  has  been  verified  by  a  case 
to  which  Dr.  Blachet  has  directed  attention.*  This  physician  relates  the 
interesting  case  of  a  patient  who  died  suddenly  in  a  faint.  At  the  autopsy, 
a  clot  was  found  occupying  the  entire  extent  of  the  trunk  of  the  pulmonary 
artery,  and  bifurcating,  it  stretched  into  the  divisions  of  the  third  and 
fourth  order  of  the  left  branch  of  the  artery.  In  this  case,  the  pleurisy 
was  chronic :  there  was  about  a  litre  and  a  half  of  effused  fluid :  the  heart 
was  not  displaced,  and  the  sudden  death  was  probably  the  result  of  the 
blood  coagulating  in  the  pulmonary  artery. 

Although  in  many  cases  the  patients  do  not  complain  of  oppression  in 
the  breathing,  although  the  existence  of  dyspnoea  is  not  very  apparent  to 
the  physician,  extensive  effusion  may  nevertheless  cause  death  by  asphyxia. 
In  these  cases,  the  asphyxia  is  slow,  the  consequence  of  great  embarrass- 
ment in  respiration,  hajmatosis  not  taking  place  in  the  affected  lung,  and 
being  but  imperfectly  performed  in  the  other,  from  its  movements  being 
necessarily  disturbed  by  the  liquid  which  fills  the  pleural  cavities,  presses 
on  the  mediastinum,  and  so  diminishes  the  capacity  of  the  other  side  of  the 
chest. 

The  only  way  to  prevent  a  fatal  termination  is  the  true  heroic  practice 
of  puncturing  the  chest  and  drawing  off  the  effused  fluid.  This  operation 
is  quite  free  from  danger.  I  shall,  however,  discuss  the  objections  which 
have  been  brought  against  it,  and  shall,  I  trust,  be  able  to  show  you  that 
the  imputed  drawbacks  are  purely  imaginary. 

Besides  the  case  which  led  to  my  giving  you  the  present  lectures  on 
pleurisy,  you  have  seen  many  others,  in  which  paracentesis  of  the  chest  was 
practiced  under  similar  circumstances,  and  with  equally  happy  results. 
The  cases  go  on  increasing  infinitely ;  for  on  all  sides,  physicians  are  in 
haste  to  publish  them.  For  my  own  share,  1  could  cite  a  greal  many; 
some  of  them  have  occurred  in  my  own  practice,  and  others  have  been 
obligingly  communicated  to  me  by  professional  brethren.  [  shall  restrict 
myself  to  giving  you  the  particulars  of  four  case-. 

The  hist  occurred  in  my  own  practice,  and  is  now  of  old  date:  the  second 

was  reported  in  the  wards  of  my  honorable  friend  Dr.  Horteloup,  my  col- 
league  in    this  hospital:    the   third  was   COmi icated    to   me  by  my  pupil 

Dr.  Bonfils:  the  fourth  you  have  recently  had  an  opportunity  of  observing 
in  my  wards,  and  I  shall  specially  call  your  attention  to  it.  as  it  presents 
import  ant  peculiarities  in  respeel  of  the  question  of  temperature. 
On  Saturday,  22d  dune,  L844,  ray  friend    Dr.    Patin  came  before  sis 


Blachet:  Union  M6dieale  i'<>r  February,  lsr.'j. 


pleurisy:   paracentesis  of  the  chest.  585 

o'clock  in  the  morning,  to  take  me  to  see  with  him  Madame  Schlaguestad, 
living  at  3,  Rue  Marcadet,  La  Chapelle-Saint-Denis.  Be  had  been  sent 
for  during  the  night  to  this  patient,  who  at  the  fourteenth  day  of  a  pleurisy 
was  so  distressed  for  breath,  thai  her  life  seemed  to  be  in  immediate  danger. 

On  Sunday,  9th  dime,  .-he  had  felt  uneasy,  and  lnul  had  a  little  pain  in  the 
left  side  .it'  the  chest.  She  had  in  a  casual  manner  consulted  a  physician, 
Who,  considering  that  the  breathiessncss,  pale  countenance,  and  stitch  in  the 
side  depended  on  chlorosis,  ordered  generous  diet,  good  wine,  ami  walking 
exercise.  The  unfortunate  patient  carried  out  only  too  scrupulously  this 
fatal  prescription;  with  energy  she  fought  against  the  fever  under  which 
she  was  sinking:  at  last,  on  the  eighth'day  of  her  pleurisy,  conquered  by 
the  disease,  she  took  to  her  bed,  and  called  in  Dr.  Patin,  who  had  no  diffi- 
culty in  discovering  the  nature  of  the  case  he  had  to  deal  with.  There  was 
complete  dulness  on  the  left  side  of  the  chest,  from  base  to  summit:  the 
intercostal  spaces  were  distended  ;  and  the  heart  was  pushed  to  the  right 
side. 

Active  treatment  gave  temporary  relief.  On  Friday  the  21st,  she  was 
in  a  somewhat  improved  state,  after  appearance  of  the  menses;  during  the 
evening  they  ceased.  In  the  night,  the  dyspnoea  having  become  rapidly 
worse,  and  death  seeming  imminent,  Dr.  Patin  was  summoned  from  his  bed. 

Dr.  Patin  found  the  patient  sitting  up  in  bed,  supported  by  pillows:  her 
face  was  pale  aud  anxious:  her  eyes  were  wide  open  :  her  nostrils  were  in 
violent  motion  :  and  her  respiration  was  extremely  difficult.  There  was 
complete  dulness  of  the  left  side  of  the  chest,  which  was  enormously  dis- 
tended :  in  that  situation,  a  blowing  sound  and  segophony  were  heard  :  the 
cough  was  moderate.  The  heart  was  beating  under  the  cartilages  of  the 
right  side  of  the  sternum.  The  pulse  was  very  rapid,  and  exceedingly 
weak.  The  amount  of  effusion  was  very  great.  Death  was  imminent. 
These  were  the  circumstances  under  which  I  was  called  in.  On  my  arri- 
val, the  course  to  be  taken  was  very  soon  decided  on  :  paracentesis  was 
immediately  performed.  By  this  proceeding,  there  was  drawn  off,  without 
much  difficulty,  exactly  two  litres  by  measure  [above  two  quarts].  You 
can  easily  understand  the  extraordinary  relief  experienced  by  the  evacua- 
tion of  these  sixteen  palettes  of  serosity.  The  poor  woman  was  in  fact 
restored  to  life.  The  heart  had  resumed  its  place,  and  the  pulse  was  full 
and  regular,  though  still  somewhat  frequent :  the  dyspnoea  was  gone.  She 
lay  almost  in  the  horizontal  position,  breathed  calmly,  and  had  some  desire 
to'  sleep.  The  dulness  still  continued  on  the  left  side  of  the  chest,  which 
now  seemed  smaller  than  the  right  side. 

The  bronchophony  and  blowing  sound  remained  as  before.  I  prescribed 
digitalis,  and  recommended  that  the  patient  should  have  as  little  as  possi- 
ble to  drink.  She  had  a  perfectly  quiet  day  :  and  during  the  night,  slept 
seven  hours.  During  some  following  days  the  digitalis  was  continued,  and 
some  purgative  medicines  were  administered. 

On  Tuesday,  25th,  I  again  saw  this  lady.  The  clavicular,  region  and 
the  entire  infraspinous  fossa  yielded  a  clear  sound,  and  the  respiratory 
murmur  was  heard  in  these  situations  :  from  the  crest  of  the  scapula  to  the 
base  of  the  lung,  segophony  and  bronchophony  were  audible.  The  patient 
had  slight  fever  and  a  little  dry  cough,  but  there  was  no  oppression  of  the 
breathing:  she  had  appetite  for  food.  The  digitalis  was  ordered  to  be  con- 
tinued ;  and  she  was  allowed  to  take  light  nourishment. 

Eight  days  later,  the  respiratory  murmur  was  heard  as  high  up  as  the 
middle  of  the  infraspinous  fossa  :  below  that  point,  the  sound  was  clear  : 
near  the  angle  of  the  scapula,  there  was  very  distinct  segophony :  lower 
down,  there  was  a  blowing  sound  and  bronchophony :  there  were  no  rales  : 


586  PLEURISY:     PARACENTESIS    OF    THE    CHEST. 

the  cough  was  still  dry.  Although  the  appetite  was  very  good,  the  fever 
continued.  I  ordered  a  blister  to  be  applied  to  the  back,  suspended  the 
other  treatment,  and  prescribed  a  decidedly  nutritious  diet.  Sixteen  days 
after  the  operation,  so  great  was  the  patient's  restoration  of  strength,  that 
she  was  able  to  walk  to  the  residence  of  a  relation  at  Clignancourt,  a  dis- 
tance of  more  than  two  kilometres  [more  than  a  mile  and  a  half],  remain 
there  during  the  day,  and  return  on  foot  in  the  evening,  without  being 
much  fatigued.  I  saw  her  three  days  after  this  imprudent  proceeding, 
when  she  was  very  well,  had  an  excellent  appetite,  and  had  neither  cough 
nor  dyspnoea.  Posteriorly,  there  was  still  dulness  in  the  lower  part  of  the 
side  which  had  been  the  seat  of  the  effusion,  but  the  respiratory  murmur 
was  everywhere  audible. 

The  following  is  the  history  of  the  second  case.  On  5th  January,  1854, 
a  man,  aged  thirty-six  years,  came  into  Dr.  Horteloup's  wards  in  the  Hotel- 
Dieu.  He  said  that  he  had  been  ill  for  three  weeks  ;  but  that  he  had  had 
cough  for  six  months.  Upon  interrogating  him  as  to  his  hereditary  ten- 
dencies and  personal  antecedents,  nothing  was  elicited  indicative  of  the 
tuberculous  diathesis.  It  appeared  that  without  any  cause  appreciable  to 
the  patient,  he  had  been  seized  three  clays  prior  to  his  admission  to  the 
H6tel-Dieu  with  shortness  of  breath  and  wandering  pains  in  the  chest,  but 
without  having  any  stitch  in  the  side.  He  had  at  that  time  no  fever,  and 
was  able  to  continue  his  ordinary  work.  In  consequence  of  increased  diffi- 
culty in  breathing,  he  applied  for  admission  to  the  hospital. 

On  admission,  he  was  suffering  from  extreme  anxiety  and  suffocative 
symptoms,  speaking  with  difficulty,  and  in  a  short,  jerking  voice.  His 
countenance  was  pale  and  blue  :  the  extremities  were  cold.  At  the  first 
examination,  the  chest  was  evidently  distended  on  the  right  side.  There 
was  complete  dulness  from  summit  to  base,  both  before  and  behind— a 
little  less,  however,  below  the  clavicle,  and  in  the  upper  part  of  the  verte- 
bral  hollow.  In  that  situation,  and  there  only,  was  heard  a  slight  distant 
blowing  sound:  the  respiratory  murmur  was  everywhere  absent.  The  pulse 
was  quick  and  small.  A  large  blister  was  applied  to  the  side;  and  a  buttle 
of  Seidlitz  water  was  prescribed. 

There  was  no  change  in  the  state  of  the  patient  by  the  10th  January, 
except  that  he  felt  better.  Bear  this  in  mind:  it  is  a  special  circumstance, 
to  which  I  have  already  directed  your  attention,  and  to  which  I  shall  have 
to  return.  The  blueness  of  the  face,  especially  of  the  lips,  was  even  more 
decided.  Asphyxia  seemed  imminent.  Under  these  circumstances,  my 
honorable  friend  Dr.  Horteloup  asked  me  to  see  the  patient.  I  stated  that 
I  considered  paracentesis  to  be  urgent;  and,  consequently,  il  was  at  once 
performed  by  M.  Dal  Piaz,  interne.  Twenty-two  palettes,  or  in  other 
words  2500  grammes  [more  than  two  quarts  and  a  half]  of  lemon-colored 
serosity,  having  a  somewhat  dirty  tinge,  were  drawn  off  Immediate  relief 
was  experienced.  The  plessimotrie  and  stefhoscopic  phenomena  were  at 
once  modified:  there  was  a  diminution  in  the  dulness,  and  a  blowing  sound 
as  well  as  mucous  rales  were  audible.  I  prescribed  the  tisane  of  digitalis. 
Eight  days  afterwards,  when   I  saw  the  patient,  he  was  so   much  improved 

in  appearance,  that  I  did  not  at  first  recognize  him.     He  had  regained  a 
plump,  healthy  appearance.     I  found  him  lying  on  Ins  back. 
On  2d  February,  lie  was  dismissed  from  the  hospital  at  his  own  request. 

His  general   state   was   then    very   satisfactory.      Sonic   harshness  of  sound 

remained  in  the  righl  Eide  of  the  chest,  hut  the  vesicular  murmur  was 
heard  from  base  to  summit. 

The  following  case,  communicated  by  Hi'.  Bonfils,  is  not  less  conclusive 
than  those  I  have  now  related  to  von. 


pleurisy:   paracentesis  of  the  chest.  587 

"On  the  10th  or  11th  July,  1861,  Madame  L.,  aged  fifty-four,  residing 

in  the  Rue  Saint-Honore,  was  seized  with  serious  pulmonary  symptoms. 
The  symptoms  were  of  the  nature  of  those  which  generally  accompany  the 
onset  of  purely  inflammatory  pleurisies,  viz.,  rigors,  general  pains,  burning 

fever,  extreme  anxiety,  headache,  and  complete  insomnia.  The  patient 
complained  of  an  acute  pain  in  the  side.  Respiration  was  anxious  and 
panting,  the  embarrassment  being  to  such  a  degree  as  to  amount  to  orthop- 
ncea.  When  summoned  in  haste  on  the  morning  of*  the  loth  July,  the 
symptoms  which  I  first  observed  at  onee  directed  my  attention  to  the 
respiratory  organs.  On  examining  the  chest,  I  detected,  without  any 
difficulty,  that  there  was  extensive  effusion  into  the  left  pleura.  The 
intensity  of  the  fever,  and  the  general  constitutional  disturbance,  showed 
the  serious  nature  of  the  case.  Blisters,  purgatives,  diuretics,  large  doses 
of  the  tincture  of  squills  and  of  digitalis,  did  not  in  any  degree  impede  the 
progress  of  the  effusion,  which  increased  with  terrible  rapidity. 

"  On  the  18th,  the  seventh  day  from  the  beginning  of  the  attack,  the 
effusion  filled  the  pleural  cavity,  coming  as  high  up  as  the  crest  of  the 
scapula,  and  displacing  the  heart,  the  apex  of  which  was  beating  to  the 
right  of  the  median  line  of  the  sternum.  There  was  complete  dulness 
throughout  the  whole  of  the  left  side  of  the  chest,  where  no  respiratory 
sound  was  heard. 

"  The  tendency  to  lipothymia  being  manifest,  and  syncope  threatening, 
I  had  no  hesitation  in  proposing  paracentesis  to  the  family.  My  excellent 
master,  Professor  Trousseau,  kindly  gave  me  his  aid  on  the  occasion.  The 
operation  was  at  once  performed  ;  and  1750  grammes  [nearly  two  quarts] 
of  serosity  flowred  from  the  canula  of  the  trocar. 

"  Immediately  after  the  evacuation  of  the  fluid,  respiration  was  heard 
throughout  the  whole  of  the  affected  side  :  and  percussion  gave  a  resonant 
sound  where  before  there  was  absolute  dulness.  The  heart  had  returned 
to  its  place,  and  the  serious  symptoms,  so  threatening  before  our  interven- 
tion, had  disappeared.  The  results  of  the  operation  were  all  that  could 
have  been  desired. 

"  Next  morning,  the  general  state  of  the  patient  was  satisfactory ;  and 
respiration  was  performed  with  perfect  freedom.  I  ought,  however,  to 
add,  that  the  fluid  was  reproduced  to  a  small  extent ;  but  the  daily  exter- 
nal application  of  the  tincture  of  iodine  speedily  caused  it  to  be  absorbed. 
Recovery  was  complete  on  the  ninth  day  after  the  operation." 

This  is  the  case  to  which  I  referred.  It  is  interesting,  notonly  because 
we  have,  like  in  many  other  cases,  had  the  opportunity  of  clinically  observ- 
ing that  convalescence  was  the  direct  result  of  paracentesis  of  the  chest, 
but  especially  because  examination  of  the  temperature  before  and  after 
the  operation,  demonstrated  this  convalescence  materially,  it  may,  in  fact, 
be  said,  mathematically.  The  coincidence  of  the  definitive  return  to  the 
normal  temperature  with  the  evacuation  of  the  fluid  was  at  once  proof  of 
the  cure  of  the  patient,  and  of  the  curative  effects  of  the  operation. 

On  11th  June,  1864,  I  received  in  St.  Agnes's  Ward,  a  young  man,  aged 
twenty-three,  of  very  delicate  constitution,  thin,  and  pale  ;  but  who,  neverthe- 
less, did  not  cough,  and  who  presented  none  of  the  rational  signs  of  tuber- 
culization. Fifteen  days  before  he  came  into  the  hospital,  he  had  a  slight 
stitch  in  the  left  side/accompanied  by  a  little  fever.  He  had  not  been 
confined  to  bed  ;  and  was  able  to  walk  to  the  hospital.  Posteriorly,  on  the 
right  side  of  the  chest,  as  high  up  as  the  spine  of  the  scapula,  I  found  abso- 
lute dulness  without  any  blowing  sound  or  segophony  ;  there  was  also  dul- 
ness in  front.  Within  a  small  space,  not  larger  than  a  five-franc  piece, 
situated   in   the  upper  part  of  the  chest,  near  the  sternum,  I  perceived 


588  PLEURISY:    PARACENTESIS    OF    THE    CHEST. 

skodaic  resonance.  For  twelve  days,  the  state  of  the  patient  was  almost 
stationary,  the  effusion,  however,  increasing  rather  than  diminishing. 
From  the  effusion  being  on  the  right  side,  from  the  patient  being  of 
feeble  constitution,  and  subject  to  fever  every( evening,  I  dreaded  pulmon- 
ary tuberculization  :  and  determined  to  resort  to  paracentesis.  The  opera- 
tion was  performed  by  Dr.  Peter,  then  my  chef  de  clinique,  on  the  morning 
of  the  26th  day  of  the  attack,  the  temperature  being  38.7°.  There  was 
withdrawn  from  the  chest  750  grammes  of  serosity,  which  by  pressure  in  a 
linen  cloth,  yielded  three  grammes  and  a  half  [44  grains]  of  moist  fibrin. 
On  the  following  days,  the  respiratory  murmur  was  heard  throughout  the 
chest,  mingled  with  some  subcrepitant  rales  behind  on  the  right  side :  in 
front,  in  the  upper  part  of  the  chest,  was  heard  the  crackling  like  that  of 
new  leather.     On  8th  July,  the  patient  left  the  hospital  perfectly  recovered. 

Let  me  now  tell  you  what  was  learned  in  this  case  by  thermometrical 
examination.  I  have  already  told  you  that  just  before  the  performance  of 
the  operation  the  temperature  was  38.7°  :  on  the  evening  of  the  previous 
day  it  had  been  38.6°,  and  for  eight  days  it  had  always  kept  about  that 
in  the  evening,  falling  in  the  morning  only  from  four-  to  six-tenths  of  a 
degree.  On  the  very  evening  of  the  operation,  however,  in  place  of  rising, 
as  before  that  date  it  had  usually  done,  it  fell  to  38° :  next  morning,  it 
continued  to  descend,  and  fell  to  thirty  degrees  and  two-tenths — that  is  to 
say,  the  temperature  became  normal.  In  the  evening,  it  fell  four-tenths, 
being  then  38.8°  :  and  that  was  the  temperature  next  morning,  forty-eight 
hours  after  the  operation.  From  that  time,  till  the  day  on  which  the  pa- 
tient left  the  hospital,  there  was  a  physiological  temperature  varying  between 
37.6°  and  36.6°.  As  temperature  is  the  best  criterion  of  the  febrile  state, 
and  as  in  the  case  now  under  consideration  the  sudden  and  permanent  fall 
was  coincident  with  the  thoracocentesis,  it  may  be  said  that  the  convales- 
cence of  the  patient  began  immediately  after  the  operation,  and  that  the 
recovery  dated  from  the  evacuation  of  the  fluid.* 

In  pleurisy,  and,  in  general,  in  all  inflammations  of  serous  membranes, 
thermometrical  investigation  does  not  furnish  a  curve  so  distinctively  charac- 
teristic as  in  certain  diseases  of  regular  type,  as,  for  example,  in  fevers. 
However,  in  pleurisy,  as  well  as  in  peritonitis,  it  is  useful  in  enabling  us  at 
once  to  distinguish  these  diseases  from  certain  very  painful  affections  which 
they  simulate.  If  we  find  that  the  temperature  remain  normal  in  a  patient 
suffering  from  intense  pain  in  the  side  or  abdomen,  we  may,  in  the  former 
case,  conclude  that  he  has  pleurodynia,  and  not  pleurisy;  and  in  the  latter, 
that  the  cause  of  the  pain  is  colic,  and  not  peritonitis.  On  the  contrary, 
we  may  announce  that  there  exists  pleurisy  or  peritonitis,  as  the  case  may 
be,  if  the  thermometer  rise  to,  or  above  38°,  or  to  38.5°,  during  the  first 
hours  of  the  attack. 

I  shall  now  resume  my  subject — paracentesis  of  the  chest. 

The  necessity  for  performing  paracentesis  in  those  cases  of  excessive  pleu- 
ritic effusion  in  which  there  is  a  danger  of  the  occurrence  of  sudden  death, 
is  now  admitted  by  all  real  practitioners;  but  its  utility,  nay,  its  uecessity, 
is  also  beyond  doubt,  when  the  object  is  to  ward  oil' those  accidents,  which, 
as  I  stated  at  the  beginning  of  this  lecture,  may  arise  from  continuance  of 
the  effusion.  In  such  cases,  it,  is  often  the  only  ineans  of  preventing  a  fatal 
issue,  or  of  prolonging  life. 

Experience  shows  that  even  in  the  simplest  case  of  pleuritic  effusion, 
resolution  requires  a  long  time,  even  when  the  effusion  is  small  in  quantity. 


■""  I >r< •[.(»:  Oui'lqur*  Ucclierchea  sur  1'Etnl  de  la  Temperature  dans  les  .Main- 
dies — These  (1864) ;  where  this  case  and  the  thermometrical  scale  relating  to  it  are 
given. 


PLEURISY:     PARACENTESIS    OF    THE    CHEST.  589 

We  all  know  how  great  a  difference  there  is  in  this  respect  between  pneu- 
monia and  pleurisy:  the  march  of  the  former  is  as  much  characterized  by 

rapidity,  as  is  the  march  of  the  latter  by  slowness,  at  least  in  the  decline  of 
the  attack.  All  practitioners  have  been  struck  with  this  fact ;  and  it  is  not 
unusual  to  see  patients — even  when  treated  most  energetically  and  most 
rationally — retain  for  a  month,  for  two  months,  or  for  a  longer  period  after 
the  termination  of  the  acute  stage,  obscurity  in  the  respiratory  sound,  and 
pleuritic  blowing,  testifying  not  only  to  the  existence  of  false  membranes, 
but  also  to  the  presence  of  a  certain  quantity  of  the  effusion.  Suppose,  gen- 
tlemen, that  you  had  to  do  with  a  case  in  which  the  quantity  of  fluid  effused 
was  not  small,  but,  on  the  contrary,  very  considerable,  you  can  understand 
why  resolution  should  be  necessarily  slower  in  the  one  case  than  in  the 
other.  Suppose,  for  example,  that  the  pleura  contains  two  or  three  litres 
of  serosity,  it  would  not  be  surprising  for  three,  four,  five,  six  months  or 
longer  to  elapse,  before  the  effusion  had  entirely  disappeared  :  this  greater 
slowness  in  the  absorption  is  perhaps  as  much  dependent  on  the  pressure 
exerted  by  the  excessive  quantity  of  fluid  upon  the  serous  membrane  by 
which  absorption  has  to  be  performed,  as  by  the  mere  greatness  of  the  quan- 
tity. The  effusion  does  not  remain  harmlessly  in  the  cavity  within  which 
it  is  inclosed — it  produces  febrile  action ;  and  the  longer  the  effusion  remains, 
the  longer  will  the  patient  continue  in  a  feverish  state.  The  nutritive  func- 
tions will  be  disturbed  ;  for,  as  has  been  clearly  shown  by  the  beautiful 
experiments  of  M.  CI.  Bernard,  there  is  a  sufficient  cause  of  fever,  whenever 
digestion  is  badly  performed,  whenever  the  gastric  secretions  lose  their 
physiological  properties,  and  become  unfit  to  accomplish  those  operations 
in  vital  chemistry  which  it  is  their  office  to  perform  in  the  process  of  ckynii- 
fication.  Fever  continuing  from  the  presence  of  pleuritic  effusion,  will 
ultimately  exhaust  the  individual,  causing  him  to  sink  in  a  hectic  state. 
This  hectic  fever  invariably  occurs  where  there  is  suppurative  pleurisy,  or 
empyema,  as  it  is  called.  Although  serous  pleuritic  effusion,  very  great  in 
quantity,  may  exist  for  a  long  time  without  becoming  purulent,  cases  occur, 
particularly  in  children,  in  whom  this  transformation  takes  place,  more  or 
less,  the  pleurisy  remaining  simple,  at  least  to  the  extent  of  not  being  ex- 
pressive of  any  diathesis. 

Gentlemen,  as  you  are  aware,  at  the  beginning  of  an  inflammatory  affec- 
tion of  a  serous  membrane,  the  microscope  scarcely  discloses  any  of  the 
constituents  of  pus ;  but  if  the  malady  continue,  the  microscope  will  enable 
us  to  see  pus-globules,  which  will  go  on  becoming  more  and  more  numerous 
as  the  inflammation  advances.  The  pleural  serous  membrane,  when  it  has 
been  for  a  long  time  the  seat  of  inflammation,  at  last  secretes  pus,  just  like 
the  cutaneous  and  mucous  membranes.  At  the  beginning  of  a  bronchial 
catarrh,  there  is  no  pus  in  the  sputa;  but  in  a  short  time,  the  expectoration 
becomes  muco-puriform. 

It  is,  therefore,  our  duty,  not  to  allow  an  inflammation  of  the  pleura  to 
go  on  too  long,  otherwise  we  shall  see  an  effusion  become  purulent  which 
originally  was  serous.  This  fact  ought  to  cause  us  to  decide  to  operate  in 
cases  in  which  there  is  a  large  quantity  of  effusion  ;  for  as  I  have  just  said, 
these  are  the  cases  in  which  resolution  will  be  slowly  accomplished. 

There  are  not  only  pleurisies  which  become  purulent  from  the  mere  con- 
tinuance of  the  state  of  inflammation,  but  there  are  also  pleurisies  which 
jfrom  their  nature  are  purulent  from  the  first.  These  suppurative  pleurisies 
now  solicit  our  attention  for  a  few  minutes. 

In  virtue  of  a  special  condition  of  the  system,  a  condition  which  often 
results  from  the  puerperal  state,  and  is  also  induced  by  the  eruptive  fevers, 
by  small-pox,  but  still  more  frequently  by  scarlatina,  inflammatory  affec- 


590  PLEURISY:     PARACENTESIS    OF    THE    CHEST. 

tions  of  serous  membranes — the  serous  membranes  which  cover  the  great 
splanchnic  cavities  and  the  synovial  membranes  of  the  joints — have  a  very- 
great  tendency  to  become  suppurative. 

For  example,  in  women  who  have  been  recently  delivered,  an  articular 
affection  which  in  auy  other  state  of  the  system  would  have  been  nothing 
more  than  simple  arthritis,  at  once  becomes  a  purulent  arthritis.  A  pleurisy, 
which  in  ordinary  circumstances  would  have  been  a  simple  pleurisy,  becomes 
purulent.  Those  of  you  who  have  read  Dr.  Charrier's  thesis  know  how 
common  these  suppurative  pleurisies  were  in  1854.* 

A  short  time  ago,  we  received  into  our  wards  a  woman  who  had  been 
confined  eleven  days  previously  in  the  Maternity  Hospital.  On  the  very 
day  of  her  return  to  her  lodgings,  she  was  seized  with  pain  in  the  side, 
shivering,  and  intense  fever.  On  the  fifth  day  from  this  attack,  when  she 
came  to  the  Hotel-Dieu,  I  found  that  there  was  pleurisy  of  the  left  side. 
The  necessity  for  tapping  very  soon  became  urgent :  the  operation  was  per- 
formed on  the  ninth  day  from  the  beginning  of  the  symptoms,  when  there 
was  drawn  off  a  dirty-looking  fluid  resembling  thick  broth.  I  have  no 
doubt  that  it  would  have  been  found  to  contain  the  constituents  of  pus,  had 
it  been  examined  by  the  microscope.  After  some  days,  there  was  a  return 
of  the  effusion  :  in  about  a  fortnight,  the  place  where  the  puncture  had  been 
made  reopened  of  itself,  and  gave  exit  to  a  large  quantity  of  fetid  pus. 
The  woman  died.  At  the  autopsy,  we  found,  on  opening  the  thorax,  that 
the  pleural  cavity  communicated  with  the  wound  made  by  the  trocar,  and 
was  filled  with  gas  and  fetid  pus ;  on  the  interior  surface  of  the  lung, 
between  the  two  lobes,  there  was  a  circumscribed  pleurisy,  which  formed  a 
sort  of  cyst  containing  nearly  two  hundred  grammes  [about  twenty-five 
fluid  ounces]  of  pus.  It  is  evident  that  the  suppuration  could  not  in  this 
case  be  attributed  to  the  puncturing  of  the  chest,  as  the  suppuration  had 
taken  place  in  the  encysted  pleurisy,  as  well  as  in  that  which  occupied  the 
great  pleural  cavity  originally  emptied  by  the  paracentesis. 

The  purulent  pleurisy  was  produced  under  the  influence  of  a  special 
diathesis,  or  suppurative  tendency  which  exists  in  puerperal  women,  and  is 
well  known  to  all  physicians. 

As  I  have  already  reminded  you,  the  same  thing  takes  place  in  eruptive 
diseases.  You  know — and  I  mentioned  the  circumstance  when  lecturing 
on  small-pox — that  in  that  disease  the  slightest  inflammation  is  very  apt  to 
become  suppurative.  A  very  frequent  sequel  of  confluent  small-pox  is  the 
formation  of  numerous  abscesses  in  various  parts  of  the  body,  which  go  on 
forming  for  six  weeks,  two  months,  three  months,  or  even  longer.  Patients 
who  have  escaped  terrible  attacks  of  the  disease  itself,  sink  from  these  ab- 
scesses, exhausted  by  interminable  colliquative  suppuration. 

But  it  is  principally  as  a  sequel  to  scarlatina  that  the  suppurative  ten- 
dency shows  itselfm  serous  and  synovial  membranes.  Thus,  scarlatinous 
arthritis,  generally  particularly  mild,  and  much  shorter  in  its  duration  than 
ordinary  articular  rheumatism,  assumes  in  some  cases  a  very  violent  char- 
acter, terminating  in  death;  and  when  at  the  autopsy  the  joints  are 
opened,  they  are  found  to  he  filled  with  pus.  In  these  cases  we  also  meet 
with  suppurative  pericarditis.   Finally,  the  suppurative  tendency  -how-  itself 

by  purulent   effusions  into  the  cavities  of  the  pleura1. 

1  directed  your  attention  to  this  important  point  when  lecturing  on  scar- 
latina.     To   the   cases  which   I  then  brought  under  your  notice  lei    me   add 

the  following. 


*  Charrier:   Sur  I'Bpidlmie  de   Fidvre    Puerpgrale  Observ6e  en    1854   :i   la 

Muturnitr  ilc;  Paris. 


pleurisy:   paracentesis  of  the  chest.  591 

On  the  9th  September,  1849,  a  boy  six  yours  of  age,  who  had  been  in  n 
very  alarming  state  from  the  end  of  August,  was  brought  to  my  wards  at 
the  Hopital  des  Enfants  Malades.  On  the  20th  of  that  month  he  was 
seized  with  scarlatina;  the  attack  seems  to  have  been  very  serious.  I  was 
at  once  struck  with  the  general  anasarcous  appearance  presented  by  the 
patient:  I  discovered  extensive  effusion  in  the  left  side  of  the  chest.  A 
large  blister  was  immediately  applied,  and  an  infusion  of  digitalis  was 
ordered  to  be  taken  in  a  tisane.  At  the  end  of  eight  days  his  state  was 
much  worse.  The  poor  child,  sitting  up  in  bed,  supported  by  pillows,  was 
panting  for  breath,  and  with  difficulty  answered  in  monosyllables  the  ques- 
tions addressed  to  him.  His  face  was  of  a  livid  blue,  and  the  extremities 
were  cold.  The  pulsations  of  the  heart  were  quick  and  small ;  the  pulsa- 
tions of  the  radial  arteries  could  no  longer  be  felt ;  and  everything  seemed 
to  indicate  speedy  death. 

There  was  complete  dulness  throughout  the  whole  of  the  left  side  of  the 
chest,  which  was  evidently  distended  ;  but  the  arched  appearance  of  the 
chest  and  the  obliteration  of  the  intercostal  spaces  were  masked  by  cedem- 
atous  infiltration  of  the  subcutaneous  cellular  tissue.  In  front,  where  alone 
auscultation  was  practicable,  no  respiratory  murmur  could  be  heard.  The 
heart  was  completely  displaced,  the  apex  beating  at  the  right  edge  of  the 
sternum.  The  tongue,  white  at  the  edges,  was  rather  dry  and  rough  in  the 
middle.     The  motions  were  loose. 

Paracentesis  was  urgently  demanded :  I  therefore  operated  at  once,  and 
withdrew  a  litre  [more  than  a  quart]  of  pus.  The  child  was  immediately 
relieved,  and  was  enabled  to  sleep,  lying  on  his  back.  During  the  day,  he 
was  obviously  much  better.  Immediately  after  the  operation,  the  heart 
moved  towards  its  position  in  the  left  side,  and  we  heard  blowing  at  the 
summit  of  the  lung. 

During  the  two  following  days  the  improvement  was  great.  The  general 
puffiness  had  diminished,  particularly  that  of  the  face,  where  lividity  had 
given  place  to  a  well-marked  rosy  tint.  The  pleura,  nevertheless,  still 
contained  a  very  considerable  amount  of  effusion,  and  the  heart,  though 
showing  a  tendency  to  take  its  normal  position,  was  still  felt  beating  in  the 
median  line. 

During  the  succeeding  days,  the  general  oedema  sensibly  decreased  ;  but 
there  was  little  change  in  the  chest  symptoms.  Although  the  appetite 
returned,  the  general  debility  went  on  increasing.  Between  my  visits  of 
the  19th  and  20th  September,  he  had,  each  twenty-four  hours,  four  loose 
motions ;  and  this  diarrhoea  continued  till  his  death,  which  occurred  on  the 
twenty-fourth.  At  the  autopsy,  we  found  the  pleural  cavity  filled  with  a 
purulent  fluid,  and  both  the  costal  and  the  pulmonary  pleura  were  coated 
with  false  membrane.  The  lung  was  shrunk  up,  and  the  bronchial  glands 
contained  tubercles. 

Suppurative  pleurisy  is  essentially  a  serious  disease,  and  indeed  generally 
proves  fatal,  the  cases  in  which  recovery  takes  place  through  the  unaided 
efforts  of  nature  being  quite  exceptional.  This  statement  is  equally  appli- 
cable to  cases  in  which  the  disease  is  purulent  from  the  beginning,  and  to 
simple  pleurisies  which  become  purulent.  It  sometimes  happens  that  the 
pus  which  has  been  poured  out  into  the  chest  finds  an  outlet  for  itself 
through  a  perforation  of  the  bronchial  tubes.  We  had  an  example  of  this 
in  a  patient  who  lay  in  bed  11  of  St.  Agnes's  Ward,  whom  you  have  seen 
bringing  up  by  the  mouth  daily  large  quantities  of  pus.  To  give  easy  exit 
to  the  pus,  it  was  sufficient  for  the  patient  to  lean  over  the  bed  with 
the  head  down,  as  you  have  seen  many  times.  This  man  had  consider- 
able hydrothorax,  but  was  otherwise  in  good  health.  He  was,  on  his  own 
request,  allowed  to  leave  the  hospital. 


592  PLEURISY:     PARACENTESIS    OF    THE    CHEST. 

Recall  to  your  recollection  the  history  of  a  man  whose  case  I  related 
when  speaking  of  the  differential  diagnosis  of  peripneumoniae  and  pleural 
vomica? — a  case  I  saw  in  consultation  with  Dr.  Bordes. 

I  must  add,  that  these  fortunate  cases  are  of  an  altogether  exceptional 
class,  and  that  most  frequently  hydrothorax,  particularly  in  the  adult, 
sooner  or  later  terminates  in  death. 

Even  in  these  cases  of  empyema,  paracentesis  of  the  chest — and  this  is 
the  point  I  wish  to  come  to — even  in  these  cases,  the  operation  renders 
great  service.  Though  it  certainly  does  not  produce  the  undoubted  benetits 
which  it  yields  in  excessive  effusion  in  simple  pleurisy,  it  at  least  retards 
the  fatal  termination,  and  in  some  cases  leads  to  recovery,  when  there  is 
adopted  at  the  same  time  a  particular  means  of  treatment  of  which  I  shall 
have  to  speak.  Of  course,  I  do  not  include  cases  of  suppurative  tubercular 
pleurisy,  nor  of  pleurisy  in  which  the  purulent  character  is  dependent  upon 
caries  of  bone;  but  even  in  such  cases,  thoracocentesis  is  of  some  use,  as  I 
shall  afterwards  show.  At  present,  we  have  only  to  consider  cases  of 
pleurisy  occurring  under  the  least  unfavorable  circumstances — conditions 
which  I  have  just  pointed  out. 

In  an  interesting  work,  my  late  lamented  colleague  Dr.  Aran,  gave  an 
account  of  the  successful  results  of  this  mode  of  treatment.  *  Similar  cases 
are  given  in  various  monographs.  You  will  find  several  in  the  inaugural 
thesis  of  Dr.  Lacase  du  Thiers,  and  a  considerable  number  have  been  col- 
lected by  Dr.  Boinet.f 

The  following  case,  which  occurred  in  my  private  practice,  deserves  to  be 
stated. 

The  widow  of  Dr.  Pauly,  an  estimable  Parisian  colleague,  when^uffei-ing 
from  the  fatigue  of  attendance  on  her  husband  (who  had  died  of  phthisis), 
was  seized  with  pleurisy  in  the  right  side,  accompanied  by  great  effusion. 
Chomel  having  been  called  in,  recommended  active  treatment;  but  as  the 
disease  became  more  serious,  he  sent  for  me  to  perform  paracentesis,  if  I 
should  think  it  necessary  to  do  so.  There  was  great  oppression  of  the 
breathing :  the  effusion  filled  both  sides  of  the  chest.  I  operated,  and  with- 
drew a  great  quantity  of  somewhat  muddy  serosity.  In  two  or  three  days, 
there  was  as  much  effusion  in  the  chest  as  there  had  been  prior  to  the  opera- 
tion of  paracentesis.  I  nevertheless  waited  for  fifteen  days,  at  the  end  of 
which  period,  it  became  urgently  necessary  to  repeat  the  operation.  This 
time  the  fluid  was  very  turbid,  opaline,  and  evidently  contained  pus.  I  was 
glad  that  1  had  given  exit  to  it.  A  third  time,  the  effusion  returned  :  and 
a  third  time  it  became  necessary  to  perform  paracentesis,  due  operation 
was  performed  by  Dr.  Boinet  and  me:  on  this  occasion,  we  followed  up  the 
withdrawal  of  the  fluid  by  injecting  a  solution  of  iodine  into  the  pleural 
cavity.  Some  months  afterwards,  1  saw  the  patient  :  she  had  then  regained 
her  plump  appearance,  and  stated  that  she  was  restored  to  her  usual  health. 

But  it  is  chiefly  in  children  that  we  can  count  on  Buccess.  At  a  meeting 
of  the  Hospital  Medical  Society,  Legroux  and  I  cadi  presented  a  child  suc- 
cessfully  treated  for  suppurative  pleurisy,  by  a  Long  course  of  injections  of 
iodine.     Let  me  give  you  an  exact  account  of  the  case  of  my  little  patient. 

On  the  b'Jth  of  January,  1853,  Ed  me  Belize,  aged  six  years,  was  attacked 
with  pleurisy,  and  was  treated  by  Dr.  Fleury.  Notwithstanding  the  most 
energetic  treatment,  the  severity  of  the  Bymptoms  increased,  and  towards 
the  cud  of  the  month  Chomel  was  summoned  in  consultation.  Drs.  Fleury 
and  Chomel  detected  thoracic  effusion  which  completely  tilled  the  right 

*  Aran:   Del'TJtHitfidel'Aspociation  des  [njectiona  [od£i'S«Lla  Thoracocentd.se— 
in  the  Treatment  of  Purulent  Eff«9ion  consecutive  to  acute  and  chronic  Pleuris; 
j  Archives  Generates  de  M6decine,  1863. 


pleurisy:   paracentesis  of  the  chest.  593 

pleural  cavity.  The  patient  had  a  great  deal  of  fever  and  dyspnoea.  Diu- 
retics, contra-stimulants,  and  cutaneous  revulsives  were  employed  with  su- 
perabundant energy;  but  still,  day  by  day,  the  effusion  seemed  to  increase, 
and  by  the  end  of  the  month,  there  was  general  anasarca  and  great  orthop- 
ncea.  It  was  under  these  circumstances  that  I  was  summoned  in  consulta- 
tion. 

Dr.  Fleury  and  I  being  of  opinion  that  paracentesis  of  the  chest  offered 
the  only  chance  of  saving  the  patient,  immediately  performed  the  operation, 
withdrawing  nearly  two  litres  of  inodorous,  creamy  pus.  Great  relief  fol- 
lowed :  however,  fifteen  day-  later,  the  pleural  cavity  was  again  filled  with 
effusion  ;  and  by  the  middle  of  June,  the  heart  and  liver  had  become  dis- 
placed. The  symptoms  being  very  serious,  the  operation  was  again  had 
recourse  to,  and  with  the  same  immediate  good  results.  The  pus  which 
was  withdrawn  had  the  smell  of  rotten  ey;^. 

At  the  beginning  of  July,  there  was  a  reproduction  of  the  effusion,  but 
there  was  tympanitic  resonance  on  the  right  side,  as  high  up  as  the  subcla- 
vicular region:  succussiqn  produced  Hippoeratic  gurgling:  there  evidently 
existed  hydrothorax.  We  resolved  to  wait,  but  on  the  loth  August,  there 
was  so  great  an  increase  in  the  severity  of  the  symptoms,  that  we  decided 
to  puncture  the  chest  a  third  time,  and  to  leave  a  canula  in  the  wound,  so 
that  the  treatment  by  iodine  injections  might  be  pursued.  Upon  this  occa- 
sion, we  withdrew  nearly  two  litres  of  horribly  fetid  pus,  mixed  with  bub- 
bles of  gas.  We  introduced  into  the  wound  a  small  canula,  slightly  conical, 
three  centimetres  in  length,  having  externally  a  button-shaped  extremity  : 
the  orifice  was  closed  by  a  metallic  stopper  which  fitted  as  tightly  as  a 
nail  fits  Which  is  driven  into  a  hole.  The  stopper  was  withdrawn  every 
morning,  to  allow  the  pus  to  flow,  after  which  there  was  injected  a  mixture 
composed  of  nearly  thirty  grammes  of  tincture  of  iodine,  forty  grammes  of 
water,  and  from  twenty  to  thirty  centigrammes  of  the  iodide  of  potassium.* 

For  six  months  the  quantity  of  pus  varied  from  100  to  300  grammes. 
In  general,  it  was  not  fetid.  From  time  to  time  there  was  no  purulent 
secretion  ;  fever  then  supervened,  and  a  dreadful  putrid  smell  came  from 
the  canula. 

At  the  end  of  six  months,  that  is  to  say,  in  February,  1854,  it  was  ob- 
served, that  when  the  fluid  was  injected  into  the  pleural  cavity,  it  passed 
into  the  bronchial  tubes,  and  even  into  the  mouth  of  the  child.  The  solu- 
tion of  iodine  was  then  replaced  by  an  injection  of  a  solution  of  chlorine  in 
water  :  afterwards,  aromatic  wine  was  used. 

In  each  successive  month,  however,  there  was  a  visible  diminution  in  the 
quantity  of  fluid :  the  chest  was  contracted,  and  the  vertebral  column  was 
inclined  to  the  right.  Strength  and  appetite  returned.  A  nutritious  diet 
was  given  :  also,  occasionally,  cinchona  wine  and  fish  oil. 

Finally,  in  July,  1854,  nearly  eleven  months  from  the  date  of  the  intro- 
duction of  the  canula,  eighteen  months  from  the  beginning  of  the  malady, 
there  was  almost  no  discharge;  and  by  the  1st  September,  it  had  com- 
pletely ceased.  Upon  introducing  a  probe,  it  was  found  that  the  fistulous 
passage  had  closed.     The  canula  was  withdrawn. 

When  I  brought  this  case  under  the  notice  of  my  colleagues,  the  child 
was  in  perfect  health.  Respiration  was  heard  throughout  the  whole  of  the 
right  side  :  the  flattening  of  the  chest  and  curvature  of  the  vertebral  column, 
so  conspicuous  six  months  previously,  were  becoming  less  and  less  day  by 
day. 

*  The  Tincture  of  Iodine  of  the  French  Codex  is  a  solution  of  one  part  i  by  weight; 
of  iodine  in  twelve  of  alcohol. 


594  pleurisy:   paracentesis  of  the  chest. 

In  this  remarkable  case,  purulent  effusion  three  times  necessitated  recourse 
to  paracentesis  :  perforation  of  the  lung  took  place ;  a  solution  of  iodine  was 
injected  more  than  two  hundred  times,  and  there  were  nearly  as  many  chlor- 
inated and  aromatic  injections  used :  in  the  end,  however,  the  cure  was 
complete. 

Let  me  call  your  attention,  as  I  called  the  attention  of  the  Medical  So- 
ciety of  the  Hospitals,  to  the  extraordinary  quantity  of  the  purulent  secre- 
tion, which  may  be  estimated  at  a  daily  average  of  200  grammes  for  about 
200  days,  which  is  the  enormous  total  of  40,000  grammes  [more  than  40 
quarts]. 

You  can  understand  how  essential  was  constant  and  copious  nourishment 
to  enable  the  child  to  struggle  with  this  prodigious  drain  on  the  system.  I 
could  lay  before  you  two  precisely  similar  cases  occurring  in  children :  one 
occurred  in  the  practice  of  Dr.  Mousset — a  case  of  empyema  following  ty- 
phoid fever ;  and  the  other,  in  the  practice  of  Dr.  Vigny — a  case  of  em- 
pyema following  chronic  catarrh.  In  both  of  these  cases,  a  more  speedy  cure 
was  obtained  than  in  the  case  the  full  particulars  of  which  I  have  just  re- 
lated.    The  medico-chirurgical  treatment  adopted  was  similar. 

I  shall  only  cite  one  other  example.  The  subject  was  a  young  lad,  to 
whom  I  was  called  by  Dr.  Bounds.  He  was  an  American,  nine  years  of 
age,  who,  about  the  end  of  May,  1862,  w7as  attacked  with  pleurisy,  well 
marked,  simple,  and,  in  the  first  instance,  of  ordinary  severity.  The  pleurisy 
was  on  the  left  side.  As  there  were  no  unusual  symptoms,  the  case  was 
considered  benignant,  and  was  treated  in  accordance  with  that  impression. 
After  some  time,  however,  it  was  observed,  that  the  effusion  increased  in 
place  of  diminishing,  and  caused  the  breathing  to  become  more  and  more 
embarrassed  :  the  fluid  nearly  filled  the  pleural  cavity,  and  the  heart  was 
pushed  out  of  its  place. 

Dr.  Bonfils  was  called  in  on  the  10th  June ;  the  diagnosis  did  not  present 
any  difficulty.  The  disease  made  rapid  progress;  and  on  the  17th  June, 
Dr.  Bonfils  looking  to  the  manner  in  which  matters  were  advancing,  think- 
ing that  the  chest  should  be  tapped,  asked  me  to  consult  with  him  on  the 
case. 

The  effusion  occupied  two-thirds  of  the  left  side  of  the  chest,  and  forced 
the  heart  to  the  right :  there  was  great  difficulty  of  breathing.  To  hesitate 
was  impossible:  paracentesis  was  an  urgent  necessity.  The  operation  was 
at  once  performed  by  my  colleague,  when  there  issued  from  the  canula  a 
continuous  gush  of  pus,  to  the  extent  of  000  grammes  [nearly  a  pint  and  a 
quarter]. 

This  result  did  not  surprise  me:  I  had  foreseen  it,  but  had  reserved  my 
opinion  upon  the  nature  of  the  fluid.  I  was  justified  in  believing  thai  the 
case  was  one  of  purulent  pleurisy,  from  the  continuance  of  the  effusion,  and 
also  because  pleurisy  seemed  to  have  supervened  on  an  attack  of  measles, 
which  the  child  had  had  some  time  previously,  but  from  which  he  had  not 
made  a  complete  recovery. 

Immediately  after  the  operation,  the  breathing  became  easier:  the  vesicu- 
lar murmur  was  heard  where  an  instanl  previously  it  was  inaudible:  there 
was  thoracic  resonance,  and  the  heart  was  regaining  its  natural  position. 

During  the  following  ten  or  fifteen  days,  the  effusion  remaining  moderate 

in  amount,  respiration  seemed  to  he  freer:  the  general  state  of  the  patient 

was    not    getting  worse,  SO    thai    there  was    room    to  hope    that    the  malady 

would  of  itself  subside.  Ere  long,  however,  unfavorable  symptoms  reap- 
peared. From  17th  dune  to  L6th  August,  complications  of  the  most  alarm- 
ing seriousness  occurred:  however,  as  at  intervals,  a  certain  amounl  of 
amelioration  in  the  general  aspect   of  the  symptoms  was  observable,  we 


pleurisy:   paracentesis  of  the  chest.  595 

remained  spectators  of  the  struggle,  waiting  for  the  occurrence  of  some 
positive  indication  to  interfere. 

About  the  middle  of  July,  the  patient  seemed,  for  twelve  days,  to  be 
getting  into  a  better  state,  when  about  the  beginning  of  August,  he  grew 
worse,  and  the  danger  became  imminent. 

On  auscultating  the  chest  posteriorly  and  laterally,  tbere  was  heard  a 
blowing-sound,  tubal  and  amphoric,  the  maximum  intensity  of  which  was 
heard  in  the  upper  part  of  the  vertebral  hollow.  On  percussion,  a  slight 
degree  of  resonance  was  observed  in  some  scattered  situations,  which  led  to 
the  supposition  that  the  effusion  was  small  in  quantity,  and  that  we  had  to 
do  with  one  of  those  circumscribed  pleurisies  in  which  we  find  false  mem- 
branes infiltrated  with  pus,  rather  than  a  collection  of  purulent  fluid.  There 
was  the  greater  reason  to  take  this  view  of  the  case,  from  the  circumstance, 
that  upon  that  side  of  the  chest  there  was  deformity  and  flattening  pos- 
teriorly, while  anteriorly  and  laterally  there  was  slight  arching,  formed  by 
projection  of  the  ribs,  which  were  abnormally  separated  from  one  another. 
In  this  situation,  the  dulness  was  complete  ;  and  no  respiratory  murmur  was 
audible.     The  heart  was  out  of  its  place,  and  forced  upwards. 

Although  the  state  of  the  patient  was  alarming,  I  hesitated  to  interfere 
surgically,  as  the  diagnosis  of  the  local  lesions  was  beset  with  causes  of 
great  uncertainty.  The  question  was  :  might  not  the  trocar,  in  the  event  of 
a  new  puncture  being  made,  come  upon  a  mass  of  false  membrane,  which 
would  prevent  the  flow  of  the  fluid  ?.  However,  as  the  deformity,  the  arch- 
ing (which  day  by  day  became  more  and  more  decided  in  front),  the  com- 
plete dulness,  and  the  absence  of  every  kind  of  sound,  made  it  evident  that 
there  was  circumscribed  effusion — as  this  effusion  was  increasing — and  as 
the  dyspnoea  was  very  great — on  the  19th  August,  two  months  after  the 
first  tapping,  Dr.  Bonfils  saw  the  necessity  for  resorting  a  second  time  to 
the  operation. 

He  withdrew7  300  grammes  of  thick  phlegmonous  pus,  similar  to  that 
which  was  evacuated  on  the  17th  June.  The  operation  again  gave  immedi- 
ate relief,  although  there  was  no  modification  in  the  signs  furnished  -by  aus- 
cultation and  percussion. 

Some  days  later,  at  the  end  of  August,  a  small  fluctuating  tumor  formed 
several  centimetres  above  the  cicatrix  of  the  wound  made  by  the  trocar:  it 
occupied  an  intercostal  space,  the  skin  over  which  was  of  a  violet  color. 
On  the  1st  September,  this  abscess  was  opened  by  the  bistoury,  and  in  this 
way,  a  pleural  fistula  was  established,  from  which,  for  ten  weeks,  there  was 
an  exudation  of  pus,  at  first  very  tenacious,  aftenvards  becoming  serous, 
but  never  presenting  an  unhealthy  character,  and  always  decreasing  in 
quantity. 

From  this  time,  the  general  health  became  satisfactory,  and  the  cure  of 
the  local  affection  showed  steady  progress.  The  effusion  steadily  diminished 
in  quantity,  while  at  the  same  time  the  chest  underwent  that  deformity  which 
is  usual  under  similar  circumstances. 

In  the  month  of  October,  the  patient  was  able  to  go  out ;  and  Dr.  Bonfils 
then  met  him  playing  in  the  gardens  of  the  Tuileries.  Three  months  later, 
the  deformity  of  the  chest  had  disappeared.  A  few  days  ago,  this  child 
was  brought  to  me  in  my  consulting-room  ;  and  I  found  that  his  cure  was 
as  complete  as  possible,  and  that  his  health  was  excellent. 

If  there  be  one  species  of  purulent  pleurisy  which  seems  to  baffle  all  the 
efforts  of  medicine  it  is  assuredly  that  species  to  which  puerperal  women 
are  subject.  The  majority  of  such  cases  terminate  in  death,  which  is  indeed 
their  almost  inevitable  issue.  Still,  even  in  these  cases,  paracentesis  affords 
a  chance  of  recovery,  as  is  shown  by  the  following  case. 


596  PLEURISY:     PARACENTESIS    OF    THE    CHEST. 

At  the  beginning  of  1858,  Dr.  Rousset  did  me  the  honor  of  calling  me 
in  to  consult  with  him  in  the  case  of  a  young  lady,  who,  nine  days  previ- 
ously, had  been  delivered  of  her  first  child.  On  the  fifth  day  after  de- 
livery, she  was  seized  with  fever  and  slight  pain  in  the  left  side  :  this  was 
the  beginning  of  a  pleuritic  attack.  Dr.  Raver  was  called  in  :  treatment, 
at  once  the  most  active  and  the  most  rational,  was  resorted  to.  The  effu- 
sion advanced  with  the  most  frightful  rapidity  :  on  the  fifth  day  of  the 
disease,  the  symptoms  assumed  such  intense  severity,  that  any  medical 
interference  seemed  useless.  Dr.  Rousset,  and  M.  Bouley  (my  colleague 
at  the  Academy  of  Medicine,  and  a  relation  of  the  patient),  thought  that 
possibly  paracentesis  of  the  chest  might  offer  a  chance  of  prolonging  life. 
When  we  met  in  consultation,  the  pulse  was  quick,  and  so  small,  that  death 
seemed  imminent  :  it  was  impossible  not  to  see  that  the  patient  had  puru- 
lent effusion.  We  were  aware  that  the  puerperal  state  imparted  a  serious 
character  to  the  local  disease:  but  life  was  ebbing,  and  the  operation  could 
not  in  the  slightest  degree  diminish  the  patient's  chances  of  recovery. 

I  performed  paracentesis,  and  withdrew  nearly  1500  grammes  of  a  tur- 
bid, semi-purulent  fluid.  Immediate  relief  was  experienced.  The  pulse 
regained  its  volume,  and  lost  its  frequency.  The  patient  seemed  to  return 
to  life,  and  testified  her  gratitude  by  a  look  which  seemed  to  me  of  very 
good  augury.  There  was  still,  however,  very  high  fever,  and  some  dysp- 
noea. Four  days  later,  the  fluid  reaccumulated  ;  and  the  orthopncea  be- 
came exceedingly  urgent,  although  life. did  not  seem  to  be  placed  in  imme- 
diate jeopardy.  I  again  tapped,  the  operation  being  performed  in  the 
intercostal  space  immediately  below  that  in  which  it  had  been  previously  f 
practiced  :  upon  this  occasion  I  withdrew  1200  grammes.  I  closed  the 
wound  in  the  same  way  as  on  the  first  occasion  ;  being  prepared  to  incise 
an  intercostal  space,  and  use  injections  of  a  solution  of  iodine,  should  the 
purulent  secretion  be  renewed  with  similar  rapidity,  particularly  if  it  as- 
sumed a  fetid  character. 

The  case  went  on  favorably  :  the  fever  abated  :  the  appetite  returned  ; 
as  did  likewise  a  hopeful,  cheerful  state  of  mind.  During  the  next  fort- 
night, I  observed  a  slow  reaccumulation  of  the  pus.  There  was  after  this 
a  tittle  inflammatory  action  in  the  situation  of  each  of  the  two  punctures, 
and  this  was  followed  by  slight  fluctuation.  Some  days  later,  both  wounds 
reopened,  and  yielded  a  large  tumbler  of  perfectly  inodorous  pus.  Daily. 
for  a  month,  a  large  quantity  of  similar  fluid  was  discharged.  One  of  the 
wounds  then  closed  :  and  for  more  than  four  months  from  that  dale,  every 
two  or  three  days,  there  was  found  in  the  bandage  which  encircled  the 
patient  V  hoily,  at  least  two  or  three  spoonfuls  of  tenacious,  inodorous  pus. 

At  lasl  the  wound  finally  closed.  Some  days  after  this  occurred,  there 
was  dyspnoea,  and  increased  uneasiness:  then,  one  day,  the  patient  brought 
up  by  the  mouth  nearly  a  tumbler  of  pus.  The  pleural  effusion,  perforat- 
ing the  lung,  had  found  exit  by  the  bronchial  tubes.  I  was  not  without 
anxiety;  but  I  was  soon  reassured  by  seeing  thai  the  purulent  expectora- 
tion rapidly  diminished  in  quantity,  and  did  not  assume  any  degree  of 
fetor. 

This  vomica  was  not  healed  till  the  n<  \t  winter,  nearly  a  year  after  the 
first  operation.  Next  year,  the  young  patient  went  to  CauteretS,  whence 
.-he  proceeded  to  Mentone,  where  .-he  passed  the  winter:  she  is  now  about 
to  Nice.  At  present,  she  is  in  quite  as  good  health  as  before  her 
marriage  ;  but  she  easily  takes  catarrh,  easily  becomes  feverish,  and  has 
--.in  linn-  oedema  of  the  inferior  extremities,  which  yield-  after  some  days 
of  violent  diarrhoea.  The  chest,  which  had  become  deformed,  as  a  conse- 
quence of  the  disease,  ha-  regained  it-  normal  configuration.     She  gener- 


pleurisy:   paracentesis  of  the  chest.  597 

ally  has  raucous  rales,  but  there  is  nothing  to  lead  to  the  belief  that  she  has 
tubercles. 

It  is  not  necessary  to  repeat  the  details  of  a  ease  which  T  referred  to  in 
my  lectures  on  scarlatina  :  the  patient  was  a  child,  whom  Dr.  Blanche  and 
I  successfully  treated  by  paracentesis  for  suppurative  pleurisy  supervening 
in  the  course  of  the  exanthematous  fever.  But  as  an  additional  example 
of  the  utility  of  tapping  the  chest  in  scarlatinous  empyema,  and  as  one 
anion-'  other  similar  eases  which  I  might  relate,  I  ask  you  to  allow  me  to 
read  an  account  of  one  of  the  cases  which  Dr.  P.  Brotherston  has  pub- 
lished in  the  "Edinburgh  Monthly  Journal  of  Medical  Science,"  for  1853. 

"  In  October,  1853,"  says  Dr.  Brotherston,  "a  boy,  four  and  a  half  years 
of  age,  was  attacked  with  serious  chest  symptoms  after  scarlatina.  The 
disease  was  in  the  left  side,  where  there  was  clulness  and  an  absence  of  res- 
piratory sound.  The  patient  had  a  very  painful  cough,  and  oedema  of  the 
extremities.  He  slept  badly.  The  application  of  leeches  and  the  admin- 
istration of  diuretics  foiled  to  give  any  relief.  On  the  2d  November, 
paracentesis  was  performed :  the  puncture  was  made  with  a  small  trocar, 
between  the  seventh  and  eighth  ribs,  at  an  equal  distance  between  the 
sternum  and  the  spine.  There  was  a  flow  of  thick,  yellow,  healthy  pus  : 
the  quantity  could  not  be  estimated.  A  large  piece  of  sponge,  cut  out  in 
the  centre,  and  soaked  in  hot  water,  was  applied  to  the  orifice  of  the  can- 
ula  :  eight  hours  afterwards,  not  only  was  the  sponge  saturated  with  pus, 
but  pus  had  soaked  through  the  child's  clothes.  Rapid  improvement  took 
place,  and  the  wound  closed.  On  the  15th  November,  there  was  distinct 
fluctuation  in  the  situation  of  the  puncture  :  a  new  opening  was  made, 
which  afforded  exit  to  ten  ounces  of  healthy  pus.  The  wound  remained 
open  for  about  a  month,  and  discharged  during  the  wThole  of  that  time. 
The  child  was  restored  to  perfect  health." 

Before  proceeding  farther  I  must  call  your  attention  to  the  fact,  that  in 
a  large  proportion  of  the  numerous  cases  of  recovery  which  I  have  brought 
under  your  notice,  the  pleurisy  was  on  the  right  side. 

In  I860  Aran  published  a  work,  from  which  it  appeared  that,  when  the 
effusion  is  on  the  right  side,  paracentesis  produces  only  a  temporarily  bene- 
ficial effect,  as  the  fluid  reaccumulates;  or,  if  at  first  all  has  gone  on  well, 
in  a  short  time  tubercles  supervene.  It  is  very  remarkable  that  Hippocra- 
tes noticed  this  fact  without  trying  to  explain  why  the  probability  of  recov- 
ery is  greater  when  the  operation  is  performed  on  the  left  side.*  Be  the 
explanation  what  it  may,  I  confess  that  my  attention  had  not  been  called 
to  the  fact  till  it  was  pointed  out  by  Aran ;  and  now  that  I  bestow  more 
consideration  upon  it,  I  am  obliged  to  admit — without,  however,  being  able 
to  explain  the  circumstance — that  effusions  on  the  right  side  are  most  com- 
mon in  tuberculous  subjects:  but  if  Aran  was  unfortunate  in  his  cases  of 
paracentesis  for  effusion  on  the  left  side,  you  have  seen  that,  by  a  chance 
which  I  cannot  explain,  I  have  cured  a  large  number  of  patients  with  pleu- 
risy on  the  right  side — very  serious  pleurisies,  giving  rise  to  effusions  enor- 
mous in  quantity,  and  of  a  purulent  character. 

Hitherto,  gentlemen,  we  have  been  exclusively  occupied  with  cases  of 
suppurative  pleurisy;  but  your  surgical  teachers  have  told  you  that  empy- 
ema may  be  the  consequence  of  a  traumatic  lesion  of  the  chest,  and  they 
have  likewise  stated  that  these  are  the  cases  in  which  paracentesis  is  indi- 
cated. 

A  patient,  who  occupied  bed  1,  St.  Agnes's  "Ward,  afforded  us  a  remark- 
able example  of  traumatic  empyema.     The  man  to  whom  I  refer  was  a  car- 

*  Hippocrates:  De  Morbis,  lib.  ii,  g  15. 


598  PLEURISY:     PARACENTESIS    OF    THE    CHEST. 

man,  of  robust  constitution,  who  was  admitted  to  our  clinical  wards  on  the 
12th  November,  1856:  on  admission,  his  malady  was  of  six  weeks'  dura- 
tion. He  got  violently  squeezed  and  bruised  between  two  carts,  and  had 
to  be  carried  to  his  place  of  residence.  A  medical  man  who  was  called  in 
ordered  (on  the  day  on  which  the  accident  occurred)  leeches  to  be  applied 
to  the  injured  part,  and  on  the  following  day  he  took  a  large  quantity  of 
blood  from  the  arm.  These  bleedings  did  not  calm  the  acute  pain  which 
the  patient  experienced,  and  which  continued  for  a  fortnight  afterwards. 
No  amendment  having  followed  the  application  of  large  blisters  to  the 
chest,  this  individual  was  sent  to  the  Hotel-Dieu. 

On  his  admission  I  found  that  there  was  very  marked  deformity  of  the 
chest,  and  that  the  right  side  was  considerably  arched.  There  was  dulness 
on  percussion,  extending  from  the  base  of  the  chest  to'  the  crest  of  the  scap- 
ula behind,  and  to  the  subclavicular  fossa  in  front:  in  that  situation  there 
was  an  abnormal  degree  of  resonance.  On  auscultation  it  was  found  that 
the  vesicular  murmur  was  absent  in  the  lower  part  of  the  chest :  in  the  iu- 
fraspinous  fossa  there  was  a  blowing  sound  and  segophony:  we  also  heard 
metallic  tinkling  in  the  infraspinous  fossa,  and  the  sound  of  fluctuation  pro- 
duced by  succussion,  indicating  the  presence  of  air  and  fluid  in  the  pleural 
cavity.  The  liver,  pushed  out  of  its  normal  position,  extended  far  beyond 
the  margins  of  the  false  ribs.  The  patient  coughed  a  great  deal:  the  sputa 
were  bloody  and  rusty,  mingled  with  frothy  aerated  matter.  Respiration 
was  rapid  and  painful.  The  pulse  was  small,  and  about  120  in  the  minute. 
The  countenance  was  flushed  and  excited.  The  patieut's  strength  did  not 
seem  to  be  exhausted.  The  physical  signs  showed  beyond  doubt  that  there 
was  pleurisy,  complicated  to  a  certain  extent  with  pneumonia;  and  also 
that  there  existed  a  communication  between  the  bronchi  and  the  pleural 
cavity.  Looking  to  the  circumstances  under  which  the  malady  originated, 
I  concluded  that  the  effusion  was  purulent. 

It  appeared  to  me  that  paracentesis  was  indicated.  I  operated — drawing 
off  five  and  a  half  litres  of  thin  inodorous  pus.  I  employed  Mathieu's 
double  syringe,  which  enabled  me,  without  removing  the  instrument,  to 
inject  250  grammes  (about  half  a  pint)  of  a  solution  of  iodine.  Decided 
relief  was  the  immediate  result  of  the  operation.  The  patient  said  that  he 
breathed  freely.  He  lay  on  his  right  side,  and  went  to  sleep  tot-  some  hours. 
During  the  night  he  sweated  profusely.  Next  morning  he  did  not  feel  so 
well  as  in  the  evening,  although  the  fever  had  subsided. 

On  the  third  day  after  the  operation,  the  15th  November,  the  pulse  was 
90,  and  the  skin  was  warm  and  moist.  On  examining  the  affected  part,  I 
found  complete  dulness  in  the  inferior  half,  and,  on  the  contrary,  above 
that,  there  was  increased  resonance.  In  that  situation,  there  was  neither 
respiratory  murmur,  blowing,  nor  segophony;  and  there  was  only  to  be 
heard  a  distant  sound  of  vesicular  expansion  coming  from  the  other  lung. 
The  metallic  tinkling  and  the  sound  of  fluctuation  on  SUCCUSsion  remained 

audible;  the  displacement  of  the  liver  continued.  Respiration  was  tolera- 
bly free  when  the  patient  was  sealed,  1m!  it  became  labored  when  he  lay 
on  the  left   side. 

From  the  loth  to  the  20th,  nothing  noteworthy  occurred  in  his  condi- 
tion ;  hut  on  the  20th,  the  dulness  was  found  to  have  increased,  and  to  have 
extended  as  high  up  as  the  third  rib.  The  abnormal  amount  of  resonance, 
and  the  stethoscopic signs  which  I  have  mentioned,  still  existed.  Above 
the  wound  made  by  the  large  trocar  with  which  I  had  operated,  the  cellular 
tissue  was  cederaatous,  the  skin  was  red,  swollen,  and  painful.  During  the 
day,  the  wound  spontaneously  re-opened,  ami  discharged  about  three-quar- 
ters of  a  lit  re  of  very  fetid  pus. 


PLEURISY:     PARACENTESIS    OF    THE    CHEST.  599 

Next  day,  the  dullness  did  not  extend  so  high  up,  and  the  exaggerated 

resonance  was  heard  in  the  situation  which  had  been  previously  dull. 
There  was  more  fever  than  on  the  previous  days.  The  patient  had  a  cough 
which,  from  its  frequency,  was  fatiguing;  the  sputa  were  rusty  and  very 
fetid. 

On  the  23d,  there  was  a  cessation  in  the  discharge  from  the  fistulous 
opening  in  the  chest.  At  that  date,  I  began  to  hear  sounds  of  respiration 
behind,  at  the  lower  part  of  the  lung,  although  there  was  still  metallic 
tinkling.     Respiration  was  freer.     There  was  no  fever. 

On  the  25th,  the  fistula,  which  had  reopened,  gave  exit  to  fetid  pus, 
which  spurted  out  with  considerable  force  during  the  fits  of  coughing.  The 
physical  phenomena  observed  on  auscultation  and  percussion  were  dulness 
and  amphoric  blowing ;  but  the  visicular  murmur  was  heard  over  a  greater 
extent,  mingled  with  coarse  mucous  rales.  The  general  condition  of  the 
patient  was  satisfactory  ;  and  though  he  ate  little,  he  ate  with  appetite. 

From  the  25th  to  the  30th  November,  there  was  a  purulent  discharge 
from  the  wound  in  the  chest,  which  was  alternately  abundant  and  scanty ; 
and  with  these  alternations,  the  -extent  of  the  dulness  on  percussion  varied. 

On  the  30th,  the  resonance  was  heard  as  high  up  in  front  as  the  fifth  rib, 
and  behind  nearly  to  the  angle  of  the  scapula.  The  vesicular  murmur 
was  audible  throughout  all  the  upper  part.  The  strength  and  appetite  of 
the  patient  were  good.     He  sat  up  out  of  bed  during  the  day. 

From  the  day  of  the  operation,  we  had  encircled  the  base  of  the  chest 
with  a  girdle  made  of  broad  bands  of  diachylon,  which  were  renewed  daily. 
During  the  whole  of  December,  the  patient  made  visible  progress ;  but  I 
do  not  find  anything  which  requires  to  be  specially  mentioned. 

On  the  10th  January,  1857,  the  dulness  continued  as  high  up  behind  as 
the  angle  of  the  scapula.  The  vesicular  murmur,  still  feeble  and  accom- 
panied by  mucous  rales,  was  heard  even  down  to  the  bottom  of  the  lung ; 
it  was  everywhere  distinctly  heard.  The  right  side  of  the  chest  was 
remarkably  constricted.  For  twenty-four  hours,  there  was  not  the  least 
exudation  from  the  wound,  which  seemed  to  be  quite  cicatrized. 

On  the  23d  January,  the  patient,  who  had  for  some  time  been  on  full 
diet,  and  eating  his  entire  allowance,  asked  permission  to  leave  the  hospi- 
tal. He  left;  retaining  no  remains  of  his  malady,  except  a  slightly  fetid 
expectoration.  He  promised  to  come  to  show  himself  from  time  to  time. 
He  came  back  for  this  purpose  on  the  30th :  his  condition  was  then  excel- 
lent, although  there  was  still  some  dulness  posteriorly,  where  the  feebleness 
of  the  respiratory  murmur  indicated  that  all  was  not  yet  right.  Fifteen 
days  afterwards,  on  the  13th  February,  he  again  returned  to  see  us,  when 
he  stated  that  he  had  resumed  his  occupation  as  a  carter. 

Gentlemen,  I  have  stated  that  pleurisy,  when  the  effusion  has  been  long 
present,  may  become  purulent,  the  pleurisy  remaining  simple,  that  is  to 
say,  not  being  the  expression  of  any  diathesis,  and  I  have  told  you,  that 
this  is  particularly  observed  in  children:  I  have  also  remarked,  that  con- 
stant determination  towards  the  thoracic  organs  may  lead  to  the  develop- 
ment of  tubercles  in  predisposed  persons. 

Whenever  chronic  inflammation  is  developed  without  any  known  cause, 
or  in  consequence  of  a  traumatic  exciting  influence,  in  individuals  under 
the  dominion  of  the  tuberculous  diathesis,  the  manifestations  of  that  diathesis 
show  themselves  in  the  affected  organs  and  tissues.  Suppose,  for  example, 
a  lad,  the  child  of  scrofulous  parents — a  subject  in  whom  there  is  reason  to 
fear  that  scrofula  exists,  though  it  has  never  shown  itself — suppose  that  this 
lad  sprain  a  joint,  it  is  necessary  to  be  very  careful,  and  to  watch  the  injury 


600  PLEURISY:     PARACENTESIS    OP    THE    CIIEST. 

much  more  closely  than  in  an  ordinary  subject,  as  there  is  a  risk  of  the 
sprain  becoming  a  white  swelling :  there  is  a  similar  danger  in  respect  of 
abdominal  and  thoracic  inflammations  in  the  scrofulous.  In  a  child  of 
good  constitution,  born  of  healthy  parents,  chronic  diarrhoea  would  not 
bring  with  it  the  same  clangers  as  in  strumous  or  tuberculous  children.  In 
strumous  and  tuberculous  subjects,  the  diarrhoea  continues  a  long  time,  the 
intestinal  inflammation  is  persistent,  involving  the  glands  of  Peyer  and  the 
mesenteric  glands.  You  will,  under  such  circumstances,  see  the  affection 
known  by  the  name  of  tabes  mesenterica  [carreau]  :  or,  perhaps,  the  intes- 
tinal inflammation,  from  its  contiguity  to  the  peritoneum,  will  give  rise  to 
chronic  inflammation  of  that  serous  membrane,  and  to  tuberculous  granu- 
lations. Likewise,  in  persons  under  the  dominion  of  the  strumous  diathesis, 
when  a  pleuritic  effusion  is  of  long  standing,  the  inflammatory  determina- 
tion towards  the  pleura  will  call  forth  manifestations  of  the  diathesis  in  that 
serous  membrane,  precisely  as  enteritis,  peritonitis,  and  arthritis,  are  called 
forth  in  the  mesenteric  glands,  peritoneum,  and  joints. 

From  these  considerations,  then,  it  follows,  that  paracentesis  of  the  chest 
ought  to  be  performed,  wjth  the  least  possible  delay,  in  cases  of  great  pleur- 
itic effusion. 

Gentlemen,  these  extensive  pleuritic  effusions  coming  on  slowlv— these 
latent  pleurisies — are  frequently  themselves  manifestations  of  the  tu'/»  rculovs 
diathesis,  the  expression  of  incipient  phthisis,  as  was  long  ago  pointed  out 
by'Stoll :  "  Est  (pleuritis  latens)  sozpe  chronica,  non  rarb  hereditaria,  tumque 
in  phthisin  terminanda."* 

These  chronic  effusions  are  not  necessarily,  as  might  be  supposed,  and  as 
has  been  said,  the  result  of  tuberculous  inflammation  of  the  pleura,  when 
we  find  the  pleura  in  such  cases  coated  with  characteristic  granulations.  It 
is  quite  true  that  these  appearances  are  often  found  ;  but  it  is  a  question, 
whether  the  tuberculous  granulations  have  not  been  developed  consecutively 
to  the  effusion.  It  sometimes  happens  that  these  chronic  effusions,  even 
when  they  remain  serous  and  limpid,  are  the  sole  thoracic  manifestation  of 
the  tuberculous  diathesis;  as  is  discovered,  when  patients  are  carried  off  by 
some  other  affection,  and  at  the  autopsy  the  pulmonary  apparatus  is  found 
to  be  perfectly  healthy.     Here  is  a  case  in  point : 

Auguste  Thillaye,  aged  twelve,  the  son  of  the  keeper  of  the  museum  of 
the  Faculty  of  Medicine  of  Paris,  a  boy  of  lymphatic  constitution,  was 
taken  home  from  school,  on  account  of  severe  headache  and  a  stitch  in  l he 
left  side  above  the  false  ribs.  He  had  no  fever.  He  was  put  to  bed,  and 
the  stitch  in  the  side  went  away  :  next  day,  he  drove  out  in  a  carriage. 
For  several  days,  lie  had  no  appetite;  but  he  made  no  complaint  of  pain, 
and  was  free  from  fever  and  cough. 

For  three  successive  days,  his  chest  was  examined  with  the  greatest  pos- 
sible care,  when  it  was  found  that  he  breathed  equally  well  on  both  sides. 

Three  days  later,  ill  the  evening,  the  left  side  of  the  chest,  from  base  lo 
summit,  was  found  to  he  tilled  with  fluid.      A  blister  was  applied. 

Next  day,  there  was  fever  for  the  firsi  lime.  Three  days  later,  the  eleventh 
day  from  the  beginning  of  the  malady,  another  blister  was  applied,  hut  with 
as  little  success  as  the  first.     The  effusion  increased;  but  nevertheless,  the 

child  made  no  complaint  of  pain.      On  the  5tb   I   was   called  in,  when   I  ex- 
pressed a  wish   to  have  Dr.  Bouillaud  associated  with  me  in  consultation. 

There  was  ureal  enlargement   of  the  lel'l  side  of  the  chest,  and  the  ribs  were 

almost   immovable:    there  was  complete  d illness,  and  we  heard  bronchial 
*  Stoll  :  Aphorism,  188, 


pleurisy:   paracentesis  of  the  chest.  601 

blowing  and  bronchophony.  The  mediastinum  was  pushed  upwards  and  to 
the  right,  two  centimetres  from  the  median  line:  the  heart  was  pushed 
over  to  the  right  side,  and  was  felt  to  beat  at  the  right  nipple:  the  liver, 
and,  in  a  still  greater  degree,  the  spleen,  were  displaced,  both  descending 
very  low  in  the  abdominal  cavity.  However,  there  was  very  little  dysp- 
noea, but  when  the  patient  was  agitated,  he  had  some  breathlessness ;  the 
pulse  was  128  and  small  :  the  skin  was  tolerably  warm  :  there  were  no  gas- 
tric symptoms.  I  recommended  that  a  third  riving  blister  should  be  ap- 
plied •  and  that  calomel  should  be  administered  in  small  doses  with  nitrate 
of  potash.  For  eight  days,  no  amendment  was  apparent :  on  the  contrary, 
the  pulse  became  very  quick,  rising  to  144,  without  any  increase  in  the  tem- 
perature of  the  skin  :  the  countenance  was  anxious.  A  fourth  blister  was 
applied.     I  also  prescribed  digitalis,  which  was  continued  for  eight  days. 

The  effusion  had  increased  :  the  heart  beat  on  the  right  side,  beyond  and 
above  the  right  nipple.  There  was  neither  orthopnoea,  dyspnoea,  nor  cough. 
Paracentesis  was  resolved  upon;  and  was  performed  with  the  usual  pre- 
cautions at  10  in  the  morning  of  Thursday  the  13th  November.  Eleven 
hundred  grammes  of  serosity,  greenish,  limpid,  and  very  albuminous,  flowed 
from  the  puncture.  Immediate  relief  was  experienced  ;  but,  as  almost 
always  happens,  the  patient  had  frequent  fits  of  coughing  after  the  opera- 
tion/ The  lung  at  once  expanded,  and  respiration  was  heard  throughout 
the  whole  of  the  lower  part  of  the  chest.  The  heart  first  came  under  the 
sternum,  and  very  soon  afterwards  assumed  its  normal  position. 

On  the  15th  November,  the  state  of  the  patient  was  good.  Subcrepitant 
mucous  rales  were  heard  through  the  whole  of  the  front  of  the  chest. 

On  the  24th  November,  there  was  a  little  fever  ;  and  some  increase  in 
the  effusion. 

The  child  made  a  perfect  recovery  from  the  pleuritic  attack  ;  but  he  died 
a  few  months  later  of  tuberculous  meningitis.  On  making  the  autopsy,  no 
lesion  of  the  pleura  was  found,  and  the  lungs  appeared  to  be  healthy. 
There  were  tuberculous  granulations  in  the  brain. 

This  case,  then,  corroborates  the  proposition  I  have  just  stated,  to  the 
effect,  that  hydrothorax,  even  when  the  effused  fluid  is  purely  serous,  may 
be  the  manifestation  of  the  tuberculous  diathesis.  It  also  shows,  that  not- 
withstanding the  unfavorable  condition  of  the  boy's  system,  a  condition 
under  which  he  was  doomed  to  succumb  ere  long,  paracentesis,  necessitated 
by  the  imminence  of  the  danger,  was  of  real  utility,  for  without  it,  death 
must  have  been  the  inevitable  consequence  of  the  pleuritic  effusion. 

When  pleuritic  effusion  accompanies  pulmonary ^manifestations  of  the  tuber- 
culous diathesis — and  then  they  are  generally  purulent — paracentesis  is 
useful  in  those  cases  in  which  the  largeness  of  the  quantity  of  the  effusion 
is  in  itself  a  formidable  complication.  Assuredly,  the  existence  of  tuber- 
cles, and  still  more  the  existence  of  pulmonary  cavities,  leaves  but  little 
chance  of  the  operation  proving  successful  ;  but  if  we  cannot  hope  to  obtain 
from  it  an  absolute  cure,  in  consequence  of  the  fatal  character  of  the  prin- 
cipal and  dominating  malady,  we  can  at  least  prevent  imminent  death,  and 
considerably  prolong  life  by  performing  paracentesis.  This  was  Laeunee's 
opinion.*  He  said  that  the  bad  state  of  a  lung,  a  lung  filled  with  tuber- 
cles, ought  not  absolutely  to  forbid  operating  for  empyema,  not  even  when 
pectoriloquy  is  audible  in  the  summit  of  the  lung  compressed  by  the  effu- 
sion, if  the  other  lung  seem  to  be  sound.  In  such  a  case,  Laenuec  consid- 
ered that  a  cure  was  possible. 

*  Laexxec:  Traits  de  PAuscultation  Mediate.     2me  Edition,  t.  ii,  p.  520. 


602  pleurisy:   paracentesis  of  the  chest. 

From  cases  observed  by  reliable  authors,  it  appears  tbat  paracentesis 
may  even  be  useful  when  there  is  kydropneumothorax. 

Many  years  ago,  I  operated,  at  an  interval  of  some  weeks,  upon  two 
individuals  who  were  both  patients  at  the  same  time  in  our  clinical  wards. 

One  of  these  persons  was  a  Piedraontese,  aged  twenty-six,  who  was  by 
profession  a  juggler.  Generally  enjoying  good  health,  but  from  his  occu- 
pation necessarily  leading  a  very  irregular  sort  of  life,  he  attributed  the 
malady  for  which  he  sought  our  aid  to  a  chill  got  in  coming  from  an  even- 
ing performance.  Two  mouths  previously,  the  period  to  which  he  referred 
the  beginning  of  his  symptoms,  he  was  tormented  by  a  fatiguing  dry  cough. 
He  continued,  nevertheless,  to  pursue  his  ordinary  avocations,  passing  from 
the  coffee-house  to  the  club,  and  from  the  club  to  the  drawing-room,  going 
late  to  bed,  eating  and  drinking  as  usual,  and  perhaps  to  excess.  The  only 
measure  he  adopted  with  a  view  to  get  rid  of  his  catarrh  was  to  take  vapor 
baths  and  Russian  baths. 

Three  weeks  prior  to  his  admission  to  the  hospital — that  is,  three  weeks 
prior  to  3d  March,  1857 — he  felt  himself  worse  than  usual,  but  still  he  did 
not  keep  his  becl,  although  he  felt  exceedingly  weak.  He  was  losing  his 
appetite,  and  after  eating,  was  often  seized  with  fits  of  coughing  followed  by 
vomiting :  at  night,  he  was  exhausted  by  profuse  perspirations :  he  was 
losing  flesh  :  the  color  of  the  skin  was  day  by  daj^  becoming  more  and 
more  leaden  :  at  last,  he  was  obliged  to  give  up  his  occupation,  and  being  at 
the  end  of  his  resources,  he  resolved  to  seek  admission  to  the  Hotel-Dieu. 

When  I  saw  him,  he  was  without  fever,  but  had  a  wretched  appearance, 
characterized  by  great  paleness,  emaciation,  and  debility.  He  had  hardly 
any  cough,  and  only  a  little  expectoration,  consisting  of  muco-albuminous 
matter  without  any  admixture  of  blood.  I  remarked  that  he  had  the  Hip- 
pocratic  deformity  of  the  fingers. 

On  examining  the  chest,  the  physical  signs  of  disease  were  found  to  be 
far  from  proportionate  to  the  almost  total  absence  of  the  general  powers  of 
reaction.  On  percussion,  I  found,  under  the  left  clavicle,  a  somewhat  di- 
minished resistance  to  the  finger,  and  an  increase  of  souud,  while  on  the 
right  side  there  was  nothing  abnormal.  On  auscultation,  supplementary 
respiration  was  heard  on  the  right  side;  while  on  the  left,  respiration  was 
of  a  blowing  character,  and  accompanied  by  vocal  resonance.  Behind, 
the  resonance  was  normal  in  the  infraspinous  fossa,  but  it  diminished  from 
below  the  crest  of  the  scapula:  from  this  point  downwards,  the  sound  was 
harsh,  and  in  the  lower  parts,  the  harshness  became  absolute  dulness.  In 
the  infraspinous  fossa,  there  was  double  tubal  blowing,  most  decided  in  ex- 
piration, during  which  tubal  blowing  alone  was  audible,  while  during  in- 
spiration, it  was  accompanied  by,  and,  after  (its  of  coughing,  even  replaced 
by  pulls  of  subcrepitant  rales.  In  these  situations,  the  voice  was  resonant 
and  bronchophonic.  On  the  right  side,  the  respiratory  sound  w;is  almost 
normal,  except  that  a  blowing  sound  was  heard,  which  seemed  to  be  pro- 
duced at  a  distance  from  the  ear,  and  which  1  regarded  a>  transmitted  from 
the  left   side. 

These  phenomena  caused  me  to  hesitate  in  my  diagnosis.     The  absence 

of  all  the  symptoms  of  fever,  and  the  chronic  progress  of  the  malady  ex- 
cluded the  idea  of  acute  pneumonia  :  then,  in  respeel  of  chronic  pneumonia, 
a  disease,  moreover,  very  rare,  such  is  not  the  manner  in  which  it  advances 

nor  are  its  symptoms  of  this  character,  as  you  can  ascertain  by  reading 
Dr.  Kay  mo]  id'.-  excel  lent  tin  sis  on  this  affection.  On  the  other  hand,  while 
the  genera]  symptoms,  the  emaciation,  the  loss  of  strength,  the  impaired 
appetite,  ami  the  profuse  nocturnal  perspirations,  considered  in  conjunction 
with  the  signs  furnished  by  auscultation  and  percussion  (and  which  might 


pleurisy:   paracentesis  of  the  chest.  G03 

depend  on  cavities)  suggested  the  idea  of  pulmonary  phthisis,  I  could  not 
harmonize  the  totality  of  the  signs  and  symptoms  with  the  extreme  scanti- 
ness of  expectoration,  and  its  want  of  special  character,  nor  with  the  ab- 
sence of  evident  signs  of  tubercle  in  the  summits  of  the  lungs.  I  conse- 
quently came  to  the  conclusion,  that  the  patient  presented  one  of  those 
forms  of  chronic  peurisy  in  which  (as  has  been  very  well  pointed  out  by 
Drs.  Rilliet  and  Barthez)  there  exists  extraordinary  vocal  resonance,  caver- 
nous respiration,  tubal  and  amphoric  blowing,  and  even  gurgling.  My 
colleague  Dr.  Behier  has  recently  called  attention  to  these  facts.* 

I  was  thus  of  opiuion  that  the  patient  had  chronic  pleurisy,  and  I  sus- 
pected, though  unable  to  make  good  my  diagnosis  on  this  point,  that  there 
was  tubercular  deposit  on  the  left  side,  when — fourteen  days  after  he  en- 
tered our  wards — the  young  man,  whose  condition  had  not  up  to  this  time 
indicated  any  danger,  was  seized  in  the  morning  with  acute  pain  in  the  left 
side,  dyspnoea,  ardent  fever,  and  a  slight  metallic  blowing  sound  [souffle 
mMalligue]. 

The  acute  symptoms,  the  pain  at  least,  abated  next  day,  but  the  dyspnoea 
and  fever  remained.  There  continued  to  be  almost  no  expectoration.  On 
this  day,  we  were  able  to  examine  the  patient  more  easily  than  had  been 
possible  on  the  previous  evening  or  during  the  previous  day,  from  his  state 
of  anxiety  and  restlessness.  I  detected  all  the  signs  of  pneumothorax : 
there  was  abnormal  distension  of  the  chest,  increased  resonance  behind, 
from  the  angle  of  the  scapula  to  the  base  of  the  lung,  and  an  absence  of 
thoracic  vibrations  on  the  same  side.  In  the  infraspinous  fossa,  there  was 
a  metallic  blowing  sound,  which  was  quite  amphoric  from  the  crest  of  the 
scapula  to  the  base  of  the  chest :  the  voice  also  was  amphoric.  On  apply- 
ing the  ear  to  the  posterior  wall  of  the  chest  on  the  affected  side,  and  per- 
cussing in  front,  striking  a  metallic  pleximeter  with  a  hammer  or  a  piece 
of  money,  a  sound  was  elicited  similar  to  that  produced  by  striking  an 
empty  barrel,  or  still  more  resembling  that  caused  by  striking  a  bronze 
vase.  This  phenomenon  wras  casually  pointed  out  by  Laennec ;  and  I  have 
long  since  called  your  attention  to  it.  Finally,  the  apex  of  the  displaced 
heart  was  beating  below  the  right  nipple. 

There  was  no  doubt  as  to  the  existence  of  pneumothorax ;  but  the  signs 
of  effusion  were  wanting.  It  was  not  till  the  8th  April — sixteen  days  later 
— that  I  detected  them. 

Day  by  day,  the  general  symptoms  were  getting  worse.  From  the  24th 
March,  in  addition  to  the  continuance  of  fever,  the  excessive  restlessness, 
and  the  sweating,  there  was  dysenteric  diarrhoea,  which  still  farther  in- 
creased the  debility.  There  was  still,  however,  little  cough,  and  the  expec- 
toration continued  unimportant  in  character.  Five  days  later,  I  distinctly 
heard  Hippocratic  fluctuation,  when  succussion  was  produced  by  an  assistant, 
or  by  the  patient  himself. 

The  new  diagnosis — hydropneumothorax — was  therefore  distinctly  es- 
tablished. To  my  great  surprise,  the  general  symptoms  improved,  although 
the  local  symptoms  continued.  On  the  29th  April,  the  general  state  of  the 
patient  was  apparently  satisfactory.  But  on  the  26th  May,  his  condition 
had  again  grown  worse.  Although  I  thought  of  practicing  paracentesis, 
the  situation  of  the  patient  did  not  seem  to  me  to  be  so  desperate  as  to 
constitute  an  absolute  necessity  for  resorting  to  this  surgical  proceeding. 
Though  far  from  being  without  anxiety  as  to  the  termination  of  the  disease, 
I  was  afraid  of  accelerating  a  fatal  issue  by  producing  within  the  chest  a 
more  violent  inflammation  than  that  which  already  existed  there ;  and 

*  Behier:    Op.  cit.,  p.  611. 


6u4  pleurisy:   paracentesis  of  the  chest. 

although  I  felt  certain  of  not  causing  death,  as  that  expression  is  generally 
understood,  I  feared  that  I  might  occasion  its  earlier  occurrence. 

Nevertheless,  as  the  patient  was  growing  weaker,  as  the  fever,  after 
temporarily  subsiding,  had  become  constant,  I  thought  that  it  was  my  duty 
to  try  the  operation,  which  (to  sum  up  the  argument  in  a  word),  however 
slight  a  chance  it  offered,  was  the  only  chance  left.  I  resolved  then  to 
operate. 

Believing  that  I  had  to  do  with  a  purulent  effusion,  I  did  not  require  to 
give  myself  any  anxiety  as  to  the  prevention  of  air  entering  the  pleural 
cavity,  which  moreover  already  contained  air,  as  the  case  was  one  of 
hydropneumothorax.  I  consequently  operated  in  accordance  with  the 
plan  followed  by  the  ancients,  that  is  to  say,  by  making  an  incision  with 
the  bistoury.  Having  introduced  my  knife  between  the  seventh  and 
eighth  ribs,  there  gushed  along  the  blade  a  serous  fluid  which  was  slightly 
turbid,  but  did  not  appear  to  contain  pus.  I  was  greatly  astonished,  for  I 
was  expecting  to  see  a  purulent  fluid :  I  withdrew  the  bistoury,  that  I  might 
introduce  an  elastic  gum  sound,  and  in  doing  so  gave  exit  to  about  two 
litres  [more  than  two  quarts]  of  serosity :  I  then  injected  250  grammes  of 
a  solution  containing  fifty  grammes  of  tincture  of  iodine  and  five  grammes 
of  the  iodide  of  potassium :  I  allowed  a  certain  quantity  of  fluid  to  flow, 
after  which  I  closed  the  wound  with  large  bands  of  diachylon,  of  which  I 
made  a  sort  of  girdle.  The  only  untoward  occurrence  to  which  the  opera- 
tion gave  rise  was  the  formation  of  a  serous  tumor — a  true  subcutaneous 
thrombus — occasioned  by  the  mode  of  operating  which  I  had  adopted-:  a 
part  of  the  pleuritic  effusion  became  infiltrated  in  the  subcutaneous  cellular 
tissue,  and  determined  this  large  thrombus,  which  had  completely  disap- 
peared in  forty-eight  hours,  from  the  pressure  of  the  bandage  which 
encircled  the  body.  The  patient  did  not  complain  of  pain  within  the  chest, 
and  the  symptoms  of  absorption  of  iodine  were  very  slight. 

During  the  day,  he  had  a  decided  shivering  fit ;  but  in  the  evening  his 
temperature  was  not  febrile,  although  his  pulse  was  120.  From  the 
beginning  of  the  pneumothorax,  the  pulse  was  120  (as  in  other  similar 
cases  I  have  met  with),  which  ought  to  be  attributed  to  the  impediment  to 
the  action  of  the  heart,  occasioned  by  the  great  displacement  of  that  organ. 

His  general  condition  improved  so  much,  that  on  the  30th  May,  he  got 
up,  stating  that  he  felt  well.  His  digestion  was  good,  and  his  bowels 
regular.  Nevertheless,  auscultation  and  percussion  furnished  the  same 
signs  ;is  before  the  operation. 

On  the  4th  June,  there  was  a  return  of  the  diarrhoea,  fever,  and  uneasy 
feelings.  On  the  7th,  I  found  the  expectoration  muco-purulent  ami  scanty. 
On. the  22*1,  the  debility  was  increasing  daily:  the  emaciation  was  greal  : 
and  he  had  some  delirium.  So  great  had  tin-  debility  become,  that  from 
this  date  we  were  not  able  to  examine  the  chest,  which  had  presented  on 
previous  days,  as  I  have  already  said,  the  same  phenomena  as  before  the 
tapping,  viz.,  distension,  exaggerated  resonance,  amphoric  blowing,  metallic 
tinkling,  Hippocratic  fluctuation,  amphoric  resonance  of  the  voice,  and  the 
sound  compared  to  that  produced  by  striking  a  vase  made  of  bell-metal 
or  an  empty  cask. 

From  that    dale,  the  hectic  \rycv  never  eea-ed  ;   and  the  patient,  reduced 

to  a  state  of  extreme  emaciation,  died  in  delirium  on  the  K>ih  duly  at  noon. 
On  that  morning,]  had  observed  in  the  spittoon  bloody,  black,  frothy, 
aerated  Bputa.  In  other  respects,  there  was  nothing  particular  in  the  ex- 
pectoration, which  was  of  the  same  nature  as  formerly. 

On  opening  the  dead  hodv,  it   was  found  that   the  left  pleural  cavity  was 

coated  with  thick  false  membrane,  and  entirely  filled  with  white,  creamy, 


PLEURISY:     PARACENTESIS    OF    THE    CHEST.  605 

inodorous  pus.  The  lung  was  so  closely  adherent  to  the  vertebral  column, 
and  to  the  anterior  wall  of  the  chest,  that  it  could  not  be  removed  without 
lacerating  it  ;  and  in  consequence  of  laceration  so  produced,  I  was  unable 
to  find  the  orifice  of  the  communication  which  must  have  existed  between 
the  bronchial  tubes  and  the  pleural  cavity.  The  pulmonary  tissue  was 
studded  with  tubercles  in  various  stages:  some  were  hard,  hut  the  majority 
were  softening.     There  were  numerous  small  cavities. 

The  cavity  in  the  right  pleura  contained  about  a  litre  of  purulent  serosity. 
The1  pulmonary  parenchyma  was  riddled  with  small  tubercular  excavations. 
The  heart  was  pushed  to  the  right,  beyond  the  sternum;  and  the  pericar- 
dium was  lined  externally  with  a  thick  layer  of  false  membrane. 

Gentlemen,  though  the  final  issue  of  this  case  was  unfortunate — and  the 
autopsy  more  than  sufficiently  explained  why  it  was  unfortunate — death 
could  not  be  attributed  to  paracentesis  of  the  chest  having  been  performed, 
as  the  patient  lived  six  weeks  after  the  operation,  which,  in  place  of  occa- 
sioning new  symptoms,  seemed  for  a  time  to  produce  amendment. 

The  other  patient  to  whom  I  referred  lay  in  bed  12  of  the  same  ward. 
He  was  a  man  of  thirty-six  years  of  age,  tall,  and  apparently  of  vigorous 
constitution,  who  had  come  to  Paris  from  Berry,  where  he  had  had  inter- 
mittent fever.  After  that  illness,  in  July,  1856,  he  contracted  a  pleurisy, 
which,  neglected  in  the  first  instance,  left  behind  it  a  great  amount  of  effu- 
sion, which  occasioned  so  much  oppression  that  he  could  neither  speak  nor 
drink  without  being  obliged  every  moment  to  take  breath.  Two  months 
later,  on  the  31st  September,  he  saw  a  physician,  in  accordance  with  whose 
advice  the  chest  was  tapped.  More  than  a  litre  of  very  clear  water  was 
drawn  off.  But  the  effusion  was  ere  long  reproduced:  on  the  25th  January, 
1857,  tapping  was  a  second  time  resorted  to.  For  two  months  after  the 
second  operation  the  patient  felt  well,  but  the  oppression  then  returned. 
The  least  amount  of  unusual  exertion,  such  as  going  upstairs,  or  walking 
rather  quickly,  brought  on  shortness  of  breath.  He  experienced  a  constant 
feeling  of  discomfort,  and  painful  feeling  of  weight  on  the  chest,  which  was 
so  much  increased  when  he  lay  on  the  right  side,  that  that  position  wras 
impossible. 

He  had  had  cough  from  the  beginning  of  his  illness.  For  several  days 
after  each  tapping,  he  had  an  increase  of  cough,  after  which,  for  some  time, 
he  had  none  at  all.  The  cough  was  accompanied  by  a  very  abundant,  quite 
watery  expectoration.  At  one  period,  when  under  the  influence  of  the  Eaux 
Bonnes,  which  he  had  been  recommended  to  take,  there  was  a  mixture  of 
blood-stained  sputa  in  the  expectoration,  but  that  entirely  ceased  when  he 
discontinued  the  use  of  the  mineral  water. 

He  had  had  a  rather  profuse  dysenteric  diarrhoea,  which  continued  from 
the  beginning  of  the  illness,  for  four  months. 

The  inconvenience  which  he  experienced  from  the  oppression  of  the 
breathing,  and  the  daily  increase  of  general  debility,  induced  the  patient  to 
come  to  Paris  for  advice.     He  entered  the  Hotel-Dieu  on  the  9th  April. 

When  he  presented  himself  to  me  he  was  apparently  in  a  tolerably  good 
state  of  body.  Except  a  bistre  tint  of  countenance,  which  recalled  the  aspect 
of  those  who  have  lived  in  an  atmosphere  contaminated  by  marsh  miasmata, 
his  general  state  seemed  satisfactory. 

Upon  examining  his  chest,  to  which  he  at  once  called  my  attention,  I 
ascertained  the  following  facts.  The  left  side  of  the  chest  was  decidedly 
dilated.  On  percussion,  the  right  side  everywhere  yielded  normal  reso- 
nance, except  at  a  distance  of  two  finger-breadths  within  the  nipple,  where 
there  was  clulness  in  a  space  of  two  or  three  centimetres  from  above  down- 
wards, and  which,  limited  transversely  outwards  at  the  point  I  have  stated, 


606  pleurisy:   paracentesis  of  the  chest. 

became  confounded  internally  with  the  dulness  of  the  left  side.  On  the 
right  side  the  respiration  was  puerile,  and  exaggerated,  without  rales. 

On  the  left  side,  in  front,  the  body  being  in  a  horizontal  position,  the 
sound  elicited  was  clear,  from  the  clavicle  to  the  nipple:  but  in  proportion 
to  the  extent  to  which  the  trunk  was  raised,  percussion  yielded  complete 
dulness,  and  when  he  was  quite  in  the  sitting  position,  the  dulness  extended 
as  high  up  as  the  third  intercostal  space.  Behind,  there  was  complete  dul- 
ness in  the  whole  of  the  lower  part  of  the  chest,  from  the  spine  to  the  scap- 
ula downwards. 

On  auscultation  the  vesicular  murmur  was  very  faintly  heard  under  the 
clavicle  and  in  the  infraspinous  fossa,  and  was  inaudible  lower  down :  the 
cough  had  an  amphoric  resonance.  During  inspiration  there  was  also  heard 
amphoric  blowing.  Finally,  by  an  assistant  percussing  in  front,  while  the 
ear  of  the  observer  was  placed  on  the  opposite  wall  of  the  chest,  an  exceed- 
ingly well-marked  bell-metal  sound  [bruit  d'airairi]  was  heard.  Succussion 
produced  the  sound  of  fluctuation  {bruit  deflot]',  and  this  was  also  audible 
when  the  patient  shook  himself  moderately.  This  bruit  deflot  was  heard  at 
a  certain  distance,  a  fact  of  which  the  patient  was  perfectly  aware. 

From  9th  April  to  28th  May,  nothing  worthy  of  being  mentioned  oc- 
curred. The  cough  was  moderate,  and  the  expectoration  was  mucous,  de- 
void of  any  special  characteristic.  There  was  no  change  in  the  general 
state  of  the  patient.  He  never  had  any  fever:  the  pulse  was  small,  and,  it 
is  true,  beat  100  in  the  minute,  but  as  its  feebleness  and  quickness  were  not 
accompanied  by  heat  of  skin,  they  were  no  doubt  dependent  upon  the  im- 
pediment to  the  action  of  the  heart  occasioned  by  that  organ  being  firmly 
pushed  over  to  the  right,  where  its  apex  was  beating  in  the  space  where  the 
dulness  was  observed  at  twice  the  breadth  of  a  finger  to  the  inside  of  the 
right  nipple. 

Evidently,  hydropneumothorax  existed  in  that  situation. 

Every  day  the  patient  besought  me  to  relieve  his  difficulty  of  breathing. 
I  consequently  resolved  to  perform  paracentesis,  and  to  follow  it  up  by  in- 
jections of  a  solution  of  iodine.  This,  in  fact,  was  the  treatment  which 
originally  suggested  itself  to  me  in  this  case  when  the  patient  came  into  my 
wards;  but  I  did  not  then  operate,  as  I  thought  that,  upon  the  whole,  the 
case  was  not  very  urgent,  and  that  the  operation  might  disturb  the  general 
state  of  the  system,  which  was  in  an  apparently  satisfactory  condition. 
However,  taking  into  account  this  satisfactory  state  of  the  general  system, 
considering  the  entreaties  of  the  patient,  encouraged,  moreover,  by  the  cases 
of  cure  of  hydrothorax  of  which  I  have  already  spoken,  1  made  up  ray  mind  : 
and  on  the  28th  May  I  performed  paracentesis. 

I  made  an  opening  into  the  chest,  by  an  incision  of  a  centimetre  in 
breadth,  in  the  intercostal  space  between  the  seventh  and  eighth  ribs.  A 
purulent  fluid  spurted  out,  mingled  with  gas,  which  escaped  with  a  bubbling 
sound.  About  lot)  grammes  [1"  ounces)  of  thin  inodorous  pus  were  with- 
drawn. Immediately  after  the  tapping  1  introduced  into  the  wound  a  hem 
silver  canula  fitted  with  a  stop-cock,  and  having  a  thin  piece  of  caoutchouc 
so  adjusted  as  to  protect  the  integuments,  and  keep  them  from  being  excori- 
ated  by  contact  with  the  metallic  beak.  Having  emptied  the  pleural  cavity, 
I  passed  into  the  canula  now  described  a  gum  elastic  catheter,  through 
which  I  injected  a  mixture  of  50  grammes  of  the  [French]  tincture  o\' 
iodine  and  6  grammes  of  iodide  of  potassium,  dissolved  in  from  l"ii  to  120 

grammes  of  water.  I  then  withdrew  the  elastic  instrument,  leaving  in  the 
chest  Dearly  half  of  the  injected  fluid;  and  shutting  the  stop-cock  of  my 
canula,  I   fixed    the  apparatus  in   its  proper  place,  by  means  of  a  diachylon 

bandage. 


pleurisy:   paracentesis  of  the  chest.  G07 

The  only  accident  which  resulted  from  the  operation  was  slight  subcuta- 
neous emphysema,  which  disappeared  in  a  few  days.  The  patient,  who  was 
at  first  a  good  deal  agitated  by  the  operation,  assured  me  when  it  was  over, 

that  it  had  not  occasioned  any  pain.  In  the  evening,  he  complained  of 
pain  at  a  point  corresponding  to  the  wound  made  in  performing  the  para- 
centesis;  but  he  had  no  fever,  and  the  pulse  had  even  comedown  to  76. 

The  heart  was  nearer  its  normal  position,  it.-  pulsations  being  felt  under  the 
right  edge  of  the  sternum. 

Next  day,  I  withdrew  from  the  chest  a  litre  and  a  half  of  fluid,  consist- 
ing of  pus  mixed  with  the  iodine  injection:  it  spurted  out  in  jets  with  the 
pressure  exerted  upon  it  by  the  cough,  which  came  on  involuntarily. 

On  30th  May,  a  second  injection,  similar  to  the  first,  was  thrown  into  the 
pleural  cavity,  after  I  had  evacuated  by  the  wound  about  a  litre  of  puru- 
lent fluid  containing  some  sanffuiuolent  stria?. 

The  injection  was  repeated  on  the  2d  and  4th  June. 

The  general  state  of  the  patient  continued  good,  and  from  day  to  day  the 
flattening  of  the  thorax  proceeded :  from  day  to  day,  also,  less  fluid  was 
withdrawn  when  the  cauula  was  opened  :  a  certain  cpiantity  escaped  during 
the  24  hours,  running  down  the  walls  of  the  chest :  but  on  the  6th  June, 
only  a  few  spoonfuls  were  collected.  The  fluid  preserved  its  purulent  char- 
acter, and  remained  inodorous  :  on  that  day,  the  fifth,  and  a  few  days  later, 
the  sixth  injection  was  made.  These  injections  were  repeated  every  three 
or  four  days,  up  to  the  28th  July,  at  which  date  the  seventeenth  injection 
was  performed.  The  patient  suffered  no  inconvenience  from  the  injections 
except  a  sensation  of  heat  in  the  chest.  The  only  symptoms  of  iodism 
which  he  presented  w7as  a  certain  amount  of  itching,  and,  on  one  occasion, 
the  taste  of  iodine  in  the  throat. 

The  chest  became  more  and  more  flattened  ;  but  the  signs  on  ausculta- 
tion remained  nearly  the  same,  till  the  12th  June.  On  that  day,  I  heard, 
under  the  left  clavicle,  some  rather  coarse  mucous  rales  which  were  not  dis- 
placed, but  rather  increased,  by  coughing.  The  effusion  was  really  dimin- 
ished, but  the  capacity  of  the  thorax  was  lessened  by  the  great  flattening 
of  its  walls  which  had  taken  place,  while  the  heart,  gradually  reoccupying 
its  normal  position,  was  now  beating  on  the  left  side,  its  apex  still  remain- 
ing, it  is  true,  three  finger-breadths  to  the  inside  of  the  left  nipple.  On  the 
17th  June,  an  instrument  made  of  gum  was  substituted  for  the  silver  canula. 
On  the  25th  June,  the  gum  sound  was  finally  removed,  as  the  wound  re- 
mained sufficiently  open  to  allowT  an  instrument  to  be  introduced  when  an 
injection  had  to  be  made. 

A  remarkable  auscultatory  phenomenon  was  present,  a  phenomenon  to 
which  I  have  often  called  your  attention.  This  was  a  sound  heard  pos- 
teriorly over  the  infraspinous  fossa,  a  blowing  sound,  so  soft  and  so  velvety 
[telfement  en  nappe],  if  I  may  venture  to  use  such  an  expression,  that  it 
might  be  mistaken  for  the  normal  respiratory  murmur;  it  was  not,  how- 
ever, exactly  the  vesicular  murmur ;  and  in  this  situation  there  was  exag- 
gerated thoracic  resonance. 

The  general  condition  of  the  patient  presented  alternations  of  amend- 
ment and  retrogression.  On  the  12th  June  he  was  seized  with  diarrhoea, 
which  continued  for  a  fortnight  to  resist  treatment  with  chalk,  bismuth, 
and  nitrate  of  silver,  but  which  at  last  yielded  to  a  pill  taken  twice  a  day, 
consisting  of  005  of  ipecacuau,  0.005  of  extract  of  opium,  and  001  of 
calomel.*     Though  the  diarrhoea  reduced  his  strength,   he  retained   his 

*  Five  centigrammes  (00-3)  is  about  five-sevenths  of  a  grain  ;  and  one  centigramme 
(001)  is  about  one-seventh  of  a  grain.  Five  milligrammes  (0.005)  is  about  five- 
seventieths  of  a  °;rain. 


608  PLEURISY:     PARACENTESIS    OF    THE    CHEST.    . 

appetite.  Under  the  use  of  cinchona  wine  and  a  tonic  regimen,  he  regained 
strength.  On  the  28th  July,  enchanted  with  his  condition,  he  was  boast- 
ing of  ascending  the  stairs  of  the  hospital  without  experiencing  fatigue,  or 
being  much  winded.  Somewhat  copious  perspirations,  the  occurrence  of 
which  was  coincident  with  the  diarrhoea,  were  now  less  considerable. 

The  amendment,  nevertheless,  did  not  continue ;  and  I  was  obliged,  at 
intervals,  to  return  to  the  use  of  the  iodine  injections,  which  were  in  all  em- 
ployed forty-two  times.  In  the  beginning  of  the  following  year  he  became 
the"  subject  of  hectic  fever,  by  which  he  was  carried  off  on  the  28th  Feb- 
ruary.     At  the  autopsy,  we  found  tubercles  in  the  lungs. 

In  1853.  I  submitted  the  history  of  a  similar  case  to  my  colleagues  of  the 
Medical  Society  of  the  Hospitals.  The  patient  was  a  woman  aged  34,  who 
when  she  came  into  my  ward.-  had  all  the  signs  of  hydropneumothorax : 
the  oppression  in  the  breathing  was  so  great  that  death  seemed  imminent. 
I  performed  the  operation  by  incision  for  empyema.  As  in  the  first  of  the 
two  cases  which  I  have  now  narrated  to  you,  the  fluid  removed  was  limpid 
and  transparent,  and  the  gases  were  perfectly  inodorous;  but  on  the  third 
day  after  the  operation  the  fluid  had  become  fetid  :  I  then  injected  a  solu- 
tion of  iodine,  which  occasioned  neither  pain  nor  feverish  reaction.  Seven 
days  later,  ervsipelas  supervened  at  the  base  of  the  chest,  under  the  dia- 
chylon bandage  "which  had  been  applied.  I  nevertheless  repeated  the 
injection,  using,  however,  a  weaker  solution :  iu  the  evening,  some  symp- 
toms of  the  toxic  action  of  iodine  showed  themselves.  The  erysipelas 
progressed,  and  invaded  the  edges  of  the  wound.  Fifteen  days  after  the 
tapping,  the  patient  died. 

At  the  autopsy,  the  pleura  was  found  coated  with  a  layer  of  pultaceous 
purulent  matter,  which  was  easily  scraped  off  with  the  back  of  the  scalpel. 
The  lung  was  so  shrunken  as  not' to  occupy  more  than  the  two  upper  thirds 
of  the  vertebral  hollow.  We  found  the  perforation.  There  were  tubercles 
iu  this  lung;  and  in  its  centre,  cavities  which  contained  neither  pus  aor 
blood. 

The  paracentesis  cannot  be  considered  as  having  been  the  cause  of  death 
in  these  two  cases,  any  more  than  in  the  first  which  I  described:  in  both 
the  men,  who  were  patient-  in  St.  Agnes's  Ward,  death  occurred  at  a  long 
interval  after  the  operation,  and  in  the  woman  of  St.  Bernard's  Ward,  the 
erysipelas  of  the  trunk  having  begun  in  a  situation  remote  from  the  trocar- 
wound,  was  a  complication  independent  of  that  wound.  Moreover,  iu  the 
last-mentioned  case,  paracentesis  was  the  only  possible  means  of  prevent- 
in-  death,  which  the  impediment  to  respiration  rendered  imminent 

i!  .  irentlcmen,  in  hydropneumothorax,  even  when  associated  with 
tubercles  in  the  lungs,  the  practitioner  ought  to  intervene  surgically,  if  the 
evolution  of  gas  and  the  effusion  of  fluid  threaten  to  produce  suffocation, 
physicians  who  deny  the  utility  and  necessity  of  tapping  thy  chest  in 
ive  effusion,  simple  or  purulent, say  that  the  operation  proves 
beneficial  when  the  hydrothorax  is  complicated  with  bronchial  fistula. 
This,  you  observe,  is  to'  go  Jar  beyond  what  I  teach  :  for  while  I  hold  that 
paracentesis  i-  necessary  in  cases  in  which  there  is  a  huge  quantity  of 
effusion  without  any  complication — while  I  consider  that  it  is  useful  in  such 
circumstances,  especially  in  children,  in  whom  the  effusion  is  apt  to  be 
purulent,  I  make  reservations  in  respect  of  hydropneumothorax,  particu- 
larly when  it  is  symptomatic  of  pulmonary  tubercle.  When  the  question 
of  performing  paracentesis  arises  in  such  cases,  1  hesitate  very  much  to 
operate;  butl  granl  that  even  in  such  cases,  though  tapping  does  not  cure, 
it  gives  great  relief  and  prolongs  life. 
Dr.  Hughes,  physician  to  Guy's  Hospital,  London,  mentions  a  case  in 


pleurisy:    paracentesis  of  the  chest.  609 

which  he  accomplished  a  cure  after  two  lappings.  The  patient  having 
succumbed  long  afterwards  under  the  progress  of  the  tuberculous  disease, 
which  showed  itself  in  the  other  lung,  it  was  observed  at  the  autopsy  that 
cicatrization  lia<l  taken  place  on  the  side  first  affected. 

Cancer  of  the  pleura  may  be  accompanied  by  effusion  in  such  quantity  as 
to  necessitate  paracentesis.  I  need  not  tell  you  that  we  possess  no  positive 
sign  by  which  to  recognize  during  life  the  cancerous  nature  of  the  pleurisy 
in  such  cases. 

However,  if  in  a  woman  affected  with  cancer,  or  particularly  in  one  from 
whom  a  cancerous  tumor  has  been  removed,  we  meet  with  pleural  effusion 
slowly  developing  itself,  we  may  conclude  that  the  bronchial  glands  and 
the  pleura  are  themselves  the  seat  of  cancerous  disease :  the  nature  of  the 
fluid  withdrawn  at  the  time  of  operation  by  the  trocar  will  have  a  great 
significance. 

In  July,  1860,  my  friend  and  colleague  Dr.  Barth  showed  me  a  bottle 
containing  a  certain  quantity  of  bloody  fluid  which  he  had  drawn  off  from 
the  chest  of  a  patient,  who  had  excessive  pleuritic  effusion.  At  first  he 
was  alarmed :  it  was  not  till  he  had  reassured  himself  by  reflecting  upon 
the  very  great  care  with  which  he  had  examined  the  case,  and  formed  his 
diagnosis  prior  to  the  operation,  that  he  could  divest  himself  of  the  idea  of 
having  penetrated  an  aneurism.  I  at  once  said  to  him,  that  he  would 
most  probably  find  at  the  autopsy  a  cancerous  pleurisy.  And  it  was  so : 
there  wTas  found  cancer  of  the  lung  and  pleura.  The  only  credit  I  deserved 
for  this  diagnosis  was  recollecting  to  have  seen  in  my  w'ards  at  the  Necker 
Hospital,  in  1844,  a  case  of  the  same  description — a  case  which  I  shall  now 
relate  to  you. 

On  the  9th  November,  1844,  a  woman,  aged  54,  suffering  from  cancer- 
ous atrophy  of  the  right  breast,  became  my  patient  in  the  Necker  Hospital. 
She  had  been  several  months  in  the  Saint  Louis  Hospital  for  rheumatic 
pains  of  the  limbs,  unaccompanied  by  any  general  disturbance  of  the 
system.  She  had  some  vapor  baths.  One  day,  about  the  20th  November, 
when  returning  from  the  hot-room,  she  felt  a  chill,  and  was  attacked  by 
an  acute  pleurisy  on  the  right  side,  wdiich  presented  nothing  special  in  its 
symptoms.  It  was  treated  by  bleeding,  blistering,  digitalis,  and  calomel. 
About  the  20th  December,  the  effusion,  so  far  from  diminishing,  was 
increasing.  There  was  at  that  date  only  a  very  moderate  degree  of  fever 
remaining.  Three  issues  were  placed  on  the  chest.  The  effusion  continued 
to  increase  to  such  an  extent,  that,  by  the  end  of  December,  it  had  reached 
the  clavicle  and  the  infraspinous  fossa  of  the  scapula.  By  the  beginning 
of  January,  1845,  the  distension  of  the  chest  had  become  evident:  in  front, 
the  dulness  soon  passed  the  median  line,  and  the  heart  was  a  little 
thrown  to  the  left :  by  the  20th  of  that  month,  the  dulness  had  passed  four 
centimetres  beyond  the  median  line,  and  the  heart  was  still  more  thrown 
out  of  its  place  :  the  liver  was  pressed  down  into  the  abdomen,  and  could 
be  felt  far  below  the  false  ribs.  Notwithstanding  this  state  of  matters,  the 
patient  had  no  dyspnoea,  except  sometimes  a  little  orthopnoea  in  the  even- 
ing. There  was  decided  fever.  I  perceived  puffiness  of  the  face,  and  infil- 
tration of  the  abdominal  parietes.  On  the  24th  January,  paracentesis 
seemed  to  be  urgently  necessary ;  and  w:as  then  performed,  in  accordance 
with  the  customary  rules.  During  the  flow  of  the  serosity,  which  was 
bloody,  no  coughing  fits  occurred.  The  amelioration  which  followed  the 
operation  was  very  slight :  the  stethoscopic  signs  remained  unchanged. 
From  the  1st  to  the  11th  February,  the  state  of  the  patient  was  nearly 
stationary  ;  but  at  the  latter  date,  erysipelas  set  in,  having  as  its  starting- 
tol.  i.— 39 


610  PLEURISY:    PARACENTESIS    OF    THE    CHEST. 

point  one  of  the  issues  on  the  chest.  Notwithstanding  these  occurrences, 
the  effusion  having  made  additional  progress,  and  threatening  to  suffocate 
the  patient,  I  again  performed  paracentesis :  again,  I  obtained  a  sero-san- 
guineous  fluid.  The  dropsy  of  the  chest  increased,  the  strength  failed,  and 
soon  afterwards,  the  woman  died. 

At  the  autopsy,  I  found  the  pleura  cancerous,  and  covered,  throughout 
its  entire  extent,  with  encephaloid  growths. 

You  will  find  in  the  thesis  of  Dr.  Lacaze  du  Thiers  a  case  identical  with 
that  now  described.  It  was  observed  in  1850  by  Dr.  Lemaitre  in  Professor 
Andral's  wards :  the  subject  was  an  old  man.  At  the  autopsy,  cancer  of 
the  pleura  and  cancerous  tumors  in  different  parts  of  the  body  were  dis- 
covered. 

Gentlemen,  changes  analogous  to  those  which  take  place  in  the  pleura 
occur  in  the  peritoneum.  Recall  to  your  recollection  two  women  suffering 
from  ascites,  in  whom  I  performed  abdominal  paracentesis  in  1860.  The 
effusion  prevented  me  from  recognizing  the  presence  of  any  tumor.  From 
the  time  that  the  fluid  began  to  flow  from  the  canula,  I  told  you  that  there 
was  cancer  of  the  peritoneum ;  and  the  autopsy,  made  soon  afterwards, 
showed  me  that  I  was  not  mistaken.  The  fluid  drawn  off  was  bloody.  I 
also  intimated  that,  in  accordance  with  the  law  established  by  Dr.  Barth, 
we  should  find  some  of  the  abdominal  viscera  affected  with  cancer;  and 
at  the  autopsy,  this  diagnosis  was  verified. 

But,  gentlemen,  let  me  impress  on  you  the  fact,  that  to  cause  excessive 
pleuritic  effusions  to  be  bloody,  it  is  not  enough  that  cancerous  productions 
should  be  disseminated  in  different  parts  of  the  body — to  produce  that 
result,  the  serous  membrane  itself  must  be  affected  with  cancer. 

In  1849,  I  received  as  a  patient  at  the  Hospital  for  Children,  a  male 
child  eight  years  old,  whose  history  is  given  at  page  71  of  the  thesis  of  Dr. 
Lacaze  du  Thiers.  This  child  had  extensive  effusion  on  the  left  side  of 
the  chest :  for  this  affection  I  performed  paracentesis,  drawing  off  an  amber- 
colored  fluid.  Recovery  from  the  pleurisy  took  place:  but  after  languish- 
ing for  some  time,  the  child  sunk  under  epileptiform  convulsions,  which 
continued  for  two  days. 

At  the  autopsy,  small  apoplectic  clots  were  found  in  the  brain.  The 
kidneys,  peritoneum,  anterior  mediastinum,  pericardium,  and  the  heart 
itself  were  invaded  by  cancerous  products:  but  there  was  no  cancerous 
disease  of  the  pleura. 

But,  gentlemen,  the  existence  of  a  sero-sanguineous  effusion  does  not 
afford  absolute  proof  that  there  is  cancer  of  the  pleura  or  peritoneum.  At 
the  57th  page  of  the  thesis  of  Dr.  Lacaze  du  Thiers,  you  will  find  an  account 
of  a  case  observed  by  Dr.  Tardieu  which  will  prove  to  you  that  the  pleura, 
oven  though  not  cancerous*,  may  yield  a  bloody  scrosity.  Dr.  Aran  commu- 
nicated to  nn'  a  case  of  the  same  description  ;  and  similar  cases  are  reported 
by  the  illustrious  author  of  the  Treatise  Oil  Mediate  Auscultation. 

In    ;i    memorable   discussion    which    took   place  in  the  Medical  Society  of 

the  Hospitals  of  Paris  in  relation  to  Dr.  Barth's  case  of  which  1  have  just 
been  speaking,  Professor  Natalis  Guillol  referred  to  the  history  of  an 
epidemic  of  measles,  during  which  he  had  seen  several  children  die  of 
hemorrhagic  pleurisy.  On  the  same  occasion,  Legroux  mentioned  two  cases 
in  which  lie  had  found  sero-sanguineous  effusion  into  the  pleura,  irrespec- 
tive altogether  of  any  cancerous  diathesis. 

It  still  remains  for  me  to  develop  another  reason — as  appears  to  mc — 
for  resorting  to  paracentesis  of  the  chesl  in  oases  of  extreme  effusion.  In 
proportion  to  its  duration,  pU  urisy  becomes  less  and  less  curable,  from  the  lung 


pleurisy:   paracentesis  of  the  chest.  611 

attracting  adhesions  which  prevent  it  from  regaining  its  "place  in  the  thoracic 
cavity  and  fulfilling  its  functions. 

In  pleuritic  effusions  of  long  duration,  the  false  membranes,  at  first 
albumino-fibrous,  then  fibre-cartilaginous,  intimately  soldered  to  each  other 
by  a  cellular  tissue,  the  product  of  a  secondary  inflammation,  fix  the  lung 
to  the  vertebral  column  at  the  points  towards  which  the  effused  fluid  has 
pushed  it.  It  then  resists  the  efforts  of  the  external  air,  which  in  the 
normal  state  contends  against  the  natural  elasticity  of  the  organ,  and  tends 
to  dilate  its  tissue.  The  lung  being  thus  fixed,  is  no  longer  able  to  fill  the 
cavity  of  the  thorax,  and  that  cavity  is  consequently  narrowed  and  con- 
tracted by  the  pressure  exerted  on  its  walls  by  the  external  air. 

Contraction  of  the  chest  consequent  on  pleurisy  is  a  subject  to  which 
Laennec  directed  the  special  attention  of  physicians;  and  all  of  you  are  no 
doubt  acquainted  with  the  article  which  he  has  devoted  to  it  in  his  chapter 
on  pleurisy.  He  has  pointed  out,  in  a  very  remarkable  manner,  the  cir- 
cumstances under  which  this  contraction  takes  place;  and  has  described 
the  anatomical  state  of  the  lung,  which  is  so  compressed  and  flabby  as  to 
resemble  muscle,  the  fibres  of  which  are  so  fine  as  to  be  undistinguishable. 
He  has  indicated,  in  a  not  less  able  manner,  the  signs  furnished  in  these 
cases  by  auscultation  and  percussion.  He  then  adds  "  that  the  contraction 
of  the  chest  may  be  regarded  as  a  real  cure,  inasmuch  as  even  when  it  pro- 
ceeds to  a  high  degree,  it  not  only  does  not  render  the  person  in  whom  it 
occurs  a  valetudinarian,  but  may  even  be  associated  with  a  certain  amount 
of  general  vigor.  Moreover,  in  his  opinion,  it  does  not  leave  any  cause  of 
a  relapse,  for  if  pleurisy  is  observed  very  seldom  in  cases  in  which  the  costal 
and  pulmonary  pleura  are  united  by  a  great  amount  of  cellular  tissue,  it 
ought  to  be  regarded  as  impossible  when  the  union  takes  place  by  means 
of  a  tissue  so  little  disposed  to  inflammation  as  fibro-cartilaginous  tissue." 

There  can  be  no  doubt  that  contraction  of  the  chest  is  one  of  the  ways 
in  which  a  cure  is  accomplished ;  but  this  mode  of  cure  sometimes  leads  to 
incurable  deformity  of  the  chest,  at  least  in  adults :  in  children  and  young 
men  the  deformity  generally  decreases  and  ultimately  quite  disappears. 
This  kind  of  deformity  has  been  admirably  described  by  Laennec. 

"The  subjects,"  he  said,  "have  the  appearance  of  being  bent  upon  the 
affected  side,  even  when  they  try  to  keep  themselves  erect.  The  affected 
side  of  the  chest  is  evidently  narrower:  on  measuring  it  with  a  cord,  a  dif- 
ference of  more  than  an  inch  is  often  found  between  it  and  the  sound  side. 
Its  breadth  is  also  diminished  :  the  ribs  are  in  closer  than  normal  proximity 
to  each  other :  the  muscles,  particularly  the  pectoralis  major,  are  only  one 
half  the  size  of  those  of  the  opposite  side.  The  difference  between  the  two 
sides  it  so  striking,  that  at  a  first  glance  one  would  suppose  that  it  is  much 
greater  than  it  is  found  to  be  on  measuring.  The  vertebral  column  gener- 
ally retains  its  straightness ;  but  sometimes,  however,  it  deviates  a  little,  in 
consequence  of  the  patient  always  leaning  towards  the  affected  side.  This 
habit  imparts  to  the  mode  of  walking  a  peculiarity  somewhat  similar  to 
limping." 

This  is  not  all :  a  long  time  elapses  before  the  cure  is  complete :  between 
the  lung  fixed  to  the  vertebral  column  and  the  thoracic  walls,  there  is  a  ' 
free  space  into  which  there  is  an  interminable  succession  of  effusions.  Para- 
centesis prevents  this ;  for  by  rapidly  evacuating  the  serosity,  it  allows  the 
lung  to  reassume  its  place  almost  immediately,  and  consequently  before 
there  has  been  sufficient  time  for  adhesions  to  form. 


612  PLEURISY:     PARACENTESIS    OF    THE    CHEST. 


The  Quantity  of  the  Effusion  regulates  the  time  at  which  Paracentesis  is  indi- 
cated.—  The  General  Symptoms  and  Oppression  of  Breathing  are  Falla- 
cious Indications. —  The  only  Trustworthy  Sign*  are  those  furnished  by 
Auscultation  and  Percussion. —  The  Manner  of  Operating. —  Certain 
Phenomena  which  supervene  during  the  Flow  of  the  Fluid. —  Coughing 
Fits. — Flow  of  blood  from  the  Wound, — The  Serosity  jellies  in  cooling, 
and  sometimes  assumes  a  rosy  color. —  Circumscribed  Pleurisies. —  Objec- 
tions to  Paracentesis. — Paracentesis  in  Empyema. — Injections  of  Iodine; 
and  the  Permanent  Canula. 

Gentlemen  :  I  have  stated  the  reasons  which  render  paracentesis  of  the 
chest  a  necessary  operation :  I  have  told  yon  the  accidents  which  it  may 
prevent,  and  the  circumstances  in  which  it  is  applicable.  I  ought  now  to 
set  forth  the  indications  for  resorting  to  it. 

"When  the  accidents  of  which  I  have  spoken,  when  the  fainting  fits  and 
the  lipothymia  recur,  when  suffocative  paroxysms  show  themselves,  surgical 
intervention  is  urgently  required ;  for  then  nothing  but  paracentesis  can 
avert  death.  I  have  already  supported  this  proposition  by  citing  a  certain 
number  of  cases.     Here  is  another  to  which  I  beg  your  attention. 

Dr.  D.,  a  physician,  aged  35,  who  never  had  had  any  pulmonary  affec- 
tion, begun  in  August,  1848,  to  experience  difficulty  in  breathing,  accelera- 
tion of  pulse,  and  general  debility.  During  the  night,  the  heart  beat 
most  quickly;  and  dorsal  decubitus  was  painful.  Matters  continued  in 
this  state  for  a  month.  My  honorable  colleague  Professor  Andral  baying 
been  consulted,  detected  thoracic  effusion,  and  attributed  it  to  a  chronic 
pleurisy  which  had  passed  unnoticed.  He  recommended  a  large  blister 
to  be  applied. 

On  the  13th  October,  Dr.  D.,  after  exposure  to  severe  cold,  was  attacked 
bv  acute  pleurisy  on  the  left  side.  During  the  following  days,  he  was 
three  times  copiously  bled  ;  and  on  the  25th,  Dr.  Andral  again  recommended 
the  application  of  a  large  blister.  When  I  was  called  in,  the  symptoms 
had  become  anxiously  severe.  The  patient  was  having  fainting  tits;  his 
features  were  distorted  ;  and  his  debility  was  extreme.  The  skin  was  pale 
and  cyanosed.  The  countenance  expressed  anxiety.  There  was  considera- 
ble dyspnoea,  and  the  respirations  were  30  in  the  minute.  The  pulse  was 
115,  and  irregular.  I  found  complete  dulness  of  the  whole  of  the  Kit  side. 
The  mediastinum  and  heart  were  pushed  to  the  right.  Such  being  the  state  of 
the  case,  delay  wa>  impossible,  and  paracentesis  was  immediately  performed. 
The  operation  afforded  an  exit  to  four  litres  of  yellow,  limpid  serosity. 

I  shall  afterwards  return  to  this  case,  and  give  you  some  interesting 
additional  particulars  regarding  it.  In  the  meantime,  I  may  add  that 
convalescence  was  rather  protracted — that  on  the  2d  December,  the  patient 
began  to  gel  up,  and  wished  at  once  to  resume  his  practice,  but  he  found 
himself  obliged  to  discontinue  making  vi.-its  in  consequence  of  the  suffoca- 
tive fits  which  he  experienced,  lie  went  to  the  neighborhood  of  Dieppe, 
where,  by  the  use  of  horse  exercise,  he  regained  strength  and  health.  From 
►  the  l.-t  June,  Dr.  D.,  considered  himself  as  cured :  but  his  chest  was  con- 
tracted on  the  left  side,  and  continued  to  present  dulness  on  percussion,  and 
obscurity  in  the  respiratory  murmur.  At  that  date, these  phenomena  were 
perhaps  more  marked  than  they  were  an  hour  after  the  operation,  eight 
mouths    previously.       Some    months    later,  however,  he    till    no    remaining 

trace  of  the  malady,  and  even  the  deformity  of  the  chest  had  disappeared. 
At  present,  Dr.  I >.  enjoys  the  best  possible  health. 
Gentlemen,  under  circumstances  Bimilarto  those  which  presented  them- 


PLEURISY:     PARACENTESIS    OF    THE    CHEST.  G13 

stives  in  the  case  now  described,  it  is  impossible  to  hesitate  ;  and  do  one 
will  deny  the  absolute  necessity  of  evacuating  the  effused  fluid  which  is  the 
cause  nt' all  the  complications. 

But  in  addition  to  these  cases,  whenever  the  signs  furnished  by  auscul- 
tation and  percussion  reveal  the  presence  of  an  extensive  pleuritic  effusion 
which  may  be  estimated  at  about  two  litres — whenever  an  effusion  of  this 
description,  irrespective  of  its  nature,  supervenes  without  very  marked 
local  phenomena,  without  decided  symptoms  of  reaction,  it  will  augment 
rapidly — when,  after  a  certain  time,  nine  or  ten  days,  for  example,  the 
disease  has  been  combated  more  or  less  energetically  by  the  ordinary  thera- 
peutic measures,  and  the  effusion  has  nevertheless  notably  increased  in 
quantity,  the  indications  seem  to  me  decisive,  that  the  chest  ought  to  be 
tapped. 

When  the  pleural  cavity  is  not  quite  full,  though  the  operation  may  be 
free  from  objection,  and  in  fact  offer  advantages,  its  performance  may  be 
delayed  for  one  or  two  or  even  for  four  days,  always  taking  care,  how- 
ever, closely  to  watch  the  patient.  In  such  cases,  it  has  happened,  as  I 
have  seen,  that  spontaneous  absorption  has  taken  place  of  extensive  effu- 
sious,  for  which  it  had  seemed  that  surgical  interference  would  ultimately 
be  necessary. 

But  paracentesis  ought  to  be  performed  with  the  least  possible  delay, 
when  the  effusion  completely  fills  the  serous  cavity,  a  condition  indicated 
by  absolute  dulness  on  percussion,  extending  from  the  base  of  the  chest  in 
front  to  the  clavicle,  and  behind,  to  the  top  of  the  infraspinous  fossa  of  the 
scapula,  forcing  out  of  their  places  diaphragm,  liver,  spleen,  and  heart. 
The  complications  which  I  have  just  been  mentioning  are  of  a  threatening 
character. 

I  certainly  cannot  affirm  that  death  would  necessarily  be  the  immediate 
consequence  of  this  excessive  effusion  ;  but  it  would  be  impossible  for  me 
to  repeat  too  often  that  there  are  cases  of  this  kind,  in  which  an  unfavor- 
able issue  has  been  the  result  of  delaying  surgical  interference,  and  that 
these  cases  are  sufficiently  numerous  to  warrant  the  clinical  physician  to 
perform  an  operation  which  is  not  dangerous  in  any  circumstances.  Grant 
that  the  patients  do  not  die  suddenly,  they  will  be  exposed  to  consecutive 
dangers  regarding  which  I  have  already  spoken  so  fully,  that  it  seems 
unnecessary  to  return  to  that  subject. 

One  might  be  tempted  to  believe  that  there  is  no  positive  indication  to 
perform  paracentesis,  except  when  the  individual  who  had  pleuritic  effusion 
suffers  from  great  oppression  in  the  breathing;  that  there  is  no  urgent 
necessity  for  operating,  unless  suffocation  is  imminent.  Gentlemen,  that  is 
a  serious  mistake  against  which  I  must  warn  you.  Oppression  is  one  of 
the  most  deceitful  of  signs  ;  and  in  speaking  to  you  of  the  young  woman 
who  has  furnished  the  text  for  the  present  lecture,  I  have  called  your 
attention  to  this  cardinal  point.  It  is,  howrever,  a  point  of  so  much  clini- 
cal importance,  that  I  do  not  scruple  again  to  insist  upon  it. 

There  are  patients  who,  from  the  very  beginning  of  the  pleuritic  attack, 
when  there  are  hardly  a  few  spoonfuls  of  fluid  effused  into  the  pleura, 
experience  great  oppression,  which  goes  on  diminishing  as  the  effusion 
increases.  There  are  others,  again,  in  whom  oppression  does  not  super- 
vene till  the  amount  of  effusion  has  become  considerable,  and  which  in- 
creases with  the  amount  of  the  effusion.  There  are  others,  also,  who, 
though  they  have  become  almost  suddenly  affected  with  a  great  amount  of 
hydrothorax,  have  never  complained  of  the  least  embarrassment  in  respira- 
tion.    It  was  so  in  the  case  of  the  woman  who  occupied  bed  12  of  St.  Ber- 


614  pleurisy:   paracentesis  of  the  chest. 

nard's  Ward  ;  and  so  it  was  also  in  the  case  of  the  man  who  lav  in  hed  19 
of  St.  Agnes's  Ward. 

The  latter  was  a  strong  and  vigorous  individual,  a  worker  in  lead,  who, 
when  admitted  as  a  patient  at  the  Hotel-Dieu,  was  complaining  of  colic. 
I  then  observed  in  the  edges  of  the  gums  a  bluish  line,  which  seemed 
clearly  to  show  that  he  was  suffering  from  saturnine  symptoms.  He  lay 
on  his  back,  and  did  not  seem  to  experience  the  slightest  degree  of  oppres- 
sion. On  feeling  the  abdomen  with  the  hand,  I  detected  in  the  right  side 
a  movable  tumor,  which  descended  as  low  down  as  the  iliac  fossa.  At 
first,  I  supposed  that  it  was  composed  of  an  accumulation  of  fecal  matter 
in  the  colon.  The  patient  made  no  complaint  of  any  thoracic  symptoms. 
On  examining  the  chest,  however,  I  was  surprised  to  find,  on  percussion, 
complete  dulness  from  the  base  to  the  top  of  the  left  lung,  even  up  to  the 
clavicle  and  to  the  summit  of  the  infraspinous  fossa  of  the  scapula.  The 
heart  was  squeezed  to  the  right,  and  was  beating  beyond  the  sternum,  even 
under  the  right  nipple:  the  abdominal  tumor  was  the  pressed  down  spleen. 
I  heard  no  respiratory  sound. 

There  was,  therefore,  nothing  in  the  case  to  lead  one  to  suspect  the  pres- 
ence of  the  enormous  effusion  which  existed,  except  the  physical  signs  fur- 
nished by  auscultation  and  percussion.  Although  the  man  did  not  seem 
at  all  inconvenienced,  I  thought  it  necessary  to  perform  paracentesis  :  and 
I  operated  next  morning.  I  withdrew  more  than  3500  grammes  [upwards 
of  3*  quarts]  of  serosity,  perfectly  limpid  and  yellowish.  In  endeavoring 
to  elucidate  the  previous  history  of  the  case,  I  ascertained  that  the  effusion 
had  begun  six  weeks,  or  two  months  previously.  The  patient  recollected 
that  he  had  had  a  chill  at  that  period  :  he  also  remembered  to  have  then 
had  a  slight  stitch  in  the  side,  and  some  cough  :  but  these  symptoms  did 
not  prevent  him  from  continuing  his  usual  routine.  In  this  case,  recovery 
took  place  rapidly  ;  and  some  days  after  the  operation  the  patient  left  the 
hospital. 

Some  time  afterwards,  my  chef  de  clinique,  Dr.  Moynier, had  occasion  to 
tap  the  chest  of  a  lad  of  thirteen  and  a  half  years  of  age,  who,  though  he 
had  more  than  two  litres  of  serious  fluid  effused  into  the  pleural  cavity,  did 
not  appear  to  be  embarrassed  in  his  breathing. 

At  the  beginning  of  April,  this  lad  had  suffered  in  health  from  hard 
work.  The  sanitary  derangement  consisted  in  a  gastric  affection,  which 
yielded  to  rest  and  a  purgative.  Recovery,  however,  was  not  complete : 
the  patient  retained  slight  feelings  of  discomfort,  and  had  not  his  usual 
vivacity. 

On  the  22d  April,  he  took  cold  from  remaining  inactive  in  a  room  on 
the  ground  floor;  and  in  the  evening,  he  had  an  attack  of  rigors,  which 
was  repeated  on  two  successive  days.  He,  at  the  same  time,  felt  a  pain  in 
the  right  side  of  the  chest,  which  afterwards  affected  also  the  left  side 
going  up  as  high. as  the  shoulder.  He  had  tits  of  coughing,  unaccompa- 
nied by  expectoration. 

He  nevertheless  continued  his  habitual  occupations,  doing  everything  as 
usual,  assisting  his  mother  in  the  household  work,  and  having  his  ordinary 
appetite.     So  little  did  lie  feel  any  difficulty  in  breathing,  that  on  the  Lei 

May,  he  carried  two  pails  of  water  up  to  the  fourth  floor  of  the  house,  and 

six  days  later  he  walked  to  the  Madeleine  and  hack  to  his  residence  in  the 
line  Lafayette. 
On  the  7th  May — the  day  after  this  walk — he  consulted  Dr.  Burq.     lie 

then    complained    of  having   had  little   inclination  for  food  for  four   or  five 

days.      He  was  distressed  by  lit>  of  coughing,  which  had  latterly  been  more 


pleurisy:   paracentesis  of  the  chest.  615 

frequent,  and  by  transient  attacks  offerer  coming  on  in  the  evening,  which, 
when  over,  allowed  him  to  Bleep  quietly  all  night. 

Dr.  Burq  having  discovered  that  there  was  a  large  amount  of  effusion  on 
the  left  side  of  the  chest,  brought  the  patient  to  me.  I  perceived  consider- 
able arching  of  the  walls  of  the  chest.  The  ribs  were  raised  up,  and  the 
intercostal  spaces  were  flattened.  There  was  an  absence  of  thoracic  vibra- 
tion ;  behind,  absolute  dulness  existed  from  the  base  of  the  chest  up  to  the 
infraspinous  fossa,  and  in  front  up  to  the  clavicle :  no  respiratory  sound 
could  be  heard.  On  the  right  side,  the  vesicular  murmur  was  exaggerated. 
The  apex  of  the  heart  was  felt  to  beat  below  and  to  the  outside  of  the  right 
mamma. 

Tapping  appeared  to  me  not  only  to  be  indicated,  but  to  be  urgently  re- 
quired. I  sent  the  lad  to  Dr.  Moynier,  who  wished  to  be  intrusted  with 
the  operation.  Two  litres  of  lemon-yellow  serosity  flowed  from  the  canula. 
As  generally  happens — as  I  shall  afterwards  have  to  tell  you — whilst  the 
chest  was  being  emptied,  the  patient  was  seized  with  constant  fits  of  cough  : 
towards  the  end  of  the  evacuation,  the  fluid  changed  its  character,  first  be- 
coming tinged  with  blood,  and  then  becoming  quite  bloody.  This  is  an 
occurrence  wdiich  I  shall  have  to*  point  out  to  you,  when  speaking  of  the 
phenomena  which  accompany  paracentesis. 

Proportionally  as  the  fluid  flowed  from  the  chest,  the  heart  resumed  its 
place  below  the  left  mamma :  sound  on  percussion,  and  also  the  vesicular 
murmur,  returned  to  the  affected  side.  After  the  operation,  he  had  a  ten- 
dency to  syncope  :  and  till  the  evening,  he  had  a  succession  of  coughing  fits. 

oSText  day,  the  state  of  the  patient  was  satisfactory  :  there  was  still  a  little 
dulness  in  the  lower  part  of  the  left  side  of  the  chest ;  and  on  that  side,  res- 
piration was  feeble.     In  seven  days,  recovery  was  complete. 

To  sum  up:  When  the  oppression  is  a  sign  in  addition  to  the  physical 
signs  furnished  by  auscultation  and  percussion,  it  has  an  important  signifi- 
cation ;  but  its  absence  ought  not  to  inspire  too  great  a  feeling  of  security  ; 
for  by  refraining  from  interference,  we  run  the  risk  of  losing  patients  whom 
the  operation  would  assuredly  have  saved.  It  is  from  auscultation,  and 
still  more  from  percussion,  that  we  must  derive  our  most  positive  indications 
as  to  the  opportune  moment  for  performing  paracentesis  of  the  chest. 

Gentlemen,  I  now  come  to  speak  of  what  pertains  to  the  operation  itself. 

In  consideration  of  the  details  into  which  I  entered  when  tracing  the 
history  of  the  question,  I  need  now  give  only  a  very  brief  account  of  the 
mode  of  operating. 

Given — an  acute  pleuritic  effusion,  for  which  it  has  beefl  decided  to 
operate :  How  ought  paracentesis  to  be  performed  ? 

I  have  already  told  you,  that  for  a  long  time  a  very  exaggerated  idea 
was  entertained  of  the  danger  of  allowing  air  to  enter  the  pleural  cavity. 
It  was  at  one  time  supposed  that  the  entrance  of  a  few  bubbles  of  air  into 
the  chest  would  be  sufficient  to  cause  death,  the  notion  being  that  the  con- 
tact of  the  effused  fluid  with  the  atmospheric  air  would  lead  to  a  sort  of 
putrid  fermentation.  I  told  you  that  surgeons,  with  a  view  to  prevent  this 
danger,  had  invented  different  apparatuses;  and  in  particular  I  spoke  to 
you  of  the  instrument  of  Schuh.  The  instrument  contrived  by  Recamier, 
constructed  on  Schuh's  principle,  is  also  upon  the  plan  of  having  a  valve 
adapted  to  the  beak  of  the  canula  of  the  trocar.  This  valve,  kept  in  its 
place  by  the  pressure  of  a  spring,  and  covei*ed  with  a  bit  of  leather,  exactly 
resembling  the  key  of  a  flute,  is  accurately  applied  to  the  orifice  of  the 
instrument,  and  can  only  be  raised  by  pressure  from  within  proceeding 
outwards.     Ingenious  though  this  apparatus  was,  much  less  complicated 


616  pleurisy:   paracentesis  of  the  chest. 

though  it  was  than  Schuh's  instrument,  it  nevertheless  presented  inconve- 
niences, not  the  least  of  which  was  its  not  being  within  the  reach  of  all 
practitioners.  The  apparatus  of  M.  Reybard,  from  its  extreme  simplicity, 
offered  every  advantage:  I  have  explained  to  you  this  apparatus:  it  is  that 
which  you  have  seen  me  use,  and  which  is  employed  at  the  present  day  by 
all  operators. 

Let  me  remark,  however,  that  in  the  cases  in  which  M.  Reybard  believed 
it  to  be  useful,  I  generally  do  without  it.  It  was  especially  for  the  evacua- 
tion of  purulent  accumulations  that  the  surgeon  of  Lyons  considered  para- 
centesis of  the  chest  necessary.  In  such  cases,  the  introduction  of  air  into 
the  pleural  cavity  is  an  almost  inevitable  occurrence,  and  one  moreover 
regarding  which  no  anxiety  need  be  entertained  ;  because  in  the  treatment 
of  empyema,  the  canula  is  sometimes  allowed  to  remain  in  the  chest,  and 
because  in  any  case  a  fistula  is  formed,  which  establishes  a  communication 
between  the  pleural  cavity  and  the  external  air. 

When  the  effusion  is  serous,  M.  Reybard's  canula  is  unquestionably  use- 
ful :  in  such  cases,  indeed,  it  is  indispensable.  I  am  speaking,  observe,  of 
M.  Reybard's  canula,  and  not  of  his  method  of  operating ;  for  the  latter  is 
far  from  presenting  the  same  simplicity  as  the  former.  Here  is  his  opera- 
tion as  described  by  himself  in  his  memoir  published  in  the  Gazette  Mcdi- 
cale  for  the  16th  and  25th  January,  1841 :  The  chest  is  penetrated,  either 
through  an  intercostal  space,  by  an  incision  with  a  bistoury,  or  by  boring 
a  hole  in  one  of  the  ribs  by  a  gimlet,  a  very  old  practice  winch,  according 
to  M.  Reybard,  affords  great  facility  for  more  securely  fixing  the  canula, 
when  it  has  to  remain  in  its  place  for  a  long  time.  The  incision  in  the  soft 
parts  ought  to  be  very  free,  but  it  is  specially  important  to  make  the  open- 
ing in  the  pleura  no  larger  than  is  necessary  for  the  admission  of  the  canula. 
As  soon  as  the  opening  has  been  made,  both  lips  of  the  wound  in  the  skin 
have  to  be  seized  between  the  thumb  and  index  finger  of  the  left  hand, 
while  with  the  right  hand,  the  operator  introduces  the  trocar  armed  with  a 
piece  of  sticking-plaster.  All  these  proceedings  W'ere  necessary,  in  the 
opinion  of  the  surgeon  of  Lyons,  to  prevent  the  entrance  of  air  into  the 
pleural  cavity.  He  also  gives  a  caution  not  to  push  in  the  instrument  too 
far,  lest  the  lung  be  grazed ;  and  to  protect  the  lung  from  being  wounded, 
he  says  that  the  extremity  of  the  canula  ought  to  be  rounded. 

Such  is  the  operative  proceeding  recommended  by  M.  Reybard  in  cases 
of  empyema — in  cases  in  which  there  is  a  collection  of  pus.  If  it  be  a  fact 
that  one  can  dispense  with  taking  so  much  precaution,  this  mode  of  oper- 
ating is  not  only  useless  but  exceedingly  dangerous  in  cases  of  simple  pleu- 
ritic effusion,  for  it  involves  the  risk  of  transforming  the  simple  pleurisy 
into  hydropneumothorax  and  empyema.  In  point  of  tact,  gentlemen,  ere 
the  canula  has  been  twenty-four  hours  in  the  wound,  it  has  acted  as  a 
foreign  body,  producing  inflammation  of  the  skin,  cellular  tissue,  and 
pleura,  in  the  neighborhood  of  the  opening  made  fur  it :  moreover,  during 
the  efforts  of  inspiration  and  expiration,  notwithstanding  every  care  taken 
t"  prevent  it,  the  air,  pressing  along  the  sides  of  the  canula,  enters  the 
pleural    cavity:    scarcely   have   a,    few  days  elapsed,  when    it    is    found    that 

there  is  hydropneumothorax,  and  that  the  serous  fluid  in  the  pleura  re- 
cently so  limpid,  has  become  fetid  and  purulent.  It  was  to  avoid  in  part 
this  inconvenience,  that  M.  Reybard  tried  to  restore  to  favor  (he  plan  of 
perforating  a  rib:  hut  he  did  not  avert — he  only  retarded  the  danger.  The 
method  of  operating  which  1  have  recommended,  and  which  Is  now  univer- 
sally adopted,  besides  being  simple,  is  free  from  danger. 
Tin'  only  instrumtnts  which  are  indispensable  are  in  the  hand-  of  all 

medical    men;   viz.,  a   bistoury,  or  heller  still  a  lancet,  which    is   much    LeSB 


pleurisy:    paracentesis  of  the  chest.  017 

alarming  to  the  patient,  to  make  the  little  Incision,  which  need  only  involve 
the  skin — and  a  common  trocar  such  as  is  used  in  puncturing  the  abdomen, 
or  a  hydrocele.  The  lips  of  the  trocar  are  surrounded  with  gold-beater's 
skin,  which  is  softened  by  being  wetted.  When  gold-beater's  skin  cannot 
be  obtained,  a  piece  of  the  intestine  of  a  fowl,  rabbit,  or  cat,  a  bit  of  blad- 
der, or  a  condom  will  serve  the  purpose.  After  tying  the  membranous 
tube  to  the  instrument,  by  means  of  a  thread,  a  trial  is  made  of  the  work- 
ing powers  of  this  sort  of  valve  by  drawing  in  and  blowing  out  alternately 
through  the  extremity  of  the  canula  opposite  that  which  has  the  lips. 
Finally,  there  is  required  a  piece  of  English  court-plaster,  or  diachylon 
plaster,  cut  in  the  form  of  a  Maltese  cross,  wherewith  to  close  the  wound 
after  the  operation. 

At  present  there  is  a  discussion  as  to  the  particular  point  where  the  punc- 
ture ought  to  be  made.  The  question  is — What  is  the  preferable  place  for 
performing  paracentesis  of  the  chest? 

The  place  which  I  select  is  (counting  from  above  downwards)  the  sixth 
or  seventh  intercostal  space,  nearly  four  or  five  centimetres  external  to  the 
outer  edge  of  the  pectoralis  major. 

The  patient  being  placed  in  a  half-sitting  position  on  the  edge  of  his  bed, 
the  trunk  supported  by  pillows,  an  assistant  is  intrusted  with  supporting  the 
opposite  side  of  the  chest  in  such  a  way  as  to  resist  the  involuntary  recoil 
of'  the  patient,  which  is  apt  to  occur  as  the  trocar  penetrates  the  pleura. 
With  the  left  hand  the  operator  renders  the  skin  very  tense,  and  then,  with 
the  lancet  held  in  the  right  hand,  he  makes  a  puncture  in  the  skin — only 
in  the  skin — no  larger  than  is  requisite  for  the  admission  of  the  trocar. 
This  preliminary  puncture  is  necessary ;  for  in  this  respect  thoracic  is  different 
from  abdominal  paracentesis.  In  the  latter  there  is  no  objection  to  making 
the  perforation  by  one  act,  because  the  abdominal  walls  are  wholly  composed 
of  soft  parts;  but  in  paracentesis  of  the  chest  it  is^ssential  to  facilitate  the 
introduction  of  the  instrument  in  the  manner  I  have  now  described,  other- 
wise you  may  incur  the  risk  of  striking  the  ribs  with  the  trocar,  from 
the  patient,  influenced  by  the  painful  sudden  contact  of  the  instrument, 
curving  the  chest  inwards,  and  so  diminishing  the  extent  of  the  intercostal 
spaces  by  approximating  the  ribs.  Thei'e  is  no  risk  of  this  occurring  if  the 
preliminary  penetration  of  the  skin  be  accomplished  in  the  manner  I  have 
pointed  out.  AVhen  the  skin  has  been  penetrated,  you  introduce  the  point 
of  the  trocar  within  the  little  wound,  and  then,  with  a  bloodless  push,  you 
easily  get  the  instrument  through  the  muscles  and  into  the  thoracic  cavity. 

Formerly  I  used  to  recommend  another  manoeuvre,  which,  latterly,  I 
have  felt  to  be  quite  superfluous.  With  the  view  of  avoiding  every  chance 
of  the  introduction  of  air  into  the  chest,  I  believed  that  it  was  necessary 
that  the  external  and  internal  openings  should  not  be  parallel.  To  accom- 
plish this  object,  I  punctured  the  skin  below  the  intercostal  space  through 
which  I  had  to  penetrate,  and  then  forcibly  drew  the  skin  upwards,  so  as 
to  make  my  little  wound  in  the  skin  correspond  with  the  intercostal  space. 
As  soon  as  the  operation  was  completed,  the  parts  resumed  their  natural 
position,  the  parallelism  between  the  two  openings  ceasing.  But  long  ago 
I  perceived  that  these  precautions  were  unnecessary :  the  parallelism  is 
naturally  destroyed  by  a  mechanism  which  is  easily  understood.  When 
the  chest  is  distended  by  a  great  quantity  of  fluid,  the  ribs  and  intercostal 
spaces  are  in  the  same  position  in  which  they  are  placed  by  a  forced  inspi- 
ration, and  have  necessarily  the  relative  situation  which  they  have  to  the 
internal  integument  when  in  a  state  of  repose:  their  play  is  under  the  skin, 
which  does  not  follow  their  movements.  Consequently,  after  the  puncture, 
and  after  the  evacuation  of  the  fluid,  the  chest  nearly  or  wholly  regaining 


618  PLEURISY:     PARACENTESIS    OF    THE    CHEST. 

its  normal  amplitude,  the  ribs  and  intercostal  spaces  sink  down,  and,  as  the 
integument  is  not  displaced,  the  result  is  that  the  parallelism  between  the 
cutaneous  wound  and  the  pleural  opening  is  destroyed.  Of  course  it  is  not 
so  completely  destroyed  as  when  my  former  little  manoeuvre  is  adopted; 
but  there  is  no  necessity  that  it  should  be  destroyed :  and  indeed,  when  the 
effusion  is  purulent,  want  of  parallelism  between  the  two  openings  is  an  evil. 

You  understand,  of  course,  that  I  am  not  now  speaking  of  those  cases  in 
which  it  is  necessary  to  leave  a  canula  in  the  wound.  Want  of  parallelism, 
which  takes  place  spontaneously,  would  in  such  a  case  be  a  complication; 
and,  besides,  there  can  be  very  little  use  in  endeavoring  to  prevent  the 
entrance  of  air  during  the  operation,  when  it  will  generally  enter  of  neces- 
sity by  the  canula  at  a  later  stage.  I  at  present  only  refer  to  cases  of  acute 
purulent  effusion  treated  by  simple  puncture.  In  such  cases,  I  say  that  a 
too  absolute  want  of  parallelism  might  lead  to  troublesome  consequences. 
Generally  after  seven,  eight,  ten,  or  fifteen  days,  a  new  purulent  secretion 
has  taken  place,  and  then  the  pus  discharges  by  the  wound,  which  opens 
spontaneously,  as  you  saw  occur  in  a  female  patient  who  occupied  bed  25 
of  St.  Bernard's  Ward.  If,  then,  the  opening  in  the  pleura  does  not  in  any 
way  correspond  with  that  in  the  skin,  the  pus  will  burrow  sinuously  under 
the  integuments,  causing  separation  of  tissues  and  fistula?  difficult  of  cure. 

Let  us  now  revert  to  the  operation  itself.  The  trocar  has  penetrated  the 
pleural  cavity — a  fact  ascertained  by  feeling  that  its  point  can  be  moved 
about  freely  in  a  hollow  space  :  the  stylet  is  withdrawn,  care  being  taken  to 
open  out  the  membrane,  temporarily  folded  round  the  handle  of  the  instru- 
ment, which  has  to  serve  as  a  valve:  the  membrane  must  be  unfolded  in 
such  a  manner  as  to  secure  the  valvular  actiou  which  it  is  meant  to  perform. 
On  the  withdrawal  of  the  stylet,  the  fluid  at  first  flows  slowly,  then  in  a 
continuous  jet,  and  at  last  in  jerking  gushes  :  I  shall  afterwards  explain  to 
you  the  cause  of  these  differences  in  the  modes  of  flowing.  During  expira- 
tion, the  membrane  is  raised  up  by  the  outflowing  matter ;  and  during  in- 
spiration, it  rests  in  exact  apposition  on  the  grooved  expansion  of  the  canula. 
When  the  flow  stops,  when  the  wished-for  quantity  of  fluid  has  been  ob- 
tained, the  instrument  is  withdrawn  by  a  quick  movement:  the  little  drops 
of  serosity  and  of  blood  are  wiped  from  the  small  wound,  and  the  Maltese 
cross  of  court  plaster,  or  of  diachylon  plaster,  is  applied  to  it,  when  thus 
freed  from  moisture. 

You  will  no  doubt,  gentlemen,  meet  with  an  occurrence  which  has  two 
or  three  times  happened  to  me,  and  which  you  have  witnessed  in  our  wards. 
On  withdrawing  the  stylet,  or  on  your  attempting  to  do  so,  not  a  drop  of 
fluid  passes  through  the  canula,  or  if  there  be  any  flow,  it  is  very  small. 
This  is  an  accident  for  which  you  ought  to  be  prepared  ;  for  you  can  under- 
stand that  its  occurrence  will  occasion  you  disappointment  and  annoyance. 
You  have  in  a  positive  manner  convinced  yourself  thai  there  iseffusion  into 
the  pleura:  mensuration  and  percussion  of  the  chest  have  demonstrated  to 
you  that  the  quantity  of  effusion  is  great  :  you  have  announced  to  the  rela- 
tions that   you  are  about   to  draw  oil'  three  litres  of  water    from  the  chest  : 

you  introduce  the  trocar,  and  not  a  drop  comes!  How  is  this  to  be  ex- 
plained ? 

Suppose  a  physician  performed  paracentesis  lor  the  first  time.  His  diag- 
nosis is  precise:  hi'  bas  accurately  ascertained  the  position  of  the  thoracic 

viscera:  he  has  felt  and  heard  the  pulsation.-  of  the  apex  of  the  heart  :  he 
has  marked  the  limits  of  the  space  occupied  by  that  organ;  and  still,  he 
cannot  divest  himself  of  a  certain  amount  of  misgiving,  Even  when  the 
effusion  is  on  the  righl  side,  when  the  heart  is  consequently  remote  from 
the  point  where  the  puncture  has  to  he  made,  he  hesitates:  though  he  would 


pleurisy:   paracentesis  of  the  chest.  619 

operate  boldly  if  he  bad  to  perform  abdominal  paracentesis — a  more  dan- 
gerous operation  than  thoracic  paracentesis — he  stays  his  hand;  and  here 
is  what  may  be  the  result  of  this  hesitation. 

The  costal  pleura  is  sometimes  lined  by  layers  of  false  membrane,  -which 
may  perhaps  be  a  centimetre  in  thickness.  During  the  first  eight,  ten  or 
fifteen  days  of  the  pleurisy,  this  pseudo-membranous  layer  does  not  adhere 
firmly  to  the  costal  pleura,  and  offers  such  an  amount  of  resistance  that 
there  is  difficulty  in  tearing  it.  In  timidly  puncturing  the  chest,  in  place 
of  piercing  right  through  this  layer,  the  trocar  raises  it  up  in  such  a  manner 
as  to  form  an  accidental  cavity  between  the  false  membrane  and  the  walls 
of  the  chest.  If,  with  a  view  to  ascertain  the  cause  of  the  obstacle  to  the 
flow  of  the  liquid,  a  probe  is  introduced  through  the  canula,  a  resisting 
body  is  felt,  which  follows  the  movements  of  inspiration  and  expiration  : 
under  these  circumstances,  the  operator  cannot  get  rid  of  the  idea  that  he 
has  come  upon  the  lung,  and  though  convinced  of  the  accuracy  of  his  diag- 
nosis, the  frightened  physician  dare  not  continue  the  operation. 

It  is  necessary  in  such  cases,  to  endeavor  to  tear  the  false  membrane,  by 
using  the  perforator  of  the  trocar,  introduced  through  the  canula,  and 
pushed  in  more  deeply,  or  by  using  a  probe  or  a  crochet  needle,  the  latter 
being  an  excellent  instrument  for  the  purpose.  Should  these  attempts  prove 
unavailing,  it  will  be  necessary  to  make  a  new  puncture  in  one  of  the  inter- 
costal spaces  above  that  in  which  the  first  was  made. 

Specially  bear  in  mind,  that  if  it  be  necessary  to  proceed  gently  in  the 
first  stage  of  the  introduction  of  the  trocar,  that  is  to  say,  whilst  the  muscles 
are  being  perforated,  you  must  proceed  quickly  in  the  second  stage,  that  is 
to  say,  after  you  have  perforated  them.  By  holding  your  instrument,  so 
as  to  leave  free  about  three  centimetres,  you  have  nothing  to  fear,  for  your 
own  finger  will  prevent  you  going  farther  than  you  wish.  By  employing 
a  quick  manoeuvre,  the  false  membrane  cannot  fly  before  your  trocar,  and 
you  will  be  certain  to  penetrate  the  pleural  cavity. 

There  are  other  cases  in  which  paracentesis  has  been  performed  accord- 
ing to  rule,  cases  in  which  you  have  unquestionably  penetrated  into  the 
pleural  cavity,  but  in  which  the  effusion  only  flows  drop  by  drop  :  you  have 
then  to  do  with  a  circumscribed,  which  you  must  not  confound  with  an 
encysted,  pleurisy.  The  serous  exudation  is  imprisoned  within  fibrinous 
partitions :  these  encysted  pleurisies  communicate  with  one  another,  or  at 
least  the  fluid  passes  from  one  into  another,  but  it  passes  slowly,  drop  by 
drop.  In  these  cases,  you  must  endeavor  to  destroy,  to  tear,  the  fibrinous 
w7alls,  employing  the  canula,  a  probe,  or  a  crochet  needle ;  and  when  you 
have  done  so,  the  flow  becomes  a  little  more  free.  I  ought  to  add,  gentle- 
men, that  cases  of  this  description  are  not  common. 

Here,  however,  is  a  case,  which  you  will  often  meet  with.  The  canula 
is  in  the  midst  of  the  effusion ;  but  nevertheless,  there  is  no  flow.  That 
depends  upon  the  manner  in  which  the  patient  breathes.  Whether  it  be 
from  a  certain  nervous  feeling,  or  from  a  habit  which  he  has  acquired,  he 
breathes  only  with  the  lung  of  the  healthy  side ;  on  the  other  hand,  the 
lung  of  the  affected  side,  completely  squeezed  up  against  the  vertebral 
column,  contains  no  air,  so  that  there  is  no  pressure  exerted  from  above 
downwards  on  the  fluid  to  promote  its  flow.  The  flow  does  not  begin  till 
the  patient  is  told  to  take  deep  inspirations;  or  better  still,  to  strain  as  if 
at  stool. 

The  effusion  then  gushes  through  the  canula,  and  after  a  certain  time 
dribbles  out,  the  gush  being  resumed  only  when  respiratory  or  straining 
efforts  are  made.  The  glottis  being  closed,  the  air,  which  cannot  escape 
by  the  superior  opening  of  the  windpipe,  continues  to  distend  the  lung; 


620  pleurisy:   paracentesis  of  the  chest. 

the  capacity  of  the  pleural  cavity  being  at  the  same  time  diminished  by 
the  contraction  of  the  expiratory  muscles  and  of  the  diaphragm,  the  effused 
fluid,  solicited  from  all  parts  to  effect  its  exit  by  the  opening  made  into  the 
chest,  escapes  in  jets,  the  spurts  corresponding  with  the  respiratory  move- 
ments and  the  expiratory  efforts. 

The  exertion  of  coughing  produces  similar  results.  Though  at  first  it  is 
necessary  to  ask  the  patient  to  cough,  that  is  soon  not  required.  The  per- 
son who  only  coughed  when  ordered  to  do  so,  at  last  has  frequent  and  in- 
voluntary coughing  fits,  because  the  lung,  which  has  not  breathed  for  a 
long  time,  experiences,  when  the  air  enters  and  opens  up  the  air-vesicles,  a 
sort  of  irritation,  a  sort  of  excitement,  from  coming  in  contact  with  its 
natural  stimulus,  to  which  it  had  become  unaccustomed. 

This  involuntary  cough  may  become  very  violent,  very  frequent,  and  very 
painful,  and  may  resist  all  treatment.  Dr.  D.,  whose  case  I  related  to  you, 
complained  of  experiencing  such  severe  pains  when  the  air  entered  the  chest 
as  made  him  afraid  to  breathe ;  his  respiration  was  short,  jerking,  and 
sobbing ;  and  an  hour  and  a  quarter  elapsed  before  it  calmed  down. 

This  fatiguing  cough  sometimes  did  not  come  on  till  very  late  in  the  day. 
The  pains  which  accompanied  it  seemed  to  me  to  depend  on  the  tearing  of 
the  false  membranes,  by  which  the  lung  was  adherent  to  the  vertebral 
column. 

Besides  being  useful  by  promoting  the  issue  of  the  fluid,  the  exertion  of 
coughing,  the  fits  of  cough,  are  beneficial  by  preventing  syncope,  when  the 
occurrence  of  this  complication  has  to  be  dreaded. 

By  chasing  and  driving  the  blood  to  the  brain,  these  efforts  produce 
a  kind  of  cerebral  plethora,  which  is  antagonistic  to  the  occurrence  of 
syncope. 

Towards  the  completion  of  the  operation,  the  fluid  which  flows  from  the 
canula  generally  presents  changes  of  color.  The  serous  effusion  has  then 
a  red  tinge  from  its  admixture  with  blood,  and  very  frequently  the  fluid 
is  almost  pure  blood.  This  occurred  in  the  young  lad  whose  case  Dr. 
Moynier  published  in  the  Bulletin  General  de  Therapeutique.  I  saw 
the  same  in  a  little  girl,  in  whose  case  I  was  consulted  by  Dr.  Dumout- 
pallier. 

The  patient  to  whom  I  refer  was  a  girl  eight  years  old,  who  neither  coin- 
plained  of  shortness  of  breath  nor  embarrassment  of  breathing,  although 
for  some  time  she  had  difficulty  in  running  or  going  up  a  stair,  and  was 
tired  by  the  least  exercise.  She  said  that  she  had  no  pain  anywhere. 
Nevertheless  she  grew  so  thin,  and  her  appetite  became  so  flagging,  that 
the  mistress  of  the  boarding-school  where  she  was  placed  gave  notice  of  her 
being  an  invalid  to  her  parents,  by  whom  she  was  taken  home. 

At  that  time  the  patient  had  very  evident  dyspnoea,  yet  .-lie  made  do 
complaint  regarding  it.  Inspiration  was  short  and  frequent  :  the  pulse  was 
small,  wiry,  and  very  quick.  There  was  a  small  dry  cough.  On  examin- 
ing the  chest,  one  was  struck  with  the  deformity  of  the  thorax.  On  the 
Left  side,  the  lower  ribs  were  prominent  in  front,  and  described  a  convex 
line  more  elevated  than  that  formed  by  the  corresponding  ribs  on  the  right 
side.     The  intercostal  .-paces  were  obviously  flattened,  an  appearance  which 

was  rendered  more  evident  by  the  emaciation  of  the  child.  Costal  respira- 
tion seemed  to  be  performed   only  on  the   right   side.      The  antero-posterior 

diameter  of  the  chest  was  greater  on  the  lefl  than  on  the  right  side.  The 
apex  of  the  heart  did   nol   beal   under  the  hit   mamma,  but   beneath  the. 

sternum.  When  the  hand  wa-  placed  on  the  trunk,  the  child  at  the  same 
time   being    made   to   speak,  no    thoracic  vibrations  were  felt.      There   was 

absolute  dulness  on  percussion  from  above  downwards,  in  from,  behind, 


pleurisy:   paracentesis  of  the  chest.  621 

and  laterally,  ascending  as  high  as  the  .subclavicular  and  infraspinous  re- 
gions,  and  unaccompanied  in  front  by  any  skodaic  resonance.  On  auscul- 
tation, it  was  found  that  the  respiratory  murmur  was  entirely  absent  from 
the  whole  of  that  side  of  the  chest ;  but  above,  along  the  vertebral  column, 
in  a  space  consequently  corresponding  to  the  bifurcation  of  the  bronchi, 
a  blowing  sound  and  vocal  resonance  were  heard.  On  the  left  side  there 
was  exaggerated  resonance  on  percussion,  with  respiration  puerile  and  sup- 
plementary, without  rales  or  other  abnormal  sounds.  There  was  evidently 
extensive  pleuritic  effusion  on  the  left  side. 

Dr.  Duinontpallier,  thinking  that  paracentesis  was  indicated,  asked  me 
to  see  the  case  in  consultation  with  him.  There  was  no  room  for  hesita- 
tion :  I  forthwith  performed  the  operation.  It  occasioned  little  pain.  The 
fluid  evacuated  was  a  perfectly  limpid  serosity,  which  at  first  was  of  a  green- 
yellow,  and  towards  the  end  of  the  flow  of  a  red  color.  There  were  some 
sanguinolent  stria?  which  fell  to  the  bottom  of  the  vessel,  and  afterwards 
there  came  several  spoonfuls  of  a  serosity  resembling  pure  vermilion 
blood.  I  withdrew  the  canula,  and  closed  the  wound  by  applying  a  piece 
of  diachylon  plaster.    The  quantity  of  fluid  evacuated  weighed  670  grammes. 

The  phenomena  which  followed  the  operation  presented  nothing  worthy 
of  special  mention.  A  perceptible  change  very  quickly  took  place  in  the 
condition  of  the  child.  Ten  days  after  the  tapping,  she  was  sent  to  the 
country,  and  after  a  month's  residence  there,  she  had  regained  her  good 
health.  All  that  remained  of  her  malady  was  flattening  of  the  chest  on 
the  affected  side,  and  this  was  showing  a  visible  tendency  to  diminish. 

The  cause  of  the  flow  of  blood  may  be  lesion  of  the  small  vessels  which 
enter  into  the  structure  of  false  membranes  which  are  becoming  organized. 
The  false  membranes  are  torn  by  coughing,  and  by  the  expansion  of  the 
lung ;  and  to  their  laceration  so  caused,  we  must  attribute,  not  only  the 
slight  hemorrhage  nowT  under  consideration,  but  also,  as  I  have  already 
remarked,  the  pains  (sometimes  pretty  acute)  of  which  patients  complain 
— pains  also,  in  part,  the  consecpience  of  irritation  of  the  bronchial  tubes 
from  the  contact  of  air  by  which  they  have  been  long  untraversed.  The 
flow  of  blood  may  also  be  explained  by  supposing  that,  at  the  time  wdien 
the  lung  opens  out,  the  pleura,  intimately  united  to  the  false  membranes, 
is  separated  at  some  points  from  the  lung  or  from  the  ribs,  in  such  a  vio- 
lent wray  as  to  tear  some  of  its  vessels. 

The  fluid  evacuated  from  the  pleural  cavity,  on  cooling  in  the  vessels  in 
which  it  has  been  collected,  forms  into  a  jelly.  In  the  more  active  pleu- 
risies, it  is  very  limpid,  and  presents  a  greenish-yellow  color :  and  in  such 
cases,  it  is  not  unusual  to  find  it  some  hours  after  cooling  with  a  rosy  tint 
due  to  the  globules  of  blood  which  it  contains,  and  presenting  an  appear- 
ance which  may  be  most  appropriately  compared  to  slightly  tinted  white 
gooseberry  jelly. 

During  the  operation,  and  as  soon  as  a  certain  quantity  of  fluid  has  been 
evacuated,  a  change  takes  place  in  the  plessimetric  and  stethoscopic  phe- 
nomena. There  is  a  return,  from  above  downwards,  of  the  resonance  on 
percussion  ;  and,  at  the  same  time,  on  applying  the  ear  to  the  chest,  the 
sound  of  vesicular  expansion  is  heard,  first  at  the  summit  of  the  lung 
before  and  behind,  and  then  progressively  throughout  the  whole  extent  of 
the  diseased  side.  This  pulmonary  expansion  is  accompanied  by  mucous 
and  subcrepitant  rales,  produced  by  the  passage  of  the  air  into  the  vesicles, 
which  contain  mucus  secreted  by  the  surface  of  the  bronchial  tubes,  and 
also  by  the  unfolding  of  these  vesicles.  This  unfolding  sometimes  gives 
rise  to  true  crackling. 

There  has  been  discussion  as  to  whether  it  is  advantageous  to  evacuate 


622  PLEURISY:    PARACENTESIS    OF    THE    CHEST. 

at  once  the  fluid  effused  into  the  pleura]  cavity.  I  do  not  understand  why 
any  inconvenience  should  result  from  doing  so  ;  and,  for  my  own  part,  have 
never  seen  the  slightest  danger  from  the  proceeding.  The  only  undesirable 
occurrences  which  I  have  observed  have  been  the  pains  and  the  hemor- 
rhages of  which  I  have  spoken— accidents  of  no  special  seriousness.  I 
believe,  indeed,  that  there  is  a  great  advantage  in  emptying  the  chest  as 
completely  as  possible,  as  this  is  the  best  means  of  putting  the  lung  into 
favorable  conditions  for  expanding  freely,  and  consequently  of  expediting 
the  cure. 

You  perceive,  gentlemen,  that  the  shorter  the  period  during  which  the 
fluid  remains  in  the  pleural  cavity,  and  the  more  complete  is  its  removal, 
the  greater  will  be  the  power  of  expansion,  because  the  lung  is  entirely 
obedient  to  the  pressure  exerted  upon  it  by  the  air,  which  entering  by  the 
trachea,  fills  the  bronchi  and  their  ramifications,  even  to  the  vesicles. 
Besides,  when  we  possess  a  means  of  cure  so  prompt,  and  so  free  from  dan- 
ger, why  should  we  wait  ?  I  am  well  aware  that  the  physicians  who,  con- 
trary to  my  view,  think  that  a  part  only  of  the  fluid  ought  to  be  evacuated, 
base  their  opinion  on  the  belief  that  in  paracentesis  of  the  chest,  as  in 
paracentesis  of  the  abdomen,  either  a  too  rapid  or  too  abundant  subtrac- 
tion of  the  fluid  may  induce  syncope. 

This  remark  leads  me  to  speak  of  the  objections  which  have  been  urged 
against  paracentesis  of  the  chest. 

It  has  been  said  that  as  syncope  may  supervene  during  Or  after  the  opera- 
tion, it  is  an  accident  against  which  precautions  ought  to  be  taken.  With- 
out entering  into  a  theoretical  discussion  on  the  point,  I  shall  answer  the 
objection  by  a  statement  of  facts.  Since  I  first  performed,  and  have  seen 
performed,  paracentesis  of  the  chest  in  cases  of  pleurisy,  I  have  neither 
heard  quoted,  nor  have  I  read,  the  history  of  any  case  in  which  this  com- 
plication is  mentioned.  I  admit  that  I  once  saw  syncope  supervene ;  but 
the  occurrence  took  place  under  very  peculiar  circumstances,  and  not  im- 
mediately after  the  operation.  The  case  is  so  interesting,  that  I  shall  give 
you  a  full  account  of  it. 

During  the  autumn  of  1848,  I  was  called  in  by  Dr.  Bonnassies  to  M.  L., 
living  at  Paris,  19  Quai  Bourbon,  in  the  Isle  St.  Denis.  M.  L.  had 
been  gouty  from  his  youth.  So  strongly  marked  in  him  was  the  gouty" dia- 
thesis, that  in  addition  to  the  chalky  tophus  which  deformed  all  the  joints, 
tophaceous  concretions  existed  in  the  thickness  of  the  skin  of  the  hands  and 
feet,  to  such  a  degree  that  the  skiu  of  these  parts  had  the  appearance  of  the 
internal  surface  of  an  aorta  studded  with  ossific  points.  Two  months  pre- 
viously M.  L.  had  been  attacked  by  pleurisy  on  the  left  side.  The  affected 
Bide  was  entirely  filled  with  effusion,  the  heart  and  diaphragm  being  pushed 
out  of  place.  For  several  nights,  he  had  had  suffocative  paroxysms,  lead- 
ing to  the  dread  of  imminent  death.  As  these  attacks  of  dyspnoea  super- 
vened on  the  slightest  movement,  it  was  necessary  for  the  patient  to  lake 
very  careful  precautions  when  he  made  water  or  went  to  stool. 

Paracentesis  was  decided  on,  and  was  performed.  The  operation  pre- 
sented this   special  feature,  that  at  each    COUgh  the  lung   struck    againsl   the 

canula.  I  evacuated  2200  grammes  of  a  purely  limpid  lemon-colored  86- 
rosity.     The  lung  unfolded;   ami  immediately  after  the  operation,  there 

was  heard,  in  the  whole  of  the  left  side,  I  he  respira lory  murmur,  mingled 
with  some  mucous  and   sulicrepilant   rales.      I  ought,  however,  to   state  that 

the  opening  out  of  the  lung  was  exceedingly  painful:  the  pain  continued 

till  the  following  morning.  M.  L.  declared  thai  he  was  familiar  with  that 
sensation:    that  it  differed    in  no    respect    from    that  which    he   experienced 

when  the  gout  invaded  the  thoracic  walls.    There  was  high  fever;  hut  there 


pleurisy:   paracentesis  of  the  chest.  G23 

was  no  return  of  the  effusion,  and  the  rales  were  coarser.  There  was  do 
symptom  which  foreboded  a  fatal  termination. 

M.  L.  was  a  man  of  very  violent  temper.  Notwithstanding  my  formal 
orders  to  the  contrary,  he  left  his  bed  to  go  to  stool.  He  got  up,  took  some 
steps,  then  sat  down  on  the  convenience,  and  after  some  minutes  spent  in  un- 
availing efforts  he  returned  to  bed.  Again  he  tried,  but  fruitlessly.  He  felt 
great  oppression  of  the  breathing.  But  he  declared  that  he  should  make 
one  more  attempt.  Neither  the  advice  nor  the  entreaties  of  his  family 
availed  to  induce  him  to  desist.  He  resolutely  got  out  of  bed,  sat  on  the 
night-stool,  where  for  some  time  he  made  new  and  unavailing  efforts  ;  he 
then  regained  the  side  of  his  bed ;  and  when  attempting  to  step  in,  he 
expired. 

When  we  consider  this  case  in  an  impartial  manner,  we  cannot  impute 
death  to  the  paracentesis ;  indeed,  we  may  say  that  the  fatal  issue  would 
have  occurred  sooner,  if,  before  the  operation,  the  patient  had  been  placed 
in  the  same  physical  and  moral  conditions. 

Syncope,  then,  is  a  very  rare  accident  as  a  consequence  of  paracentesis  of 
the  chest,  judging  by  the  published  accounts  of  cases  in  which  this  opera- 
tion has  been  performed,  and  by  the  numerous  cases  which  I  have  seen. 
No  doubt  it  may  occur,  but  when  it  does  occur,  is  it  to  be  attributed  to  the 
paracentesis?  Ought  it  not  rather  to  be  attributed  to  the  circumstances, 
to  the  organic  conditions,  which  necessitated  surgical  interference,  and 
which  are  not  always  immediately  altered  by  the  removal  of  the  fluid  from 
the  chest? 

To  avoid  the  risk  of  this  complication,  which  may  prove  fatal,  the  pa- 
tients ought  to  be  recommended  to  give  both  body  and  mind  the  greatest 
possible  amount  of  repose  after  the  operation.  The  same  advice,  however, 
is  necessary  when  there  exists  a  large  amount  of  effusion,  particularly  if  it 
has  displaced  the  heart  and  large  vessels. 

When  I  communicated  the  case  I  have  now  laid  before  you  to  my  col- 
leagues of  the  Medical  Society  of  the  Hospitals,  one  of  them  asked  whether 
the  sudden  death  might  not  be  attributed  to  rupture  of  the  pulmonary  vesi- 
cles, and  the  introduction  of  air  into  the  veins.  To  that  question,  I  would 
reply  that  this  alleged  rupture  was  either  very  late  in  occurring,  inasmuch 
as  death  did  not  take  place  till  the  day  after  the  operation ;  or,  that  if  the 
rupture  happened  at  the  time  when  the  fluid  was  evacuated,  it  is  impossi- 
ble to  understand  how  the  entrance  of  air  into  the  veins  should  have  been 
so  long  delayed. 

It  has  been  alleged  that  sanguineous  expectoration  sometimes  follows  the 
coughing  fits  with  which  patients  are  seized  during  the  evacuation  of  the 
effusion.  Cases  of  this  description  have  been  quoted  ;  and  they  have  been 
explained  in  the  following  manner.  The  rapid  unfolding  of  the  lung,  by 
promoting  a  sudden  afflux  of  blood  from  the  pulmonary  and  bronchial 
vessels,  leads  to  congestion  of  the  lung,  of  such  an  active  character  as  to 
rupture  vessels  and  cause  hemorrhage.  I  admit  the  possibility  of  such  an 
occurrence,  although  I  have  never  seen  anything  more  than  a  frothy, 
•  somewhat  rosy,  expectoration  ;  but  I  cannot  accord  to  the  accident  that 
importance  which  the  opponents  of  the  operation  would  seem  to  attach  to  it. 

I  shall  not  stop  longer  at  the  other  objection,  viz.,  that  in  performing 
paracentesis  there  may  be  a  risk  of  wounding  the  intercostal  artery. 

By  making,  with  the  precautions  which  I  have  indicated,  the  puncture 
in  an  intercostal  space,  by,  in  the  first  instance,  incising  the  skin  so  as  to 
enable  the  pleural  cavity  to  be  penetrated  without  an  effort — the  manual 
operation  becomes  exceedingly  simple,  and  much  less  liable  to  mishaps 
than  bleeding  from  the  arm,  or  opening  an  abscess — operations  which  we 


624  PLEURISY:     PARACENTESIS    OF    THE    CHEST. 

nevertheless  intrust  to  the  most  inexperienced.  Who,  I  ask,  has  seen  these 
lesions  of  the  intercostal  artery?  Your  teachers  of  surgery  have  informed 
you  that  in  sword  wounds  this  vessel  is  seldom  injured.  The  anatomical 
disposition  of  the  parts  explains  the  rarity  of  the  occurrence,  for  the  inter- 
costal artery  is  placed  in  the  groove  of  the  bone,  which  circumstance,  and 
the  smallness  of  its  calibre,  protect  it  from  being  wounded.  This,  then,  is 
an  objection  which  spontaneously  falls  to  the  ground. 

This  cannot  be  said  of  other  objections  of  which  I  am  now  going  to  speak. 
Though  they  admit  of  being  very  easily  refuted,  they  are  of  sufficient  im- 
portance to  require  to  be  discussed. 

I  begin  with  the  statement  to  the  effect,  that  the  operation  has  been  useless, 
when  tapping  has  been  performed  for  effusion  in  acute  pleurisy,  and  the  effu- 
sion has  been  reproduced  by  the  continuance  of  the  pleurisy  renewing'  the 
pleuritic  secretion. 

The  possibility  of  the  reproduction  of  the  fluid  cannot  be  denied.  Two 
things  have  to  be  considered  in  pleurisy  with  effusion.  Pleurisy,  properly 
so  called,  inflammation  of  the  pleura,  lasting  for  eight,  ten,  or  fifteen  days; 
and  the  effusion,  which  is  at  first  under  the  influence  of  the  inflammation, 
remains  for  a  longer  or  shorter  period  after  the  inflammation  is  at  an  end, 
just  as  a  collection  of  pus  in  the  cellular  tissue  remains  after  the  inflamma- 
tory condition  which  gave  rise  to  it  has  passed  away.  The  collection  of 
pus,  or  the  serous  effusion,  are  effects,  the  results  of  a  pathological  action 
which  constitutes  phlegmon  or  inflammation  ;  but  they  must  not  be  con- 
founded with  it. 

I  take  for  granted,  that  at  the  time  when  the  excessive  quantity  of  the 
effusion  necessitated  the  operation,  the  pleurisy  still  continued.  To  give 
precision  to  the  question,  let  me  put  a  case  with  figures  :  I  assume  that  the 
pleurisy  has  gone  on  for  twelve  days,  and  that  its  natural  course  will  be  to 
continue  for  three  days  longer :  in  such  a  case,  we  may  possibly  see  the 
resulting  effusion  increased  or  reproduced  during  that  period  ;  but  let  us 
inquire  what  are  the  consequences  of  the  surgical  interference  judged  so 
opportune. 

8uppo.se,  for  example,  that  there  were  three  litres  of  effusion,  and  that 
by  the  tapping  I  evacuated  two  and  a  half.  Suppose,  that  after  the  opera- 
tion, one  litre  was  secreted,  the  remaining  effusion  would  only  be  a  litre 
and  a  half,  only  the  half  of  what  it  was  originally,  a  quantity  which  might 
continue  to  exist  without  causing  the  risks  incident  to  an  excessive  amount 
of  effusion — taking  no  account  of  the  fact,  that  we  should  have  had  not 
three  but  four  litres  of  fluid  in  the  pleural  cavity.  In  place  of  allowing  the 
state  of  the  patient  to-  become  worse,  wo  have  granted  time  to  the  inflam- 
mation to  terminate  without  inducing  accidents  ;  and  also  by  withdrawing 
a  portion  of  the  fluid,  we  have  made  the  absorption  of  the  remainder  a 
more  easy  process. 

Moreover,  gentlemen — to  continue  the  comparison  which  I  have  just 
instituted  between  pleuritic  effusions  and  purulent  collections— pus,  when 
shut  up  iii  its  circumscribed  locality,  becomes  a  source  of  inflammatory 
action,  and  is  then  a  foreign  body  seeking  to  he  eliminated  from  the  living 
parts:  fluid  effused  into  the  pleural  cavity  may  likewise  excite  inflamma- 
tion.    To  put  an  end  to  the  inflammation  occasioned  by  the  presence  of 

pus,  the  besl  thing  which  can  he  done  is  to  open  the  abscess,  and  the  quickesl 

method  of  terminating  an  inflammation  excited  by  pleural  effusion  is  at 

once  to  relieve  the  pleura  from  the  presence  of  the   cause  of  the  inflamma- 
tion.    To  accomplish  this  object,  paracentesis  is  unqestionably  the  tnosl 

expeditious  and  certain  measure  which  can  lie  adopted. 

1  have  no  objection  to  adm.il   thai  effusion  may  he  reproduced  to  -neli  an 


pleurisy:   paracentesis  of  the  chest.  625 

extent  as  to  necessitate  a  repetition  of  the  tapping.  But  whal  objection 
ran  there  be  to  the  repetition  of  an  operation  which  is  bo  absolutely  devoid 

of  da  unci-?  It  has  been  said  that  upon  this  principle,  the  patient,  soon 
exhausted  by  successive  tappings,  must  inevitably  sink  into  marasmus. 
This  inevitability  is,  in  my  opinion,  anything  hut  demonstrated.  We  very 
seldom  require  to  repeat  the  operation  several  times  in  the  same  individual, 
when  the  affection  is  simple  acute  hydrothorax.  Reproduction,  when  it 
does  take  place,  is  never  to  the  extent  of  the  original  effusion  ;  and  gener- 
ally, the  fluid  is  absorbed.  Generally,  a  single  tapping  suffices,  and  it  is 
an  exception  to  the  rule  to  require  to  perform  the  operation  twice  in  the 
same  case.  I  admit,  however,  that  the  effusion  may  be  reproduced  to  such 
an  extent  as  to  necessitate  several  repetitions  of  the  paracentesis.  Why 
should  we  pursue  a  different  plan  in  pleuritic  effusions  from  that  which  we 
adopt  in  ascitic  effusions?  Has  the  quantity  of  fluid  which  we  withdraw 
from  the  pleural  cavity,  relatively  small  as  compared  to  that  which  we  are 
constantly  in  the  habit  of  withdrawing  unhesitatingly  from  the  peritoneum, 
the  special  power  of  debilitating  the  patients  and  plunging  them  in  maras- 
mus? No  one  will  venture  to  say  so.  The  theoretical  objections  to  para- 
centesis are  completely  refuted  by  the  imposing  mass  of  clinical  facts  which 
demonstrate,  to  all  true  practitioners,  the  chimerical  character  of  the  oppo- 
sition which  some  adduce  to  the  operation  I  defend. 

Some  physicians  have  maintained  that  the  duration  of  pleurisy  is  pro- 
longed in  place  of  being  curtailed  by  paracentesis,  the  traumatic  condition 
consecutive  to  tapping  being,  according  to  them,  a  neiv  cause  of  inflammation 
of  the  pleura.  It  is  easy  to  refute  this  objection,  not  only  by  appealing  to 
clinical  facts,  but  likewise  by  referring  to  what  has  been  observed  in  experi- 
ments made  on  animals,  and  to  the  recorded  cases  of  wounds  of  the  chest 
in  the  human  subject. 

When  the  chest  of  an  animal  is  punctured  by  a  pointed  instrument, 
whatever  number  of  punctures  may  be  made,  we  find,  on  killing  and  exam- 
ining the  animal,  nothing  more  than  a  little  effused  blood  in  the  neighbor- 
hood of  the  wounds,  and  traces  of  slight  inflammation,  extending  sometimes 
around  the  wound  to  the  distance  of  half  a  centimetre.  You  are  aware  of 
the  small  amount  of  seriousness  which  attaches  to  wounds  of  the  chest  made 
by  puncturing  or  cutting  instruments ;  and  that  whatever  they  may  some- 
times possess  that  is  formidable  depends  on  the  complications  which  ac- 
company them.  If  pleurisy  has  been  mentioned  as  one  of  these  complica- 
tions, care  has  been  taken  to  add  that  it  remains  local  and  benignant,  so 
long  as  there  is  neither  effusion  of  blood  nor  entrance  of  air  into  the  chest; 
and  so  long  as  no  foreign  body,  such  as  a  fragment  of  the  sternum,  or  of  a 
rib,  fall  into  the  pleural  cavity — in  which  case  a  suppurative  pleurisy 
supervenes. 

Leaving  these  special  complications  out  of  account,  wounds  of  the  chest, 
even  those  inflicted  by  very  large  instruments,  are  free  from  danger ;  but 
still  more  exempt  from  risk  must  be  the  little  wound  of  the  trocar,  made 
with  all  the  precautions  necessary  to  prevent  the  entrance  of  air  into  the 
pleural  cavity.  Interrogate  the  patients  who  have  been  the  subjects  of 
paracentesis,  and  they  will  all  tell  you  that  they  experience  no  pain  in  the 
situation  in  which  the  instrument  penetrated  the  chest.  If  the  effusion  in- 
crease consecutive  to  the  operation,  this  increase  results  from  the  pleurisy 
which  existed  prior  to  the  operation  not  having  been  extinguished  ;  and 
there  is  no  ground  for  concluding  that  there  is  an  exacerbation  of  the  in- 
flammation, as  the  quantity  of  fluid  left  in  the  pleural  cavity,  in  place  of 
being  augmented,  usually  decreases. 

In  early  times,  when  the  operation  was  somewhat  of  a  novelty,  it  was 
vol.  i. — 40 


G26  PLEURISY:     PARACENTESIS    OF    THE    CHEST. 

excusable  for  Stokes  and  Watson  to  entertain  the  fear  that  paracentesis  of 
the  chest  might  convert  a  serous  into  a  purulent  effusion,  but  now  that  ex- 
perience has  superabundantly  demonstrated  that  the  fear  was  groundless, 
to  bring  forward  an  argument  of  this  description  against  the  operation  is 
either  an  indication  of  bad  faith  or  of  unpardonable  ignorance.  In  this 
matter,  gentlemen,  I  appeal  to  such  of  you  as  regularly  follow  the  practice 
of  my  clinical  wards. 

The  most  serious  accident,  and  indeed  the  only  one  to  be  feared  in  para- 
centesis of  the  chest,  is  the  persistent  entrance  of  air  into  the  pleural  cavity, 
inasmuch  as  it  may  cause  suppurative  inflammation;  but  this  danger  has 
ceased  to  be  a  serious  objection  to  the  operation,  because — thanks  to  the 
improvements  in  the  method  of  performing  it — thanks  to  the  valve  added 
to  the  canula — the  entrance  of  air  into  the  pleural  cavity  is  no  longer  a 
possibility. 

To  complete  my  remarks  upon  the  subject  of  paracentesis,  I  have  a  word 
to  add  on  the  consecutive  treatment,  which  is  just  the  treatment  of  ordinary 
pleurisy.  To  expedite  the  resolution  of  the  effusion,  to  facilitate  the  absorp- 
tion of  the  remains  of  the  fluid  not  evacuated  by  the  canula,  I  prescribe 
digitalis  to  be  taken  internallv :  I  generallv  order  an  infusion  of  50  centi- 
grammes  [nearly  8  grains]  of  the  leaves  in  a  litre  [rather  more  than  a  quart] 
of  water.  I  likewise  order  the  affected  side  to  be  painted  with  tincture  of 
iodine,  the  resolutive  influence  of  which  I  consider  a*  at  least  as  powerful 
as  that  of  blisters. 

Hitherto,  gentlemen,  I  have  spoken  to  you  only  of  paracentesis  in  cases 
of  serous  effusion.  In  purulent  effusion,  the  operation  must  be  performed 
in  a  different  manner. 

Although,  from  the  symptoms  which  I  have  indicated,  you  may  infer 
the  existence  of  a  purulent  pleurisy,  you  can  only  in  particular  cases  attain 
sufficient  certainty  on  this  point,  to  dispense  with  the  precaution-  which 
ought  to  be  taken  when  the  effusion  is  serous.  You  begin,  therefore,  by 
puncturing  the  chest  with  the  trocar:  you  withdraw  the  canula,  and  per- 
form the  dressing  as  in  a  case  of  simple  hydrothorax.  It  may  happen 
sometimes,  though  seldom,  that  there  is  no  new  effusion  ;  or,  the  effusion 
may  recur  and  be  evacuated  by  the  bronchial  tubes,  which  is  a  still  more 
unusual  occurrence,  and  one  which,  relatively,  is  very  favorable.  Almost 
in  every  case,  however,  the  purulent  fluid  reaceumulates,  and  the  original 
wound  made  by  the  trocar,  opening  spontaneously,  gives  issue  to  the  pus. 
A  fistula  is  afterwards  established,  which  will  not  close  till  the  cure  is  com- 
plete, or  till  the  pus  finds  an  exit  by  the  bronchial  tubes,  as  I  have  just 
stated  may  occur.  If,  through  some  unusual  circumstance,  the  pus  flows 
only  in  small  quantities,  the  chest  may  become  flattened,  at  the  same  time 
that  the  lung  resumes  its  place,  and  then  the  cure  is  accomplished  without 
the  occurrence  of  pneumothorax.  Generally,  I  might  say,  in  nearly  all 
cases,  a  very  large  quantity  of  pus  is  discharged,  and  i>  replaced  by  air 
entering  the  chest:  the  result  is  hydropneumothorax,  for  which  surgical 
interference  will  afterward-  he  required.  In  such  cases,  you  enlarge  the 
wound  with  the  bistoury,  so  a-  to  allow  a  larger  canula  to  be  introduced, 
which  ha-  to  he  left  in  the  wound.  The  canula  OUghl  to  he  of  metal,  and 
hut  in  such  a  manner  a-  ool  to  injure  the  lung  a-  ii  expands. 

The  rim  of  the  canula  is  furnished  with  a  caoutchouc  ring,  which,  by 
coming  between  the  instrument  and  the  -kin,  prevents  excoriation. 

In  cases  of  this  description,  bo  far  from  regetting  a  want  of  parallelism 

between  the  .'Xt'Tiial  ami  internal  openings,  a-  in  CBSes  of  serous  etfu-ion.  it 
-   ntial  that  the  parallelism  he  a-  complete  a-   possible.       The   introduc- 
tion of  air  into  the  pleural  cavity  ceases  to  he  a  can-'  of  dread,  a-  you  are 


50  grammes, 

2 

" 

00 

!< 

PLEURISY:     PARACENTESIS    OF    THE    CHEST.  627 

going  to  endeavor  to  modify  the  condition  of  the  diseased  serous  membrane 
by  applying  to  it  the  tincture  of  iodine,  or  sonic  other  irritant  fluid.  The 
absence  of  parallelism  between  the  openings  would  make  it  more  difficult 
to  retain  the  cannla  in  its  place,  and  would  also  lead  to  the  formation  of 
abscesses  and  subcutaneous  fistuhe.  Nevertheless,  it  is  necessary  to  prevent 
air  from  entering  in  great  quantity,  because  its  presence  in  the  chest  would 
impede  the  action  of  the  lung,  and  produce  irritation  of  the  pleura  of  an 
injurious  character.  Hence,  the  incision  made  with  the  bistoury  ought  not 
to  be  more  than  just  sufficient  to  permit  the  passage  of  the  canula. 

When  you  have  made  the  incision,  you  allow  a  large  portion  of  the 
effused  pus  to  flow,  without,  however,  completely  emptying  the  pleural 
cavity,  though  this  I  consider  useful  in  cases  of  serous  effusion.  You  then 
inject  a  solution  of  iodine.  The  following  is  the  formula  for  preparing  the 
injection  which  I  employ: 

Tincture  (Frencli)  of  Iodine, 
Iodicle  of  Potassium,     . 
Distilled  Water,   .... 

The  injection  consists  of  the  above  solution,  with  the  addition  of  an  equal 
quantity  of  tepid  water. 

You  tell  the  patient  to  move  about  in  such  a  way  as  to  cause  the  injec- 
tion to  come  in  contact  as  much  as  possible  with  the  surface  of  the  pleura. 
You  then  allow  a  part  of  the  fluid  to  escape,  so  as  to  prevent  the  iodine 
from  producing  toxic  effects,  which,  though  they  might  probably  not  be 
serious,  ought  not  the  less  to  be  guarded  against.  You  close  the  canula, 
and  you  put  large  bands  of  adhesive  plaster  round  the  chest. 

You  open  the  canula  daily  to  allow  a  certain  quantity  of  fluid  to  escape; 
and  you  repeat  the  injection,  increasing  or  diminishing  the  quantity  injected, 
and  the  proportions  of  the  tincture  employed,  according  to  the  degree  in 
which  the  pleural  cavity  tends  to  contract,  according  also  to  the  greater  or 
less  fetor  of  the  fluid  which  it  contains,  and  its  greater  or  less  approxima- 
tion to  the  character  of  laudable  pus.  The  injection  is  then  repeated  only 
once  in  two,  three,  or  four  days ;  taking  care,  however,  to  empty  the  chest 
at  least  once  in  the  twenty-four  hours. 

It  may  be  necessary  to  continue  this  treatment  for  a  long  time :  in  chil- 
dren, I  have  continued  it  for  four,  five,  and  even  six  months. 

These  are  the  cases,  gentlemen,  in  which  we  see  very  considerable  defor- 
mities of  the  chest.  The  chest  becomes  flattened;  and  the  individual  is 
forcibly  bent  to  the  affected  side,  his  shoulder  approximating  to  the  base 
of  the  thorax,  which  presents  a  notable  contraction,  varyiug  from  two  to 
seven  centimetres.  In  front,  there  is  very  great  flattening,  and  the  clavicle 
projects:  there  is  also  flattening  behind. 

You  understand  the  mechanism  by  which  this  deformity  is  produced. 
The  lung,  by  means  of  false  membranes,  is  squeezed  back,  and  kept  in  con- 
tact with  the  vertebral  column,  near  the  root  of  the  bronchi :  when  the 
effused  fluid  has  been  almost  completely  evacuated,  a  vacuum  is  produced 
in  the  chest  at  the  moment  the  ribs  ascend,  particularly  at  the  time  the 
diaphragm  descends :  the  pressure  of  the  atmosphere  then  compresses  the 
thoracic  walls,  whereas  in  the  normal  state,  the  equilibrium  is  maintained 
by  the  vacuum  which  has  a  tendency  to  be  produced  during  inspiration 
being  filled  up  by  air  rushing  into  the  bronchial  tubes. 

This  deformity,  which  increases,  and  sometimes  assumes  formidable  pro- 
portions in  young  subjects,  produces  alarm  in  families.  Dispel  their  fears: 
when  once  the  effusion  has  been  cured,  the  deformity  will  disappear.  In 
children,  although  the  thoracic  deformity  assumes,  as  I  have  said,  a  fbrmida- 


628  PLEURISY:     PARACENTESIS    OF    THE    CHEST. 

ble  appearance,  it  is  seldom  painful ;  but  in  adults,  whose  bones  are  less  easily 
bent,  the  pains  are  sometimes  intolerable,  a  fact  which  you  ought  to  bear 
in  mind,  so  that  you  may  not  impute  the  sufferings  of  the  patient  to  some 
serious  lesion. 

As  the  quantity  of  fluid  in  the  pleural  cavity  diminishes,  the  lung  will 
respond  to  the  pressure  of  the  atmospheric  air.  which  will  at  each  in- 
spiration— that  is,  from  twenty  to  twenty-five  times  a  minute — enter  the 
bronchial  tubes.  You  can  understand  how  great  must  be  the  effect  of  this 
pressure  repeated  an  immense  number  of  times  in  the  twenty-four  hours  : 
you  can  understand  how  the  lung,  under  the  influence  of  this  pressure,  dis- 
engages itself  from  the  adhesions  by  which  it  is  confined,  and  expands  suffi- 
ciently to  resume,  to  a  certain  extent,  its  place  in  the  thoracic  cavity.  The 
flattened  ribs  are  approximated  to  the  lung,  having  gone  half  way  to  meet 
it,  if  I  may  so  express  myself. 

The  thoracic  deformity,  then,  is  a  condition  favorable  to  the  cure  of  effu- 
sion, inasmuch  as  it  diminishes  the  containing  cavity,  while  by  the  lung 
progressively  expanding,  the  capacity  of  the  cavity  is  likewise  le>sened, 
till  at  last,  there  only  remains  a  sort  of  small  pouch,  which  closes  spon- 
taneously. 

In  adults,  and  still  more  in  old  people,  in  whom  the  thoracic  walls,  being 
more  rigid  than  in  children,  yield  less  easily  to  the  pressure  of  the  atmos- 
phere, the  deformity  is  much  less  observed.  This,  probably,  is  one  of  the 
reasons  why  chronic  purulent  pleurisies,  from  which  in  childhood  recovery 
generally  takes  place,  are  almost  always  fatal  in  old  age. 

Gentlemen,  before  concluding  these  lectures  on  paracentesis  of  the  chest, 
let  me  mention  an  additional  case,  interesting  in  more  than  one  aspect,  and 
which  is  peculiarly  fitted  to  demonstrate  the  advantages— to  me  incontest- 
able— of  this  operation,  as  well  as  its  harmlessness  in  the  very  cases  in 
which  it  seems  to  be  most  contraindicated  on  account  of  the  complications 
which  accompany  hydrothorax. 

You  have  all  seen  the  subject  of  the  case  to  which  I  refer:  he  was  a  man 
who  lay  in  bed  25  of  St.  Agnes's  Ward,  to  which  he  was  admitted  a-  a 
patient  on  the  11th  April,  1863.  I  cannot  do  better  than  read  the  history 
as  written  out  in  detail  by  Dr.  Michel  Peter,  my  chef  de  dinique.* 

"A  man,  aged  36,  was  admitted  to  Dr.  Trousseau's  clinical  wards  on  the 
11th  April,  1863,  and  placed  in  bed  25  of  St.  Agnes's  Ward. 

"He  stated  that  his  illness  had  commenced  three  months  previously,  and 
that  up  to  that  date,  he  had  had  neither  cough  nor  oppression  <>f  breathing. 
Subsequently,  he  had  both,  as  well  a-  spitting  of  blood  from  time  t"  time. 

"On  admission,  he  was  diagnosed  to  be  suffering  from  a  serious  lesion  of 
the  let't  side  of  the  heart;  viz.,  insufficiency  'if  the  aortic  valve,  probably 
combined  with  contraction  of  the  orifice.  The  heart  was  greatly  hyper- 
trophied:  and  over  the  precordial  region,  the  chesl  was  arched.  At  the 
base,  accompanying  the  second  sound,  there  was  loud  though  soft  blowing; 
and  with  the  firsl  sound,  there  was  blowing  of  a  much  less  decided  charac- 
ter, in  other  words,  the  signs  of  insufficiency  of  the  aortic  valve  were 
much  more  marked  than  the  signs  of  contraction.  The  pulse  was  bound- 
ing, a-  in  cases  of  insufficiency.  There  was  oedema  of  the  inferior  extremi- 
ties, which  hail  existed  for  three  weeks. 

••  (  >n  the  1  1th  May,  after  gnat  oppression  of  breathing,  the  patient  -pal 
bloo.l  in  large  quantity.  The  blood  was  not  red — not  vermilion  ami 
frothy— as  in  tubercular  haemoptysis:  it  was  blackish,  or  mixed  with  bron- 


*  Pktkb  (Michel   :  Gazette  dea  H6pitaux,  18th  June,  1868 


PLEURISY:     PARACENTESIS    OF    THE    CHEST.  629 

chial  mucus,  as  in  pulmonary  apoplexy.  In  fact,  au  attack  of  pulmonary 
apoplexy  bad  supervened. 

'•  Next  day,  15th  May,  the  patient  complained  of  pain  in  the  left  side  of 
the  chest,  of  so  violent  a  character  as  to  cause  him  to  utter  piercing  cries. 
On  auscultation,  however,  nothing  remarkable  was  heard. 

"On  the  follow  in--  day,  16th  May,  slight  crepitation  was  heard  when  the 
ear  was  applied  over  the  axillary  margin  of  the  scapula. 

"On  the  17th  May,  a  superficial  harsh,  noisy  sound  had  taken  the  place 
of  the  crepitation  of  the  previous  evening.  There  was  marked  dulness  in 
the  lower  third  of  the  chest.  The  pleuritic  pain  continued  with  diminished 
intensity. 

"  On  the  18th  May,  all  the  indubitable  signs  of  effusion  were  present, 
There  was  dulness  in  the  two  lower  thirds  of  the  left  side  of  the  chest,  in 
which  situation  the  vesicular  murmur  could  not  be  heard.  Posteriorly,  at 
the  junction  of  the  upper  and  middle  third  of  the  chest,  there  was  typical 
blowing  and  segophony.     The  pain  was  still  very  acute. 

"On  the  19th  May,  there  was,  posteriorly,  dulness  at  the  summit  of  the 
chest,  and,  anteriorly,  skodaic  resonance.  The  heart  was  inclined  to  the 
right  of  its  natural  place.  The  breathing  was  very  much  oppressed.  Ex- 
treme anxiety  existed,  having  as  its  causes,  the  cardiac  disease,  the  turning 
of  the  heart  on  its  own  axis,  profuse  effusion,  and  continuance  of  the  pain. 

"  On  the  20th  May,  numerous  causes  of  impediment  to  the  function  of 
hsematesis  induced  Professor  Trousseau  to  have  recourse  to  paracentesis ; 
and  the  operation  was  on  that  day  performed  by  M.  Peter,  his  chef  de  clin- 
ique.  From  the  puncture  made  in  the  sixth  intercostal  space  and  in  the 
axillary  line,  there  issued  2000  grammes  [more  than  two  quarts]  of  serosity, 
which,  though  rich  in  fibrin,  was  unmingled  with  blood.  The  fact  that 
hsematopneumothorax  did  not  exist  was  established  by  there  being  no  blood 
in  the  serosity  evacuated  ;  and  that  the  hydrothorax  was  not  simple  was 
shown  by  the  secrosity  being  fibrous :  in  other  words,  there  was  a  true 
pleurisy. 

"  The  evacuation  of  the  serosity  was  followed  by  great  relief.  But  three 
days  later,  there  was  a  recurrence  of  the  pulmonary  apoplexy,  which  led  to 
the  return  of  the  pains,  and  a  reproduction  of  the  effusion. 

"  On  the  25th  May,  the  sixteenth  day  after  the  paracentesis,  the  effusion 
was  as  high  up  as  the  first  rib.  The  apex  of  the  heart  was  beating  below 
the  right  nipple.  As  there  w7as  very  great  oedema  of  the  lower  extremities, 
friction  with  croton  oil  was  ordered,  with  a  view  to  bring  about  the  dis- 
charge of  the  serosity  with  which  the  cellular  tissue  was  infiltrated. 

"  On  the  29th  May,  thanks  to  the  frictions  with  croton  oil,  the  serosity 
flowed  in  very  great  profusion  from  the  legs.  The  patient  was  altogether 
in  a  better  state. 

"Although,  however,  the  thoracic. effusion  was  a  little  diminished,  it  was 
necessary  to  repeat  the  puncture  of  the  chest  on  the  31st,  when  there  was 
drawn  off  1700  grammes  of  a  serous  fluid  absolutely  similar  to  that  obtained 
by  the  first  paracentesis.  This  second  operation  was  followed  by  fits  of 
coughing,  during  which  the  lung  was  heard  to  unfold  and  resume  its  place, 
whilst  at  the  same  time  the  heart  was  observed  to  return  towards  its  normal 
position  :  its  pulsations,  however,  were  still  a  little  nearer  than  natural  to 
the  median  line. 

"  From  the  date  of  the  second  operation,  respiration  was  audible  through- 
out the  whole  of  the  left  side  of  the  chest,  though  the  sound  was  obscured 
by  false  membranes  which  lined  the  pleura.  There  was  no  return  of  the 
effusion. 

"  Ten  days  have  nowT  elapsed  since  the  second  operation  was  performed, 


630  pleurisy:   paracentesis  of  the  chest. 

and  since  that  time  a  state  of  agonizing  suffering  has  ceased,  the  long  con- 
tinuance of  which  was  incompatible  with  life,  judging  from  the  circumstance 
that  the  effusion  had  just  been  added  to  numerous  other  risks  of  death,  sup- 
pressing, so  to  speak,  one  entire  lung  of  a  man  in  whom  hsematosis  was 
already  interfered  with  by  heart  disease. 

"It  will  no  doubt  be  observed  that,  without  being  dependent  on  the  affec- 
tion of  the  heart  in  respect  of  the  hydrothorax,  the  pleurisy  was  in  this  case 
indirectly  connected  with  the  cardiac  disease.  The  pulmonary  apoplexy 
was  the  link  which  united  the  disease  of  the  heart  with  the  pleural  effusion ; 
not  that  there  had  been  rupture  of  the  pulmonary  pleura  and  sanguineous 
effusion  into  the  cavity  of  the  chest  (fur  the  absence  of  color  showed  that 
this  had  not  occurred),  but  that  some  superficial  clots  had  irritated  the 
pleura,  and  had  so  determined  serous  exudation. 

"Ought  we  in  this  case  to  dispute  the  utility  of  paracentesis  of  the  chest, 
because  there  was  recurrence  of  effusion  after  the  first  tapping?  Before 
doing  so,  it  would  be  necessary  to  forget  that  the  evacuation  of  the  fluid,  in 
all  probability,  prevented  the  patient  from  dying  in  a  state  of  asphyxia,  or 
from  sudden  syncope.  The  duration,  moreover,  of  the  pleurisy  was  veiy 
short,  if  we  compare  its  duration  with  that  which  it  was  natural  to  expect 
from  so  profuse  an  effusion  in  a  man  doomed  by  the  cardiac  disease  to 
serous  infiltrations,  and  whose  tissues  were  consequently  in  a  condition  ill 
suited  to  accomplish  absorption. 

"Perhaps  there  may  be  a  reproduction  of  the  fluid  ;  but  should  the  gen- 
eral state  of  the  patient  be  ameliorated,  a  third  tapping  may  prolong  the 
life  of  the  patient,  who,  had  it  not  been  for  the  relief  afforded  by  paracen- 
tesis, could  not  have  supported  two  extensive  effusions,  and  still  less  have 
been  able  to  support  a  third  without  sinking  under  its  consequenc 

Gentlemen,  I  entirely  agree  with  the  judicious  remarks  of  Dr.  Peter  ;  and 
I  do  so  with  the  more  satisfaction  that  the  patient,  still  in  our  wards  on 
account  of  his  cardiac  affection,  for  which  we  can  do  nothing,  is  at  present 
relieved  from  certain  serious  symptoms,  for  which  we  can  do  something. 
The  effusion  in  his  case  would  have  proved  mortal,  for  it  was  not  dropsy  of 
the  pleura,  the  final  phenomenon  of  cardiac  cachexia,  from  which  he  suf- 
fered, but  a  pleurisy  consequent  upon  pulmonary  apoplexy.  From  a  con- 
viction of  the  utility,  or  I  should  rather  say  of  the  necessity,  of  our  having 
intervened  surgically  on  behalf  of  this  man,  I  earnestly  call  your  attention 
to  his  case,  which,  in  my  opinion,  teaches  more  than  one  useful  lesson. 

In  connection  with  this  case,  the  editor  of  the  Gazette  des  Hopitaux  men- 
tions that  one  of  my  pupils,  Dr.  A.  Masson  (of  Yvetot  ,  has  published  a 
memoir  containing  twelve  cases  in  which  he  performed  paracentesis  of  the 
chest.  The  note  of  the  editor  of  the  Gazette  <\r<  Hdpitaus  is  to  the  follow- 
ing effect :  "  In  ten  out  of  twelve  cases,  tin  operation  was  completely  success- 
ful; and  the  author  being  favorably  Bituated  for  keeping  his  eye  on  the 
patients,  was  able  to  assure  himself  that  the  cure,  almost  always  rapidly 
obtained,  was  final.  Never  was  the  cure  impeded  by  the  slightest  compli- 
cation attributable  to  the  paracentesis.  In  two  cases  only,  the  operation 
failed  to  effect  a  cure  :  or  rather,  in  two  cases,  death  occurred,  notwithstand- 
ing the  tapping.  A  woman  tapped  for  tubercular  pleurisy  died  of  phthisis 
six  months  after  the  operation:  ami  a  man  Buffering  from  hydropneumo- 

thorax,  with  absceSB   of  the  lung,  died  after   having   Beveral    time-  vomited 

enormous  quantit  ies  of  pus. 

'•  For    mosl    of  the    cases    in  which   Dr.    Ma-son   operated,  the   heart  was 

displaced  by  the  effusion.  His  knowledge  of  the  possibility  of  sudden  death 
occurring  simply  in  consequence  of  the  greatness  of  the  quantity  of  the 
effusion  contributed  not  a  little  to  divesl  his  mind  of  all  hesitation  a-  to 


TRAUMATIC    EFFUSION    OF    BLOOD    INTO    CHEST,    ETC.        631 

the  propriety  of  opeiating.     Tlio  ease  detailed  in  Dr.  Masson's  memoir 
strikingly  illustrates  this  terrible  termination  of  some  pleurisies. 

"Dr.  Nfasson  also  operated  upon  two  patients  in  whom  there  was  not  much 

effusion  ;  but  who  nevertheless  wasted  away  rapidly,  leading  to  the  fear  that 
a  sudden  outburst  of  tubercular  disease  was  impending." 

( rentlemen,  I  have  thought  it  right  to  lay  before  you  these  cases  derived 
fr<un  the  practice  of  one  of  our  honorable  colleagues.  Taken  along  with 
Others  which  you  will  find  recorded  in  medical  works,  they  corroborate  all 
that  I  have  said  to  you  of  paracentesis  of  the  chest.  I  shall  have  a  feel- 
ing of  great  satisfaction,  if  I  have  convinced  you  of  the  vast  services  which 
this  operation  can  render,  and  if  I  cau  diminish  the  fears  which  it  still 
inspires  in  the  breasts  of  some  physicians. 

[During  the  summer  and  autumn  of  this  year  [1869],  I  have  had  opportunities  of 
seeing  Professor  Michel  Peter  perform  paracentesis  of  the  chest:  and  have  also, 
both  in  conversations  and  in  his  clinical  lectures  at  La  Pitie,  heard  him  give  very 
able  expositions  of  the  subject.  His  practice  strongly  corroborates  the  teaching  of 
Dr.  Trousseau. 

Professor  Peter,  in  his  clinical  lectures  at  La  Piti6,  laid  great  stress  upon  the  fact, 
that  a  continuance  of  the  febrile  state  was  ordinarily  opposed  to  the  absolute  and  im- 
mediate success  of  the  operation  Tn  such  cases,  from  the  inflammation  not  being 
extinct,  reproduction  of  the  effusion  almost  invariably  takes  place  ;  and  it  may  be 
necessary,  according  to  the  quantity  of  the  effused  fluid,  to  tap  again  or  apply  blisters. 
It  sometimes  happens  that  the  new  effusion  becomes  purulent ;  and  that  the  original 
puncture  in  the  thoracic  walls  becomes  a  fistulous  opening.  The  patient  may  live, 
retaining  this  fistula  for  an  indefinite  period  ;  or  he  may  be  speedily  carried  off  by 
hectic  fever  This  latter  termination,  Dr.  Peter  has  only  seen  three  times  in  the 
very  large  number  of  cases  in  which  he  has  performed  thoracic  paracentesis.  In 
two  of  the  three  cases,  the  patients  were  highly  lymphatic,  though  not  tuberculous 
subjects  :  in  the  other  case,  the  patient  was  rheumatic.  These  are  facts  which  ought 
to  be  known. 

Besides  the  flow  of  bloody  serosity  of  which  Dr.  Trousseau  speaks,  and  which  is 
characteristic  of  cancerous  pleurisies,  Dr  Peter,  in  his  clinical  lectures,  remarked, 
that  the  tapping  itself  might  occasion  the  issue  of  bloody  or  sanguinolent  serosity. 
Dr.  Peter  has  twice  met  with  this  form  of  hemorrhage:  both  patients  made  com- 
plete recoveries.  He  attributes  the  bleeding  in  these  cases  to  the  trocar  having  torn 
some  vessels  belonging  to  very  vascular  false  membranes.  Blood  is  consequently 
discharged  into  the  pleura,  which  renders  bloody  the  fluid  issuing  from  the  canula. 
It  is  obvious,  therefore,  that  there  is  no  great  cause  for  alarm  when  the  fluid  drawn 
off  is  bloody,  provided  the  patient  is  otherwise  in  a  good  state. — Translator.] 


LECTUEE   XXXIII. 

TRAUMATIC  EFFUSION  OF  BLOOD  INTO  THE  PLEURA— 
PARACENTESIS  OF  THE  CHEST. 

Effusion  of  Blood  into  the  Cavity  of  the  Pleura  mechanically  arrests  Traumatic 
Hemorrhage. — In  such  cases  Paracentesis  is  not  only  useless,  hut  may  even 
prove  injurious. —  The  Blood  coagulates  immediately. — It  scarcely  irritates 
the  Pleura. — Reabsorption  takes  place  very  rapidly. 

Gentlemen  :  In  one  of  my  previous  lectures  I  spoke  to  you  of  serosan- 
guineous  effusion  into  the  pleura,  recurring  sometimes  in  an  acute  manner, 
particularly  during  eruptive  fevers,  and  in  a  chronic  form,  when  there  is 
cancerous  disease  of  the  pleura.     I  now  propose  to  speak  to  you  of  san- 


632  TRAUMATIC    EFFUSION    OF    BLOOD    INTO    CHEST: 

guineous  collections  formed  in  the  pleura  consequent  upon  wounds  of  the 
chest. 

Although  effusion  of  blood  into  the  pleural  cavity  is  a  subject  which  be- 
longs more  particularly  to  Surgery,  and  may  seem  "to  be  somewhat  foreign 
to  a  chair  of  Clinical  Medicine,  I  think  it  right  to  go  into  the  subject,  rather 
than  leave  you  in  ignorance  of  what  I  know  about  it.  I  think  so,  because 
it  is  a  pathological  question  in  relation  to  which  I  have  made  many  experi- 
ments, the  results  of  which  have  not  received  adequate  publicity* — and, 
also,  because  sanguineous  effusions  into  the  pleura  very  frequently' occasion 
attacks  of  pleurisy  and  empyema,  thus  bringing  them,  to  a  certain  extent, 
within  the  domain  of  medicine. 

What  ought  the  physician  to  do  when  a  wound  of  the  chest  is  followed 
by  an  effusion  of  blood  into  the  pleura? 

Many  surgeons  inculcate  the  withdrawal  of  the  blood  by  suction  of  the 
wouud:  some  have  recommended  tapping,  and  others  have  counselled  the 
removal  of  the  effused  blood  through  an  incision  in  an  intercostal  space. 

Allow  me,  gentlemen,  to  discuss  these  different  proceedings;  but,  in  the 
first  instance,  let  us  endeavor  to  understand  the  indications  which  present 
themselves.  Let  us  suppose  that  there  is  a  great  sanguineous  effusion  ;  for 
as  yet  no  one  has  recommended  active  interference  in  cases  of  very  limited 
hemorrhage.  There  are  two  sources  whence  extensive  hemorrhage  may 
arise :  from  an  artery  of  the  thoracic  walls,  or  from  one  of  the  vessels  of 
the  lung.  If  the  hemorrhage  come  from  one  of  the  vessels  of  the  walls  of 
the  chest,  I  cannot  conceive  the  least  benefit  to  result  from  any  of  the  dif- 
ferent proceedings  of  which  I  have  just  been  speaking:  I  could  better  under- 
stand how  pressure  exerted  on  the  opening  by  the  accumulated  blood  might 
assist  in  the  formation  of  a  clot,  and  so  plug  the  vessel.  But  if  the  hemor- 
rhage come  from  the  lung,  it  is  easy  to  see  that  the  effusion  itself  will  be 
one  of  the.  most  important  curative  agencies.  In  proportion  to  the  degree 
in  which  the  blood  is  effused  into  the  pleura,  the  lung  is  flattened  and 
squeezed  up;  and  at  last  the  cut  vessels  cease  to  bleed,  because  they  are 
strongly  compressed.  In  this  way  the  effusion  materially  assists  in  accom- 
plishing the  cure. 

When  a  horse  is  wounded  in  the  lung  a  curious  occurrence  takes  place. 
If  a  vessel  of  large  calibre  is  cut,  profuse  hemorrhage  takes  place  into  the 
pleura,  while,  simultaneously,  the  blood  flows  into  the  bronchial  tubes,  and 
in  a  short  time  the  animal  dies.  But  if  only  some  of  the  vessels  of  secon- 
dary size  have  been  wounded, a  rather  profuse  hemorrhage  takes  place  into 
the  pleura,  and  on  the  bronchial  surface:  soon,  however,  from  the  accumu- 
lation of  effused  blood  compressing  the  lung,  the  hemorrhage  ceases. 

If  the  animal  be  killed  soon  afterwards,  there  is  found  in  the  lung  itself, 
besides  the  effusion  of  which  I  have  just  been  speaking,  an  exceedingly 
curious  lesion,  which  as  yet  has  been  very  ill  described.  In  I  he  whole  course 
of  the  penetrating  wound,  the  pulmonary  cells  are  infiltrated  with  blood, 
and  (his  infiltration  extends  from  one  to  several  centimetres.  The  blood 
effused  into  (he  cells  is  much  blacker,  and  much  more  minutely  infiltrated 
in  the  immediate  vicinity  of  the  passage  made  by  the  instrument  inflicting 

the  wound  ;   and  in  that  situation  there  are  structural  changes  identical  with 
those  which  characterize  recent    nuclei  of  pulmonary  apoplexy. 

The  passage  made  by  the  instrument  is  itself  closed  by  fibrin,  a  true 
coagulum  occupying  the  course  of  the  wound,  jusl  as  a  blade  tits  into  its 
sheath.    This  protective  clot  is  sometimes  found  half  an  hour  after  the  wound 


*  Tin'  results  of  the  experiments  made  in  1829  bj   M.  Leblanc  and  me  were  pub- 

li>-lir.|  in  is::4,  in  the  "Journal  de  MSdecine  V6t6rinaire. " 


PARACENTESIS.  033 

has  been  made.  It  is  imbedded  in  the  interlobular  cellular  tissue,  or  in  the 
cells, by  innumerable  fibrinous  roots, which  break  when  an  attempt  is  made 
to  tear  it  out. 

If  the  autopsy  of  the  animal  be  not  made  for  forty-eight,  or  seventy-two 
hours  after  the  infliction  of  the  wound,  the  wound  is  found  to  he  closed  by 
a  most  remarkable  process.  The  lips  of  the  wound  of  the  lung  are  in- 
flamed, and  the  pleura  surrounding-  it,  to  the  extent  of  several  centimetres, 
participates  in  the  inflammation  ;  a  plastic  exudation  is  then  thrown  out, 
which  forms  adhesions  with  the  serous  membrane,  and  becomes  intimately 
amalgamated  with  the  fibrinous  mass  occupying  the  course  of  the  wound, 
to  which  it  has  become  closely  adherent.  The  wound  is  in  this  way  oblit- 
erated throughout  its  entire  course  by  a  fibrinous  clot,  and  its  lips  are  covered 
by  a  fibrinous  disk,  adherent  to  the  pleura,  to  the  lips  of  the  wound,  and 
to  the  plugging  fibrinous  clot.  It  bears  a  considerable  resemblance  to  a 
large  fibrinous  nail,  the  stem  occupying  the  course  taken  by  the  wounding 
instrument,  and  the  head  being  flattened  upon  the  lung,  to  which  it  closely 
adheres. 

Gentlemen,  who  can  fail  to  see  that  the  surgeon  by  emptying  the  pleura 
of  the  blood  effused  into  it  from  the  wolmded  vessels  must  prevent  flatten- 
ing of  the  lung,  so  powerful  a  preventive  of  hemorrhage,  and  must  likewise 
frustrate  the  formation  of  that  plugging  clot  which  I  have  been  so  care- 
fully describing  to  you  ? 

Weigh  well  the  fact,  that  by  making  an  opening  in  the  thoracic  wall* 
you  excite  violent  efforts  at  coughing,  which  will  be  peculiarly  apt  to  in- 
crease the  hemorrhage,  and  to  break  down  the  plugging  clot  as  fast  as  it 
forms. 

I  have  been  reasoning  upon  the  supposition  that  an  attempt  is  made,  by 
the  operation  for  empyema,  to  clear  the  pleura  of  the  clots  by  which  it  is 
filled.  Let  us  now  inquire  whether  it  be  possible  to  accomplish  this  object. 
I  shall  sum  up  in  a  few  words  the  series  of  experiments  by  which  M.  Le- 
blanc  and  I  attempted  to  elucidate  the  question. 

We  made  a  small  incision  in  the  skin  of  a  horse  between  the  middle  ribs  ; 
we  carefully  divided  the  tissues  of  the  intercostal  space,  and  wdien  we 
reached  the  pleura,  wre  opened  it  in.  such  a  w7ay  as  to  avoid  the  lung,  and 
to  limit  the  incision  to  some  millimetres.  By  a  stroke  of  the  fleam,  we 
then  opened  the  jugular  vein  of  the  animal ;  and  then,  by  means  of  a  kind 
of  funnel,  the  small  end  of  which  was  placed  in  the  pleura,  and  the  other 
used  to  receive  the  product  of  the  venesection,  we  introduced  into  the 
pleural  cavity  one  hundred,  two  hundred,  four  hundred,  or  even  as  many 
as  three  thousand  grammes  of  blood.  Having  introduced  the  blood,  we 
closed  the  wound  by  means  of  a  twisted  suture.  In  place  of  transmitting 
the  blood  directly  from  the  jugular  vein  into  the  pleura,  we  generally  re- 
ceived it  in  a  syringe,  and  before  it  had  time  to  coagulate,  we  injected  it 
into  the  pleural  cavity.  We  also  divided  an  intercostal  artery,  and  allowed 
a  certain  quantity  of  blood  to  flow  from  it  into  the  pleura. 

This  experiment  was  performed  on  several  horses.  They  were  killed ; 
some  immediately  after  the  operation,  and  others  after  an  interval  of  one, 
two,  twenty-four,  forty-eight,  and  seventy-two  hours,  and  of  from  six  to  ten 
days.  Without  a  single  exception,  however  short  was  the  interval  between 
the  injection  and  the  autopsy,  we  found  the  blood  coagulated.  So  rapidly 
did  coagulation  take  place,  that  when,  in  our  experiments,  we  opened  an 
intercostal  artery  and  caused  the  blood  to  flow  directly  into  the  pleural 
cavity,  making  at  the  same  time  an  opening  in  a  more  dependent  part  of 
the  chest,  hardly  a  drop  of  blood  flowed  out  by  it.  The  same  thing  took  place 
when  we  injected  from  one  to  three  kilogrammes  of  venous  blood  taken 


634  TRAUMATIC    EFFUSION    OF    BLOOD    INTO    CHEST: 

from  the  jugular  vein,  and,  at  the  time  of  iujection,  in  a  perfectly  liquid 
state. 

We  repeated  the  following  experiment  several  times.  As  soon  as  the 
injection  was  completed,  we  felled  the  animal  by  a  blow  on  the  head  with 
a  hammer ;  we  then,  without  a  moment's  delay,  opened  the  abdomen,  ex- 
posing the  diaphragm  ;  while  the  heart  was  still  beating,  and  eonsecpjently 
while  physiological  life  was  still  quite  preserved,  I  opened  the  pleural 
cavity  through  the  diaphragm,  and  found  the  blood  in  a  clot.  It  was  firmly 
coagulated,  although  the  blood  of  the  same  horse  taken  at  the  same  bleed- 
ing, but  before  the  blood  injected  into  the  pleura  and  left  exposed  to  the 
air  in  an  evaporating  vessel,  was  only  partially  coagulated.  Let  me  arid, 
that  in  cases  in  which  the  autopsy  was  made  with  the  greatest  possible 
celerity,  not  more  than  five  minutes  elapsed  between  injecting  the  blood 
into  the  pleura  and  ascertaining  its  condition  there. 

Gentlemen,  when  we  received  at  the  same  time,  in  two  separate  evapor- 
ating vessels,  the  blood  from  the  vein  of  a  healthy  man,  and  the  blood  from 
the  vein  of  a  healthy  horse,  it  was  observed  that  the  human  blood  coag- 
ulated much  the  most  quickly. 

Now  for  the  inferences  from  these  facts.  These  conclusions  you  have 
already  deduced.  When  blood  is  effused  into  the  pleura,  consequent  upon 
a  wound  of  the  chest,  coagulation  takes  place  in  a  few  minutes,  so  that  to 
perform  the  operation  for  empyema  with  a  view  to  remove  the  blood  is  as 
senseless  as  it  is  useless.  Whether  it  be  suction,  the  worst  and  most  absurd 
of  all  the  operations,  or  pumping  out  the  blood  —  (a  still  more  danger- 
ous proceeding,  as  it  is  a  more  forcible  kind  of  suction) — whether  simple 
tapping  be  resorted  to,  or  whether  an  incision  be  made  in  an  intercostal 
space,  it  will  be  impossible  to  withdraw  the  blood,  on  account  of  its  coag- 
ulated condition. 

You  will,  gentlemen,  nevertheless,  hear  it  said  by  the  most  experienced 
surgeons,  you  will  read  in  the  works  of  the  most  accredited  authors,  that 
they  have  been  able  after  wounds  of  the  chest,  to  withdraw  a  great  part  of 
the  sanguineous  fluid  by  tapping,  or  by  incision.  The  experiments  of  which 
I  have  given  you  an  account  were  performed,  as  I  have  already  told  you, 
thirty  years  ago,  by  M.  Leblanc  and  me.  As  you  can  well  believe,  they 
have  been  discussed  and  their  results  disputed.  In  the  first  place,  it  has 
been  said  that  blood  in  contact  with  living  parts,  consequently  at  the  same 
temperature  it  possessed  when  leaving  the  vein,  does  not  coagulate,  or  at 
least  coagulates  more  slowly  than  blood  which  has  remained  in  a  vessel  ox- 
posed  to  the  air,  and  the  rapid  coagulation  which  we  described  was  abso- 
lutely denied,  or  at  least  otherwise  explained.  The  experiments  which  M. 
Leblanc  and  I  made  upon  the  influence  of  temperature  upon  coagulation 
of  blood  taken  from  the  vessels,  experiments  which  have  been  repeated, 
and  are  at  present  no  longer  disputed,  show  that  coagulation  takes  place 
most  quickly  when  the  blood  is  placed  in  a  higher  temperature.  Thus, 
to  give  only  a  summary  of  our  experiments:  when  we  received  the  blood 
of  a  horse  in  ten  evaporating  vessels,  and  placed  these  vessels  in  fluids  vary- 
ing in  temperature  from  zero  to  lu  degrees,  we  ascertained  that  by  main- 
taining the  blood  at  zero,  it  remained  fluid  for  several  successive  days,  al- 
though it  coagulated  in  less  than  two  minutes  when  the  evaporat  ing  saucer 
was  kept  in  water  at  40  degrees,  and  that  the  coagulation  became  Blower 
and  slower,  in  proportion  as  the  temperature  was  lower. 

Matters  do  aol  proceed  differently  within  the  pleural  cavity.  The  blood 
coagulates  there  in  a  very  brief  space  of  time,  because  it  there  finds  a 
high  temperature,  and  the  slight  amount  of  motion  communicated  to  it  by 
respiration  only  retard-  coagulation  by  a  few  minute.-,  if  it  retards  it  at  all. 


PARACENTESIS.  635 

Surgeons,  then,  have  not  properly  understood  what  takes  place.  There 
is  a  confusion  about  the  subject  winch  I  wish  to  dissipate. 

The  clot  which  forms  within  the  pleura  docs  not  differ  much  from  that 
which  forms  in  vases  where  the  blood  is  by  itself.  Between  the  two,  how- 
ever, there  is  a  slight  difference.  In  a  vase,  coagulation  takes  place  more 
slowly  ;  consequent^  the  red  globules  being  heavier  have  time  to  be  pre- 
cipitated before  the  "fibrin  has  contracted :  the  result  is,  that  that  which  is 
called  the  huffy  coat  [couenne  inflammatoire]  composed  of  fibrin  and  serum, 
is  always  more  abundant,  other  things  being  equal,  when  the  blood  remains 
longest  in  a  fluid  state.  The  clot,  on  the  contrary,  coagulates  in  the  mass, 
and  without  forming  any  huffy  coat,  when  it  coagulates  very  quickly :  that 
is  what  takes  place  in  the  pleura.  But  after  a  very  short  time,  the  serosity 
imprisoned  within  the  clot  partly  bursts  forth,  and,  shaken  up  as  it  were 
by  the  movements  of  respiration,  is  always  mixed  with  a  great  quantity  of 
blood-globules :  at  the  first  glance,  it  has  the  appearance  of  fluid  blood. 
There  are  two  things  then  to  be  considered  in  cases  of  effusion  of  blood 
into  the  chest :  there  is  the  clot,  which  generally  occupies  the  most  depen- 
dent parts  ;  and  there  is  the  bloody  serosity,  which  comports  itself  exactly 
like  the  serosity  of  a  pleurisy.  If  the  surgeon  were  to  tap,  he  would  be 
able  to  withdraw  a  large  quantity  of  serosity  deeply  colored  by  the  cruor; 
and  might  thus  come  to  the  conclusion  that  he  had  withdrawn  fluid  blood. 

The  quantity  of  this  sanguineous  fluid  may  be  still  farther  augmented 
by  a  circumstance  which  I  ought  to  mention.  The  presence  of  some  blood 
is  not  a  cause  of  much  irritation,  as  I  shall  forthwith  be  able  to  prove  to 
you,  but  the  lesion  which  has  caused  the  sanguineous  effusion  is  a  source  of 
considerably  more  mischief,  and  very  usually  leads  to  inflammation  of  the 
pleura  and  lung.  Matters  become  much  more  serious  when  there  is  pneu- 
mothorax. In  such  a  case,  the  serous  effusion  comes  from  two  sources ; 
viz.,  from  the  clot  itself,  which  is  the  least  abundant  source,  and  from  the 
inflamed  pleura,  whence  it  is  impossible  to  calculate  how7  much  may  be 
exuded.  In  any  case,  the  fluid  secreted  by  the  irritated  pleura  continually 
in  contact  with  the  crassamentum  will  dissolve  a  large  amount  of  blood- 
globules,  so  that  if  paracentesis  were  to  be  performed,  it  might  be  supposed 
that  fluid  blood  was  being  withdrawn,  whereas  there  is  nothing  evacuated 
but  sanguineous  serosity. 

We  have  seen,  gentlemen,  that  making  an  opening  into  the  chest,  wdiether 
by  tapping  or  by  incision  in  the  intercostal  spaces,  is  a  useless  measure  in 
the  treatment  of  traumatic  extravasation  of  blood  :  it  would  be  easy  for 
me  to  prove  that  it  is,  at  the  very  least,  injurious,  and  is  frequently  fatal. 
I  have  no  difficulty  in  admitting  that  tapping,  performed  with  the  instru- 
ments and  the  precautions  which  are  universally  adopted  in  the  present 
day,  that  is  to  say  with  a  trocar  fitted  with  the  proper  membranous  valve, 
is,  for  the  most  part,  a  harmless  operation  ;  but  there  are  exceptional  cases, 
in  which  it  gives  rise  to  a  circumscribed  pleurisy,  which  cannot  fail  to  be 
troublesome.  Were  there  nothing  in  the  pleural  cavity  but  the  serosity 
which  had  separated  from  the  crassamentum,  it  would  hardly  be  worth 
while  to  tap,  for  that  serosity  would  soon  be  absorbed.  If  the  extra vasated 
blood — in  particular,  if  its  traumatic  cause — has  given  rise  to  pleurisy, 
with  consecutive  effusion,  tapping  may  be  useful ;  but  under  no  other  cir- 
cumstances can  it  prove  beneficial. 

As  to  making  an  incision  in  an  intercostal  space,  a  proceeding  I  adopt 
in  cases  of  purulent  effusion,  when  the  effusion  has  been  reproduced  after 
simple  tapping,  it  cannot  be  otherwise  than  a  very  dangerous  proceeding 
in  traumatic  extravasation  of  blood. 

I  have  said  sufficiently  often,  that  it  must  be  useless,  because  the  blood 


636  TRAUMATIC    EFFUSION    OF    BLOOD    INTO    CHEST: 

having  coagulated,  there  is  no  possibility  of  the  eoagulum  finding  an  exit 
by  the  opening,  even  were  it  infinitely  larger  than  it  is  generally  made. 

Not  only  is  the  incision  useless,  but  is  far  from  being  exempt  from  dan- 
ger. However  small  it  may  be,  it  necessarily  leads  to  the  introduction  of 
air  into  the  pleural  cavity,  and  this  occurrence  when  repeated  is  certain  to 
lead  to  pleurisy,  and  hydropneumothorax,  affections  of  an  exceedingly 
serious  character.*  The  blood  poured  into  the  pleura  putrefies ;  and  it  is 
easy  to  understand  the  risks  consequent  upon  this  occurrence.  I  have  the 
most  profound  conviction  that  the  majority  of  failures  which  surgeons  for- 
merly had  in  treating  wounds»of  the  chest,  were  due  to  this  perilous  pro- 
ceeding, now,  thank  God,  abandoned  by  the  majority  of  practitioners.  Our 
experiments  have  superabundantly  demonstrated  its  peril. 

Those  who  still  wish  to  try  to  evacuate  blood  extravasated  into  the  pleural 
cavity,  following  in  this  respect  the  example  of  the  illustrious  Dupuytren, 
after  the  assassination  of  the  Duke  de  Berry,  are  under  the  influence  of 
three  false  ideas.  They  think  that  the  blood  remains  fluid  :  they  think  that 
it  irritates:  and  they  think  that  it  is  absorbed  with  great  difficulty.  The 
experiments  made  by  M.  Leblanc  and  me  demonstrate  the  falsity  of  these 
three  suppositions. 

We  have  already  seen  that  the  blood  coagulates  at  the  moment  it  is  ex- 
travasated ;  and  that  we  can  withdraw,  by  tapping  or  incision,  only  the 
serum,  without  the  crassamentum,  a  result  which  is  really  not  worth  the 
trouble. 

Let  us  now  inquire  whether  the  blood  produces  irritation.  In  our  numer- 
ous experiments,  when  we  killed  a  horse,  four,  six,  or  eight  days  after  the 
injection  of  blood  into  the  pleura,  if,  as  sometimes  happened,  we  found  a 
clot,  we  never  detected  any  traces  of  pleurisy.  I  grant,  however,  that  ex- 
travasation of  blood  is  not  a  perfectly  harmless  occurrence,  and  that  it 
must  somewhat  irritate  the  serous  membrane.  More  particularly  I  grant 
that  it  may  predispose  to  pleurisy  an  individual  who  but  for  it  would  have 
escaped. 

Some  months  ago,  a  young  man  was  practicing  fencing  with  a  friend :  in 
an  animated  encounter,  the  knob  of  his  adversary's  foil  was  broken  off 
without  the  occurrence  being  perceived;  and  a  strong  thrust  penetrated  the 
chest  at  the  right  arm-pit.  There  was  neither  external  bleeding,  nor  sub- 
cutaneous ecchymosis,  and,  consequently,  none  of  the  vessels  of  the  axillary 
region  were  injured.  But  scarcely  had  a  few  moments  elapsed,  when  the 
wounded  young  man  felt  very  acute  pain  in  the  region  of  the  liver,  exactly 
similar  in  character  to  that  produced  in  the  pelvis  by  that  hemorrhage 
from  the  fimbriated  extremity  of  the  Fallopian  tube  which  constitutes  retro- 
uterine and  peri-uterine  hematocele. 

All  the  symptoms  quieted  down  during  a  few  days  of  repose.  The 
patient  had  no  fever,  and  was  able  without  fatigue  to  attend  a  horse-race 
a  fortnight  after  he  received  the  wound  in  the  chest.  Bui  seme  days  later, 
he  experienced  a  feeling  of  unease,  and  bad  some  cough.  Under  these  cir- 
cumstances, I  was  summoned  by  my  honorable  friend  Dr.  Reis  to  meet  him 
in  consultation:  we  detected  an  extravasation  of  blood — not  much  in  quan- 
tity— in  the    righl    pleura.      This   extravasation    made    rapid    progress.      It 

soon  became  so  extensive  as  to  suggest  to  me  the  propriety  of  considering 

*  By  experiments  <>n  animals,  ii  is  easy  t"  satisfy  oneself  thai  tin'  accidental  ad- 
mission nfair  in!"  iIm'  pleural  cavity  is  perfectly  harmless:   bul  :i  repetition  of  the 

admission  of  air,  even  when   (1 peration  is  sel  about  with  care,  causes  pleurisy, 

When  a  permanent  opening  is  made  in  the  chest,  pleurisy  and  hydrothorax  are 
inevitable.— See  tic  account  of  our  experiments  in  tic  Journal  de  fileaecine  \ 

in  aire,  already  cited. 


PARACENTESIS.  637 

whether  we  might  not  to  resort  to  paracentesis.  A  third  physician  was 
associated  with  us  in  consultation ;  and  the  result  of  our  meeting  was  an 
adjournment  of  the  operation.  A  fortnight  later — ten  weeks  after  the  acci- 
dent— the  pleural  effusion  found  a  passage  outwards  by  the  bronchial  tubes. 
In  this  way,  the  young  man  got  rid  of  an  enormous  quantity  of  pus  slightly 
tinged  with  blood,  after  which  the  expectoration  diminished  very  gradually, 
and  finally  ceasedfour  months  subsequent  t<>  the  accident. 

If  the  traumatic  hemorrhage  into  the  pleura  may  occasion  a  fluxionary 
determination,  predisposing  to  pleurisy,  will  not  the  operation  for  empyema 
exert  much  more  powerfully  an  evil  influence  on  the  state  of  the  patient? 

We  have  seen,  gentlemen,  that  the  blood  coagulates  as  soon  as  it  is 
poured  out  in  the  pleural  cavity  ;  that  it  there  excites  only  a  very  moder- 
ate amount  of  irritation.  It  is  now  necessary  to  show  you  that  it  is  absorbed 
with  a  rapidity  so  extraordinary  as  to  be  incredible,  were  not  the  fact 
demonstrated  by  experience  in  the  most  positive  manner. 

When  we  injected  into  the  chest  of  a  horse  200  grammes  of  blood  drawn 
from  the  vein,  or  when  an  intercostal  artery  was  opened,  and  the  blood 
allowed  to  flow  into  the  pleural  cavity,  there  were  in  the  majority  of  cases 
no  traces  of  it  to  be  found  after  forty-eight  hours,  or  at  the  most,  only  a 
little  bloody  serosity.  Supposing  that  the  effusion  amounted  to  500 
grammes,  only  a  small  clot  will  be  found  at  the  end  of  three  days  :  more 
than  four-fifths  of  the  fluid  will  have  been  absorbed. 

Even  when  the  experiments  were  made  with  from  one  to  three  kilo- 
grammes of  blood,  more  than  half  of  the  entire  quantity  was  found  to  have 
disappeared  in  forty-eight  hours:  after  three  days,  there  only  remained,  as 
in  the  former  case,  a  small  clot  and  a  little  reddish  serosity.  Throughout 
our  experiments,  we  did  not  in  a  single  instance  find  the  slightest  trace  of 
inflammation  of  the  pleura.  I  grant  that,  perhaps,  the  pleura  of  a  horse 
is  more  tolerant  than  the  pleura  of  a  man :  I  admit  also  that,  perhaps,  the 
blood  may  be  the  temporary  cause  of  inflammatory  determination  to  the 
pleura ;  but  still,  from  the  cases  and  experiments  wdiich  I  have  laid  before 
you,  am  I  not  entitled  to  say  that  in  cases  of  traumatic  extravasation  into 
the  pleura,  the  surgeon  ought  to  remain  as  a  spectator  ?  Absolute  rest, 
and  very  low  diet,  were  probably  the  best  means  of  promoting  absorption. 

Wounds  of  the  chest  complicated  with  pleural  hemorrhage  are,  however, 
sometimes,  frightfully  dangerous,  irrespective  of  the  loss  of  blood,  a  fact 
which  our  experiments  do  not  fully  explain.  I  must,  therefore,  add  a  few 
words  to  the  remarks  I  have  already  made  on  this  subject. 

The  blood  injected  into  the  pleura  does  not  there  comport  itself  after  the 
manner  of  a  foreign  body.  It  does  not  seem  to  irritate  the  serous  mem- 
brane more  than  food  irritates  the  stomach,  than  fecal  matter  irritates  the 
colon,  or  than  urine  irritates  the  bladder.  But  we  know  that  sometimes 
the  urine  does  irritate  the  bladder  :  it  does  so  when  there  is  a  change  in  its 
character.  Affections  of  the  bladder  also  often  occasion  changes  in  the 
urine;  but  on  the  other  hand,  an  altered  state  of  the  urine  may  cause 
catarrh  of  the  bladder.  The  case  is  similar  in  respect  of  blood  extrava- 
sated  into  the  pleura.  If  the  wound  of  the  chest  give  rise  to  an  escape  of 
air  as  well  as  of  blood  into  the  pleura,  there  will  be  an  immediate  change 
in  the  character  of  the  blood,  which  will  then  act  as  a  foreign  body. 
When,  in  our  experiments,  wre  allowed  the  blood  to  accumulate  in  an 
evaporating  vessel,  and  when  some  hours  later,  we  introduced  the  coagu- 
lated blood  into  the  pleural  cavity,  it  putrefied  there  :  and  the  animals 
sunk  under  formidable  attacks  of  pleurisy.  This  experiment  is  an  addi- 
tional proof  of  the  dangers  wdiich  attend  the  operation  for  empyema,  when 
performed  with  a  view  to  remove  coagulation  from  the  chest. 


638  HYDATIDS    OF    THE    LUNG. 

But  if,  in  spite  of  the  physician,  blood  and  air  make  their  appearance 
simultaneously  in  the  pleural  cavity,  violent  inflammation  is  kindled:  it  is 
then  a  duty  to  resort,  with  the  least  possible  delay,  to  the  operation  for 
empyema — to  inject  the  tincture  of  iodine.  In  a  word,  it  is  necessary  to  act 
in  the  same  way  that  I  have  counselled  you  to  proceed  in  formidable  col- 
lections of  pus,  and  in  hydropneumothorax. 


LECTURE  XXXIV. 

HYDATIDS    OF    THE   LUNG. 

Hydatids  of  the  Lung  though  rare  are  not  so  rare  as  Hydatids  of  the 
Pleura. — Diagnosis  is  exceedingly  difficult. — Resemblance  to  Pulmonary 
Phthisis. — Possibility  of  Cure  by  Spontaneous  Evacuation  by  the  Bron- 
chial Tubes. — Reserve  required  both  in  respect  of  the  Prognosis  and 
Treatment. 

Gentlemen  :  The  examples  of  hydatids  of  the  lung  given  by  Dr. 
Davaine  in  his  beautiful  work  on  the  entozoa,  are  comparatively  very  few:* 
and  if  you  make  inquiries  on  the  subject  of  your  hospital  teachers,  you  will 
find  most  of  them  admitting  that  they  have  never  met  with  a  case  of  this 
affection.  Bricheteau,  who  specially  devoted  his  attention  to  diseases  of 
the  chest,  only  saw  two  cases  of  it  during  a  medical  practice  of  more  than 
forty  years;  and  my  honorable  and  learned  colleague,  Dr.  Andral,  has  only 
recorded  five  cases.  Professor  Monneret  has  only  met  with  a  single 
instance,  and  that  was  detected  on  the  dead  body.  For  my  part,  I  had 
likewise  only  seen  a  single  case,  till  I  met  with  that  which  I  now  propose 
to  make  the  text  of  some  remarks  on  this  singular  affection. 

You  will  recollect  that  the  patient  to  whom  I  refer  was  a  young  man  of 
seventeen  years  of  age,  who,  about  the  end  of  December,  1861,  became  a 
patient  in  St.  Agnes's  Ward.  On  his  admission,  I  found  that  he  had  acute 
general  bronchitis,  and  that  the  right  lung  was  most  affected.  From  hear- 
ing on  that  side  coarse  mucous  rales  like  gurgling,  a  prolonged  expiratory 
sound,  diminished  resonance  on  percussion  over  the  infraspinous  fossa  of 
the  scapula,  and  finally  Ilippocratic  deformity  of  the  lingers,  1  was  led  to 
fear  that  the  bronchitis  was  only  symptomatic  of  tubercles.  This  hypothesis 
was  all  the  more  probable  from  the  fact,  that  the  patient  was  said  to  have 
been  liable  to  take  catarrhal  affections  every  winter  from  the  time  he  was  six- 
years  old  ;  and  that  it  was  added  he  had  had.  on  different  occasions,  pro- 
fuse haemoptysis:  1  nevertheless  reserved  my  diagnosis,  the  acute  catarrhal 
affection  of  the  bronchial  tubes  masking  the  characteristic  signs  of  the 
tuberculous  affection.    The  acute  symptoms  having  moderated,  the  fever 

having  ceased,  and  the  rales  Steadily  diminishing,  the  respiratory  sound  in 
the  righl  lung  seemed  to  me  to  become  more  normal.  Some  days  later, 
however,  there  was  a  return  of  the  lever,  particularly  in  the  evening;   and 

the  young  man  complained  of  pains  in  his  righl  side.     On  examining  that 

side  of  the  ehe-t   we  found  diilness  on  percussion  in    its   two   inferior  thirds, 


*  Davaine:   Traits  dee  Entozoairea  de  I'homme  et  dea  animaux  domeatiquea, 

8vo.     Paris:   1860. 


HYDATIDS    OF    THE    LUNG.  639 

absence  of  thoracic  vibrations,  and  the  presence  of  broncho-asgophony ; 
these  omens,  which  conjoined  with  marked  oppression  in  the  breathing, 
indicated  the  existence  of  pleuritic  effusion  complicated  with  bronchitis, 
and  anew  characterized  by  mucous  rales,  and  niuco-purulent  expectoration. 
These  local  symptoms  and  the  bad  general  state  of  the  patient,  led  me  to  fear 
that  new  tubercular  mischief  was  going  on  in  the  right  lung,  when  all  at 
once  during  the  night  between  18th  and  19th  January,  he  was  seized  with 
great  difficulty  of  breathing,  accompanied  by  a  threatening  of  suffocation, 
and  after  some  violent  paroxysms  of  cough,  he  ejected  by  the  mouth  a  great 
quantity  of  muco-purulent  matter.  This  afforded  him  some  transient  relief: 
but  renewed  attacks  of  coughing  induced  renewed  purulent  vomiting.  Next 
morning,  I  ascertained  that  the  quantity  which  he  had  brought  up  was  half 
a  litre.  The  vomiting  now  described  was  followed  by  a  great  change  in 
the  symptoms.  I  thought  that  the  effusions,  the  existence  of  which  I  had 
detected  on  the  previous  evening,  had  found  an  exit  by  an  opening  in  a 
bronchial  tube,  and  as  there  was  no  sign  of  hydropneumothorax,  I  sup- 
posed that  there  was  very  probably  an  encysted  or  interlobular  pleurisy, 
because  on  attentively  examining  the  contents  of  the  spittoon,  whitish  shreds 
of  false  membrane  were  seen.  When  these  shreds  were  carefully  washed, 
they  appeared  white,  opaque,  thickish,  torn  at  the  edges.  Notwithstand- 
ing the  great  rarity  of  such  cases,  I  came  to  the  conclusion  that  what  we 
saw  was  the  debris  of  an  hydatid  tumor  of  the  lung.  This  view  was  estab- 
lished, beyond  any  doubt,  to  be  correct,  by  a  microscopical  examination 
made  by  M.  Charles  Robin.  For  three  days,  the  patient  continued  to  eject 
fragments  of  false  membrane  and  muco-purulent  matter  mixed  with  a  little 
blood.  The  expectoration  gradually  diminished  in  quantity,  the  fever 
ceased,  and  day  by  day,  there  was  an  appreciable  amelioration  in  the  state  of 
the  patient.  Very  soon  there  was  no  dulness  on  percussion  in  the  inferior 
and  posterior  part  of  the  lung,  expiration  continuing,  however,  to  be 
blowing  in  that  situation,  where  coarse  mucous  rales  were  still  audible. 
Convalescence  advanced  rapidly;  and,  all  the  local  phenomena  having 
disappeared,  the  young  man  left  us  quite  cured,  after  two  months'  residence 
in  hospital. 

The  principal  points  in  this  interesting  case  may  be  thus  summed  up : 
the  rational  signs  were  those  of  pulmonary  phthisis:  the  physical  signs 
were  doubtful :  there  was  bronchitis  and  pleurisy:  then,  under  the  influence 
of  the  acute  disease,  a  hydatid  tumor,  developed  in  the  inflamed  lung,  be- 
came the  seat  of  inflammation,  an  eliminative  process  began  around  it,  and 
the  patient  ejected  hydatid  fragments  mixed  with  a  vast  quantity  of  pus. 
Immediately  consequent  upon  the  ejection  of  a  great  quantity  of  muco-pur- 
ulent matter,  auscultation  revealed  the  existence  of  a  cavity  in  the  inferior 
third  of  the  right  lung,  where  blowing  respiration  could  be  heard.  By  de- 
grees this  cavity  disappeared,  the  normal  respiratory  murmur  again  became 
audible  throughout  the  whole  extent  of  the  chest,  and  the  general  state  of 
the  patient  became  more  and  more  satisfactory.  I  said  that  in  all  proba- 
bility the  hydatid  had  its  seat  in  the  lung,  because  after  the  vomiting  we 
could  discover  no  signs  of  hydropneumothorax,  which  signs  would  certainly 
have  existed  had  the  tumor  projected  into  the  pleural  cavity. 

Gentlemen,  before  commenting  on  this  case,  which  is  similar  to  others, 
and  suggests  considerations  relative  to  the  difficulties  attending  the  diag- 
nosis of  hydatids  of  the  lung,  the  progress  of  the  case,  aud  the  different 
modes  of  termination,  let  me,  in  passing,  direct  your  attention  to  the  semei- 
ology  of  that  deformity  of  the  fingers  which  we  have  observed  in  our  patient. 

It  is  stated  in  the  works  of  Hippocrates  that  the  nails  of  phthisical  sub- 
jects become  contracted — tabidis  ungues  contrahuntur — and  crooked — tabidis 


640  HYDATIDS    OF    THE    LUNG. 

ungues  adunei.  This  clinical  fact,  though  not  denied,  was  forgotten,  till 
1832,  when  Dr.  Pigeaux  pointed  it  out  anew.  In  the  following  year  I  pub- 
lished in  the  "  Journal  des  Connaissances  Medico-Chirurgicales  "  a  paper 
on  this  subject,  accompanied  by  a  plate  drawn  by  my  pupil,  Dr.  Jardon; 
and  now  there  is  no  physician  ignorant  of  what  is  meant  by  the  expression 
— "Hippocratic  deformity  of  the  fingers."  This  deformity  consists  in  con- 
traction of  the  ungual  phalanx,  with  enlargement  and  thickening  of  the 
digital  pulp.  Whilst  the  nail  becomes  curved  towards  the  palm  of  the 
hand,  the  extremity  of  the  finger  assumes  the  form  of  the  large  end  of  a 
,club,  and  sometimes,  in  enlarging,  it  flattens  so  as  to  resemble  the  head  of 
a  serpent.  This  deformity,  generally,  comes  on  by  slow  degrees ;  but,  at 
other  times,  it  is  produced  with  great  rapidity,  the  patients  suffering  pain 
from  the  change  which  is  going  on.  The  other  phalanges  do  not  undergo 
any  change.  In  some  persons  the  toes  are  the  seat  of  a  similar  deformity; 
but,  when  it  occurs  in  the  toes,  it  is  geuerally  in  a  much  less  degree  than  in 
the  fingers. 

Hippocratic  deformity  of  the  fingers  is  chiefly  observed  in  persons  who 
have  reached  the  second  or  third  stage  of  pulmonary  phthisis:  it  is  not  met 
with  in  scrofulous  subjects,  and  it  seldom  exists  in  patients  affected  with 
abdominal  phthisis,  unless  they  are  likewise  the  subjects  of  pulmonary 
tubercle. 

It  is  also  observed,  as  the  older  physicians  stated,  in  individuals  affected 
with  non-tuberulous  chronic  diseases  of  the  chest.  Some  years  ago  I  ob- 
served it  in  a  child  whom  I  believed  to  be  tuberculous,  and  in  whom  para- 
centesis of  the  chest,  performed  for  an  enormous  pleuritic  effusion,  had  left 
a  fistula,  by  which  for  several  months  a  large  quantity  of  purulent  serosity 
was  discharged.  This  child  grew  up  to  adolescence,  retaining  the  fistula: 
the  chest  had  undergone  considerable  contraction,  but  I  was  never  able  to 
detect  any  signs  of  tubercle.  In  1S59  I  had  a  female  patient  whom  I  twice 
tapped — the  interval  between  the  tappings  being  short — in  a  case  of  empy- 
ema following  parturition,  who  retained  a  thoracic  fistula  for  two  years: 
this  woman  had  Hippocratic  deformity  of  the  fingers,  but  I  could  nol  detect 
in  her  any  sign  of  tubercle.  I  believe,  then,  that  Hippocratic  deformity  of 
the  fingers  may  be  an  accompaniment  of  chronic  chest  affections  unconnected 
with  phthisis.  The  two  cases  which  I  have  narrated,  and  others  which  I 
could  cite,  show  that  it  is  liable  to  occur  in  diseases  of  the  pleura:  I  have 
observed  it  in  patients  with  bronchitis,  with  emphysema,  and  in  others  who 
had  nothing  more  than  nervous  asthma  :  I  have  also  seen  it  in  patients  with 
organic  disease  of  the  heart.  It  must  be  remembered,  however,  that  it  is 
principally  in  cases  of  phthisis  that  it  is  met  with,  and  that  the  curving  of 
the  nail  is  the  more  marked  the  more  advanced  is  the  stage  of  phthisical 
disease.  For  this  reason  Hippocratic  deformity  of  the  fingers  has  some 
value  as  a  diagnostic  Bign  of  phthisis. 

Gentlemen,  excuse  me  for  making  this  digression.     In  clinical  studies 

facts,  apparently  the st  insignificant,  may  have  their  importance,  and  so 

we  ought  m»t  to  neglect   I  hem. 

Lei  us  now  return  to  our  subject — hydatids  of  the  lung. 

The  details  into  which   I  entered  in  reference  to.  hi  i-  patient  of  Si.  A-gnes's 

Ward,  bave  shown  you  the  embarrassing  nature  of  the  diagnosis.  The 
difficulty  lies  in  the  fact,  that  there  is  no  special  Bign  of  hydatids  of  the 

lung.      Study  the  cases  which  are  recorded  in  scientific  works,  ami  you  will 

perceive  that  in  a  great  nu  m  her,  perhaps  in  the  majority  of  them,  the  mor- 
bid phenomena  are  sometimes  dependent  on  pleuritic  effusion,  and  some- 
times upon  pulmonary  phthisis.  ( )f  course,  when  the  hydatids,  or  fragments 
of  hydatids,  have  been  expectorated,  there  is  nor fordoubl  as  to  the 


HYDATIDS   OF    T1IE    LUNG.  G-il 

nature  of  the  ease;  but  there  will  still  be  an  uncertainty  as  to  the  precise 
scat  of  the  tumor:  it  will  be  a  question  whether  it  is  situated  in  the  paren- 
chyma of  the  lung  or  in  the  pleural  cavity,  or  whether  the  hydatids  have 
not  come  from  the  liver  by  way  of  the  lungs. 

Intrathoracic  hydatid  tumors  occur  much  more  frequently  in  the  paren- 
chyma of  the  lung  than  in  the  pleural  cavity,  as  has  been  shown  by  M. 
Dayaine  by  an  analysis  of  eases  collected  by  him.  This  opinion  had  been 
previously  enunciated  by  Laeiinec,  and  is  likewise  that  of  Professor  J. 
Cruveilhier.  By  simply  reasoning  from  analogy,  moreover,  the  same  con- 
clusion might  have  been  come  to;  for  it  is  in  parenchymatous  organs,  such 
as  the  liver,  spleen,  and  kidney.-,  and  in  the  thickness  of  muscular  masses, 
that  hydatids  are  generally,  or  indeed  nearly  always,  developed.  The  res- 
piratory apparatus  is  no  exception  to  this  general  rule:  and  M.  Davaine 
believes  that  a  great  many  alleged  hydatids  of  the  pleura,  are  really 
hydatids  of  the  lung  which  have  fallen  from  their  original  situation  into 
the  cavity  of  the  pleura.  It  may  likewise  happen,  that  tumors  situated 
near  the  periphery  of  the  lung,  as  they  slowly  develop  themselves  at  the 
edge  of  that  organ,  may  become  detached,  to  a  greater  or  less  extent,  from 
the  pulmonary  pleura,  which  they  push  over  to  the  costal  pleura,  in  such  a 
manner  that  the  hydatid  pouch  seems  to  be  placed  in  the  serous  cavity, 
although  in  reality  it  is  wholly  external  to  it.  Such  seems  to  have  been 
the  state  of  matters  in  a  case  reported  by  Dupuytren  and  Geoffrey,  and 
designated  by  them — double  cyd  of  the  pleura.  In  that  case,  it  is  stated, 
that  the  patient  had  had  numerous  attacks  of  haemoptysis,  which  one  can 
hardly  understand,  unless  the  cyst  had  in  the  first  instance  occupied  the 
pulmonary  parenchyma,  as  we  know  that  haemoptysis  is  a  very  common 
symptom  of  diseases  of  the  lung,  while  it  never  supervenes  in  affections  of 
the  pleura. 

Haemoptysis,  moreover,  has  been  remarked  to  have  occurred  in  nearly  all 
the  cases  of  pulmonary  hydatids.  A  man  whose  case  lias  been  published  in 
the  Bulletins  de  la  Societe  Anatomique  by  M.  Husson,  expectorated  hydatids 
upon  fifteen  different  occasions,  and  each  time  the  occurrence  was  preceded 
by  spitting  of  blood.  He  never  had  any  of  the  rational  or  physical  signs 
of  pulmonary  tuberculization  ;  and  his  general  health  was  satisfactory. 

Gentlemen,  when  hydatid  tumors  seated  near  the  periphery  of  the  pul- 
monary parenchyma  are  slowly  developed  in  the  direction  of  the  pleura, 
there  can  be  no  symptoms  except  those  which  accompany  more  or  less 
pleuritic  effusion,  or  are  caused  by  the  squeezing  of  the  lung  into  the  verte- 
bral hollow.  You  can  understand,  however,  that  these  symptoms  are  more 
or  less  serious,  and  that  when  they  are  caused  by  a  double  cyst,  as  in  the 
case  narrated  by  Dupuytren  and  Geoffroy,  the  embarrassment  in  the  breath- 
ing may  proceed  to  such  an  extent  that  the  patients  are  carried  off  by  suf- 
focative fits. 

But  when  a  hydatid  tumor  of  the  lung  bursts  suddenly  into  the  pleural 
cavity,  the  symptoms  are  very  much  more  serious,  as  a  subacute  pleurisv  is 
set  up,  and  when  the  bursting  is  both  into  the  pleura  and  the  bronchial 
tubes,  there  is  produced  hydropneumothorax,  as  happened  in  the  follow- 
ing case,  recorded  by  Dr.  Mercier  in  the  Bulletins  de  la  Societe  Anatomique. 
A  man,  thirty-eight  years  of  age,  subject  for  years  to  frequent  haemoptysis, 
although  he  presented  no  other  sign  of  tubercular  disease  at  the  summit  of 
the  lung,  was  suddenly  seized  with  acute  pain  in  the  right  side:  on  exam- 
ining the  chest,  hydropneumothorax  was  discovered :  the  patient  sank 
rapidly.  At  the  autopsy,  there  was  found  in  the  pleural  cavity,  a  hydatid 
floating  in  the  effused  fluid  :  in  the  part  of  the  lobe  of  the  lung  correspond- 
ing to  the  interlobular  cleft,  there  was  an  excavation  in  the  parenchyma 
vol.  i. — 41 


642  HYDATIDS    OF    THE    LUNG. 

of  the  organ,  and  in  the  same  situation  Avas  observed  an  ulcerated  bron- 
chial tube. 

It  is  evident,  or  at  least  very  probable,  that  in  this  case,  the  process  of 
elimination  going  on  simultaneously  in  the  bronchial  tubes  and  pleura,  led 
to  perforation  of  the  lung,  and  so  to  hydropneumothorax.  The  attacks  of 
haemoptysis  which  occurred  during  life,  the  discovery  after  death  of  an  ex- 
cavation in  the  parenchyma  of  the  lung  still  containing  the  hydatid,  seemed 
to  point  out  clearly  the  seat  of  the  affection.  However,  inasmuch  as  the  exca- 
vation was  situated  in  the  interlobular  fissure,  it  may  be  asked  whether  the 
pouch  was  not  originally  formed  in  that  fissure,  whence  it  had  invaded  and 
excavated  the  pulmonary  parenchyma :  and  on  comparing  this  case  with 
cases  in  which  hydatids  unquestionably  occupied  the  lung  itself — in  con- 
sidering, as  I  have  just  been  saying,  that  it  is  generally  in  parenchymatous 
organs  that  these  entozoa  become  developed,  it  was  justifiable,  arguing  from 
the  general  to  the  particular,  to  conclude,  that  in  this  case  the  original  seat 
of  the  tumor  was  really  that  which  the  examination  of  the  dead  body 
enabled  us  to  assign  to  it. 

This  case  may  give  you  an  idea  of  the  difficulty  which  there  is  some- 
times of  determining  in  the  dead  body  the  precise  seat  of  an  hydatid  of  the 
lung,  when  the  tumor,  not  being  situated  in  the  interior  of  the  parenchyma, 
has  burst  at  the  surface  of  the  organ.  I  need  not  say  that  the  difficulty 
will  be  infinitely  greater  when  we  make  our  examination  in  a  living  patient. 
However,  when  the  radical  cure  takes  place,  after  the  ejection  of  hydatids 
by  expectoration,  the  physician  may  conclude  that  the  hydatids  occupied 
the  substance  of  the  lung,  the  nature  of  the  affection  being  shown  by  the 
discharge  from  the  bronchial  tubes;  and  when  a  hydropneumothorax  is 
produced,  it  may  be  presumed,  not  only  that  the  hydatids  are  situated  in 
the  pleural  cavity,  but  also,  that  they  occupy  a  position  near  the  periphery 
of  the  lung. 

Sometimes,  the  hydatids  are  not  inclosed  in  an  adventitious  cyst ;  and  at 
other  times,  the  containing  cysts  are  exceedingly  thin,  a  circumstance  which 
well  explains  the  facility  with  which  they  may  find  an  exit  by  the  bron- 
chial tubes,  when  these  canals  are  opened  by  ulceration.  This  was  pointed 
out  by  M.  Houel  in  a  report  which  he  read  to  the  Anatomical  Society  upon 
the  occasion  of  M.  Pinault  communicating  a  case  of  pulmonary  hydatids. 
The  absence  of  the  adventitious  cyst,  or  the  extreme  tenuity  of  the  envelop 
by  which  the  cyst  is  constituted,  likewise  explains  how  hydatid  tumors  of 
the  hum;  may  become  ruptured  under  the  influence  of  an  inflammatory 
affection  of  the  respiratory  apparatus,  as  occurred  in  the  ease  of  our  patient 
of  St.  Agnes's  Ward. 

Gentlemen,  from  M.  Davaine's  statistical  researches,  it  appears  thai  it  is 
much  more  unusual  to  meet  with  several  hydatid  tumors  in  a  single  lung, 
than  a  single  hydatid  tumor  in  each  lung;  but  it  is  still  more  common  to 
find  a  single  hydatid  in  only  one  Lung,  and  in  that  ease,  it  is  generally  in 
the  right  lung — usually  in  the  inferior,  hut  sometimes  in  the  superior,  lobe. 

The  much  greater  frequency  of  hydatids  in  the  inferior  lobe  of  the  right 
lung,  considered  in  connection  with  the  extreme  frequency  of  these  entozoa 
in  lli''  liver,  has  led  to  the  supposition  that,  in  a  certain  number  of  cases, 
tin;  intrathoracic  hydatids  have  passed  from  the  liver  into  the  chest. 

There  have  now  been  recorded  numerous  eases  in  which  this  passage  of 

hydatid-    from    the    liver   into   the   thorax    has   taken    place.      In    1866,  Dr. 

Dolbeau  called  the  attention  of  physicians  to  the  tendency  which     large 


Dolbkaxj:  Etudes  sur  les  grands  Kvstes  de  la  surface  eonvexe  du  Foie.     These 
.!■■  Paris,  1856 


HYDATIDS    OF    THE    LUNG.  643 

cysts  of  the  convex  surface  of  the  liver  have  thus  to  invade  the  chest, 
pressing  the  diaphragm  against  the  lung,  at  the  same  time  depressing  the 
liver,  and  so  gaining  the  epigastric  region.  The  invasion  of  the  thoracic 
cavity  by  these  cysts  may  be  so  great,  that  the  lung,  packed  into  the  cla- 
vicular region,  and  into  the  vertebral  hollow,  is  reduced  to  a  third,  or  even, 
it  may  be,  to  a  fourth  of  its  normal  volume.  You  can  understand  how  such 
an  invasion  of  the  chest  by  an  abdominal  tumor,  cannot  take  place  without 
the  diaphragm  becoming  exceedingly  attenuated.  This  is  what  takes  place : 
the  attenuated  diaphragm  contracts  adhesions  with  the  hydatid  pouch, 
which  is  consequently  dragged  up  in  the  ascending  movement.  The  result 
of  this  is,  that  when  it  is  wished  to  determine  the  nature  of  the  affection 
with  which  we  have  to  do,  we  may  possibly  find  nothing  more  than  signs 
of  a  pleuritic  effusion — absolute  dulness  of  a  greater  or  less  extent  of  the 
lower  part  of  the  chest,  absence  of  thoracic  vibration,  absence  of  vesicular 
murmur,  absence  of  blowing  and  segophony,  the  results  of  the  displacement 
of  organs,  and  crushing  up  of  the  lung,  the  place  of  which  is  occupied  by  a 
liquid  tumor.  The  progress  of  the  disease,  and  the  thoracic  deformity  (a 
deformity  which  extends  to  the  region  of  the  liver,  where  it  presents  a  pecu- 
liarly characteristic  aspect),  furnish  the  only  elements  of  diagnosis. 

The  slow  unobtrusive  inflammation  which  has  caused  the  formation  of 
the  adhesions  between  the .  hepatic  cyst  and  the  diaj)hragm,  may,  extend- 
ing, in  virtue  of  contiguity,  to  the  pleura  and  the  lung,  produce  similar 
adhesions  between  the  lung,  the  pleura,vthe  diaphragm,  and  the  tumor, 
which  adhesions  conduce  to  the  favorable  termination  of  the  disease.  If — 
as  occurs  in  a  few  exceptional  cases — adhesions  do  not  form  between  the 
hydatid  pouch  and  the  lung,  the  pouch  opens,  through  a  perforation  of  the 
diaphragm,  into  the  pleural  cavity,  occasioning  an  almost  invariably  mortal 
pleurisy.  But  if  the  adhesions  are  such  that  the  lung,  the  pleura,  the  dia- 
phragm, and  the  cyst,  are  intimately  united,  the  tumor,  which  ultimately 
always  bursts,  opens  into  the  cavity  it  has  dug  for  itself  in  the  pulmonary 
parenchyma,  and  discharges  by  the  bronchial  tubes. 

A  great  number  of  cases  of  this  character  have  now  been  published  ;  and, 
among  other  places,  you  will  find  them  in  the  thesis  of  Dr.  Cadet-Gassicourt,* 
and  in  the  memoir  of'  Dr.  E.  Leudet  (of  Rouen).f  Bricheteau,  setting  forth 
all  the  interest  which  attaches  to  this  subject,  pointed  out  the  propitious 
manner  of  evacuating  hydatid  tumors  by  the  bronchial  tubes. |  In  the 
case  of  a  patient  whom  he  saw  with  Professor  Natalis,  Guillot  states,  that 
immediately  after  the  patient  had  expectorated  matter  containing  the 
debris  of  hydatids,  there  was  detected,  by  auscultation,  a  cavity  excavated 
both  in  the  pulmonary  pai'enchyma  and  in  the  liver ;  and  which  was  char- 
acteristically indicated  by  amphoric  blowing  and  pectoriloquy.  That  the 
liver  was  the  seat  of  the  tumor  was  sufficiently  shown  .by  the  expectoration 
being  constituted  by  a  yellow  fluid  which  assumed  the  color  of  verdigris 
when  treated  by  nitric  acid.  At  the  time  of  bringing  it  up  the  patient 
felt  a  very  marked  saline  taste  in  the  mouth,  due  probably  to  the  chloride 
of  sodium,  which  chemical  analysis  has  shown  to  exist  in  hydatid  cysts. 

This  fluid,  taking  a  yellow  color  from  the  bile,  has  also  sometimes  a 
chocolate-brown  hue  derived  from  the  coloring  matter  of  the  blood,  and 

*  Cadet-Gassicotjrt:  Kecherches  sur  hi  Bupture  des  Kyetes  Hydatiques  du  Foie 
a  travers  la  paroi  abdominale  et  dans  les  organes  voisins.  These  de  doctorat,  Paris, 
1806. 

f  Lecdet:  Memoire  sur  le  Traitement  des  Kystes  Hydatiques  dn  Foie,  lu  a  la 
Societe  Medicate  des  Hopitaux.  [Archives  Generales  de  Medecine,  for  January  and 
February,  I860.] 

?  Bricheteau:  in  the  Eevue  M6dico-C'hirursricale  for  1852. 


644  HYDATIDS    OF    THE    LUNG. 

also  from  microscopic  hepatic  cells.  These  facts  which  have  served  as  the 
basis  of  Bricheteau's  work — a  work  to  which  I  refer  you — were  obtained 
in  his  hospital  practice,  and  he  has  added  to  them  others,  quoted  from  the 
curious  memoir  of  Hebreard,  formerly  a  physician  of  the  Bicetre.  But 
what  I  have  to  say  on  this  subject,  will  be  more  in  place  when  I  come  to 
speak  of  cysts  of  the  liver:  I  therefore  defer  to  another  occasion  some  re- 
marks required  to  complete  my  account  of  this  subject.  I  shall  only  add 
that  the  thesis  of  Dr.  Cadet-Gassicourt  has  given  us  new  means  of  diag- 
nosing intrathoracic  cysts,  a  very  important  matter  for  clinical  physicians. 

Before  concluding,  I  must  succinctly  mention  a  case  published  by  Dr. 
Vigla.* 

The  patient  was  a  man,  aged  thirty-two  years,  who,  consequent  upon  a 
violent  contusion  produced  by  the  kick  of  a  bull  on  the  right  side  of  the 
chest,  complained  of  pain  in  the  right  hypochondrium,  and  an  oppression 
of  the  breathing,  which  from  the  date  of  the  accident,  fifteen  months  pre- 
viously, had  been  constantly  increasing.  For  the  preceding  five  months, 
the  dyspnoea  had  been  so  considerable,  that  the  patient  had  been  obliged  to 
give  up  his  employment.  He  had  little  or  no  cough,  and  no  expectoration: 
he  had  never  had  haemoptysis :  although  he  had  in  a  marked  manner  the 
symptoms  of  anaemia,  he  complained  of  no  organic  suffering,  except  that  of 
which  the  respiratory  organs  seemed  to  be  the  seat ;  and  he  stated  that  the 
pulmonary  symptoms  had  never  been  accompanied  by  fever. 

The  intense  pain  of  which  he  complained  seemed  to  be  limited  to  a  small 
space  under  the  right  mamma.  The  oppression  of  the  breathing,  which 
was  continuous,  became  excessive  when  he  walked,  or  even  after  the  exer- 
tion of  speaking  for  some  time :  he  could  not  lie  on  the  left  side,  and  gen- 
erally sat  when  in  bed.  On  examining  the  chest,  it  was  observed  that 
there  was  a  much  greater  development  of  the  right  than  of  the  left  side, 
and  that  anteriorly  the  right  side  was  very  much  arched  in  appearance : 
there  was  distension  of  the  intercostal  spaces,  which  projected  at  least  as 
much  as  the  ribs.  On  the  right  side  also,  the  normal  resonance  was  com- 
pletely replaced  by  absolute  dulness,  which  extended  from  the  second  in- 
tercostal space  to  the  umbilicus,  measuring — taking  a  line  parallel  to  the 
sternum — 28  centimetres,  and — transversely — crossing  the  median  line  in 
such  a  manner  that  the  space  occupied  by  it  was  circumscribed  below  by 
a  line,  which  after  passing  beyond  the  navel,  proceeded  in  an  oblique 
direction  under  the  left  axilla;  and  above,  by  a  line  which,  following  the 
upper  edge  of  the  second  rib,  passed  over  the  sternum  at  three  centimetres 
below  the  bifurcation  of  that  bono,  and  proceeded  by  a  curve  to  rejoin  the 
lower  line  under  the  left  axilla.  Tims,  it  occupied  the  whole  of  the  righl 
side  of  the  chest,  encroaching  a  little  on  the  left  side.  Applying  the  hand 
to  this  side,  and  at  the  same  time  requesting  the  patient  to  speak,  it  was  as- 
certained that  an  entire  absence  of  thoracic  vibration  existed  ;  and  on  apply- 
ing the  car,  there  was  heard  neither  vesicular  murmur,  nor  any  anomalous 
sound  in  front,  although  posteriorly,  the  respiratory  sound  was  exaggerated 
in  the  three  superior  fourths  of  the  right  side,  as  it  was  also  in  the  left  side. 
There  was   heard,  moreover,  on    the   righl    side,  amphoric  resonance   of  the 

voice,  and  even  respiratory  murmur,  like  that  heard  in  certain  pleuritic 
effusions,  unaccompanied  by  blowing  or  segophony. 

No  lesion  of  the  pulmonary  parenchyma,  as  is  justly  observed  by  lb-. 
wigla,  seems  capable  of  producing  similar  deformity  of  the  chest.      Nor  was 

there  any  ground  for  entertaining  the  idea  that  there  was  hydrothorax ;  for 


*  Viola:  MSmoire  but  les  Bydatidea  de  la  cavite  thoracique.     {Archives  Gfntr- 
<tlen  di  Midecitte,  for  September  ami  November,  1855.     Vol.  ii  of  Hub  series.] 


HYDATIDS    OF    THE    LUNG.  645 

it  would  be  difficult  to  believe  that  an  encysted  pleuritic  effusion  could  be 
distributed  so  unequally  and  so  irregularly  aa  to  respect  tbe  first  intercostal 
space,  the  three  superior  and  posterior  fourths  of  the  right  side  of  the  thor- 
acic cavity,  while  it  invaded  the  left  side,  and  pushed  the  diaphragm  as  far 
down  as  the  umbilicus.  The  hypothesis  that  there  existed  a  solid  tumor — a 
cancer,  an  aneurism  of  the  aorta  or  of  one  of  its  principal  branches — was  un- 
tenable. In  the  first  place,  a  solid  tumor  would  transmit  the  respiratory  and 
cardiac  sounds,  which  were  entirely  absent  in  this  case:  and  then  again,  a 
cancerous  tumor,  the  only  tumor  which  could  take  so  large  a  development, 
could  not  have  been  formed  without  producing  general  cachectic  symptoms. 
Dull  and  deepseated  fluctuation  was  perceptible,  and  furnished  a  sign,  which, 
in  conjunction  with  others,  justified  the  j)resumption  that  there  was  a  hydatid 
cyst. 

An  exploratory  puncture  made  by  M.  Monod,  surgeon  to  the  Maison  de 
Sante,  proved  this  diagnosis  to  be  correct.  The  fluid  which  issued  from  the 
capillary  canula  of  the  trocar  was  clear  as  water  from  the  crystal  spring: 
it  produced  no  change  on  litmus-paper,  and  no  albuminous  precipitate  when 
treated  by  nitric  acid  or  heat.  Tapping,  consequently,  was  performed  with 
a  larger  trocar,  when  2450  grammes  of  fluid  similar  to  that  originally  with- 
drawn were  evacuated.  That  portion  of  this  fluid  which  flowed  last  from 
the  canula,  contained  the  shreds  of  transparent  membrane,  which  M.  Charles 
Robin  found  on  examination  to  be  the  debris  of  hydatids. 

A  solution  of  iodine  was  injected.  Thirty-seven  days  after  the  operation 
— fifty-one  days  after  his  entering  the  Maison  de  Sante — the  patient  asked 
and  received  permission  to  leave,  that  he  might  resume  his  employment. 
Eleven  months  afterwards,  when  M.  Vigla  saw  him,  the  cure  was  as  com- 
plete as  possible. 

Gentlemen,  let  me  say  a  word  to  you  on  the  great  value  of  that  peculiar 
arching  of  the  thorax,  observed  in  the  case  of  which  I  have  just  given  you 
an  abridged  history.  It  is  a  diagnostic  sign  full  of  meaning,  and  is  in  itself 
sufficient  to  justify  an  exploratory  puncture  such  as  M.  Vigla  practiced  in 
his  case.  This  form  of  arching  of  the  chest,  so  very  peculiar,  enabled  me 
so  far  back  as  1848,  to  diagnose  an  intrathoracic  hydatid  tumor  in  a  girl 
seven  years  old. 

This  little  girl  presented  the  general  appearance  of  a  phthisical  subject. 
For  a  long  time,  she  had  had  cough  and  oppression  of  the  breathing.  Her 
emaciation  wras  extreme.  On  examining  the  chest,  I  found  complete  dul- 
ness  on  percussion,  and  an  absence  of  thoracic  vibrations  :  there  was  a  glob- 
ular projection  of  the  thorax,  the  maximum  of  which  corresponded  with  the 
sixth  and  seventh  ribs.  As  there  had  been  no  hemorrhage,  and  as  auscul- 
tation did  not  disclose  any  lesion  of  the  upper  parts  of  the  lungs,  I  proposed 
to  tap  the  chest.  I  was  not  allowed  to  do  so :  and  the  child  died  some 
weeks  after  my  visit. 

Gentlemen,  the  clinical  history  of  hydatid  cysts  of  the  lung  is  far  from 
being  complete.  The  insidious  commencement,  the  sometimes  slow,  and  at 
other  times  rapid  progress  of  the  affection,  our  almost  complete  ignorance 
of  its  etiology,  sufficiently  proclaim  the  difficulty  of  the  subject.  In  the 
majority  of  cases,  the  nature  of  the  affection  has  been  mistaken,  and  very 
rarely  even  suspected  during  the  life  of  the  patients,  so  that  for  a  long 
period  the  only  data  which  we  had  in  relation  to  it  were  those  furnished  by 
pathological  anatomy.  These  data,  however,  were  important,  and  such  as 
to  throw  light  on  the  manner  of  forming  a  diagnosis  on  the  living  subject. 
They  informed  the  physician,  for  example,  that  he  might  meet  with  hyda- 
tids in  the  lung,  but  that  they  seldom  if  ever  existed  in  the  pleura :  they 
told  him  that  hydatids  of  the  liver  might  pass  from  the  liver  into  the  thor- 


646  HYDATIDS    OF    THE    LUNG. 

acic  cavity :  that  the  existence  of  hydatids  in  the  chest  generally  coincided 
with  their  presence  in  other  organs,  particularly  in  the  liver,  and  that  their 
favorite  locality  is  the  right  lung. 

Pathological  anatomy  has  also  taught  us  that  pulmonary  hydatids,  of 
which  generally  there  is  only  one  found  in  the  same  lung,  may,  within  the 
parenchyma  of  the  lung,  become  as  large  as  the  head  of  an  adult ;  that 
their  adventitious  envelope  may  either  be  very  thin  or  entirely  wanting ; 
that  an  acute  inflammation  of  the  lung  may  cause  them  to  burst,  either  into 
the  pleural  cavity  where  they  produce  the  symptoms  of  hydrothorax,  or 
into  the  bronchial  tubes,  in  which  case  they  may  be  expectorated  either  in 
shreds,  or  in  their  totality.  Pathological  anatomy  has  shown  us  that  these 
vast  pulmonary  and  hepatic  warrens  communicate  by  one  large  diaphrag- 
matic fistula.  In  these  facts,  there  is  enough  to  lead  us  to  suspect  in  some 
cases,  and  to  affirm  in  others,  that  our  patients  have  pulmonary  hydatids. 
An  attentive  examination  of  the  other  organs,  and  the  progress  of  the  affec- 
tion, ought  to  enable  us  to  bring  together  all  the  probabilities  in  such  a 
manner  as  to  determine  the  original  seat  of  the  affection  which  we  suppose 
to  exist. 

To  Hebreard  and  Bricheteau,  and  MM.  Vigla,  Cadet-Gassicourt,  and 
Da vaine,  belong  a  large  share  of  the  merit,  which  I  am  pleased  to  acknowl- 
edge, of  elucidating  this  important  question  of  the  diagnosis  of  hydatids  of 
the  lung. 

We  may  suspect  the  existence  of  hydatids  of  the  lung,  if,  along  with  the 
coexistence  of  cei"tain  symptoms,  Ave  find  that  peculiar  deformity  of  the 
chest  of  which  I  have  been  speaking.  When  once  the  existence  of  the 
affection  has  been  made  out,  it  is  then  necessary  to  try  to  determine  which 
is  the  probable  original  seat  of  the  entozoa. 

In  general,  patients  affected  with  hydatids  of  the  lung,  present  many  of 
the  rational  and  physical  signs  of  phthisis  or  chronic  pleurisy.  In  fact, 
the  majority  of  this  class  of  patients  will  tell  you  that  they  have  been  sub- 
ject for  a  long  period  to  haemoptysis,  more  or  less  profuse,  and  more  or  less 
frequent,  as  well  as  to  oppression  of  the  breathing.  You  will  hear  rales 
disseminated  over  the  chest,  and  sometimes  you  will  find  dulness  at  one  or 
both  summits,  when  tubercles  will  coexist  with  the  hydatids.  But  inde- 
pendently of  this  exceptional  complication,  the  attentive  study  of  the  prog- 
ress of  the  affection,  the  rational  explanation  of  some  of  the  symptoms, 
will  enable  you  to  reject  the  hypothesis  that  there  is  tubercular  phthisis, 
when,  for  example,  there  is  no  disease  of  the  summits,  as  in  the  case  observed 
by  M.  Husson :  the  haemoptysis  in  such  circumstances  will  then  probably 
have  no  other  cause  than  the  continuous  irritation  excited  by  the  presence 
of  a  foreign  body,  which  will  frequently  occupy  the  middle,  and  still  more 
commonly  the  lower,  lobe  of  the  lung.  The  general  condition  of  the  patient, 
his  age,  and  the  progress  of  the  affection,  will  aid  your  diagnosis;  and  if 
you  have  had  occasion  to  Suspect  the  presence  of  hydatids  in  the  liver,  or 
in  any  other  organ,  you  will  be  entitled  to  conclude  that  the  pulmonary 
parenchyma  is  itself  their  seat. 

A.gain,  attention  is  nol  directed  to  hydatids  of  the  lung  till  they  have 
attained  a  great  size,  when  they  are  Liable  to  be  mi-taken  for  Beveral 
descriptions  of  encysted  and  interlobular  pleurisy,  a^  occurred  in  the  case 

of  the  young  man,  our  patient  of  St.  A.gnes'8  Ward.  However,  when,  OD 
examining  a  patient,  you  find  a  globular  deformity  of  the  chesl  of  limited 
extent,  the  probability  of  the  case  being  one  of  encysted  hydatid  is  greatly 
strengthened:  sooner  or  later,  the  progress  of  the  affection,  which  is  very 
differenl  from  thai  of  pleurisy,  and  particularly  the  expectoration  of  hyda- 
tids, when  it  occurs,  will  remove  all  doubts.     You  will  perhaps  be  justified, 


HYDATIDS    OF    THE    LUNG.  647 

even  in  cases  in  which  this  valuable  diagnostic  occurrence  does  not  take 
place,  to  suppose  lliat  there  are  hydatids,  when  you  see  sudden  symptoms 
of  inflammation  of  the  pleura,  while  at  the  same  time  there  is  flattening  of 
the  globular  tumor,  because  there  will  then  be  ground  to  suppose  thai  the 
flattening  is  consequent  upon  rupture  of  the  hydatid  pouch  into  the  pleural 
cavity.  This  probably  correct  diagnosis  will  attain  almost  a  certainty  of 
being  correct,  if  symptoms  of  acute  pleurisy  come  to  be  added  to  the  signs 
of  hydropneiimothorax.  In  such  a  case,  ulceration,  in  virtue  of  which  the 
hydatid  lias  emerged  into  the  pleura,  has  likewise,  at  the  same  time  impli- 
cated a  bronchial  tube. 

I  have  said  that  it  is  needless  to  insist  on  the  fact,  so  palpably  evident, 
that  when  the  debris  of  hydatids  has  been  discovered  in  the  expectoration, 
there  can  be  no  possible  doubt  as  to  the  nature  of  the  case.  There  will 
still  remain  some  uncertainty  as  to  the  original  seat  of  the  hydatids.  This 
is  a  point  in  diagnosis  which  has  to  be  elucidated. 

Beyond  all  doubt,  hydatid  cysts  have  been  found  in  the  pleural  cavity. 
M.  Vigla's  ease,  two  similar  cases  narrated  in  his  paper,  furnish  additional 
proof  of  this,  up  to  a  certain  point.  As  for  myself,  I  accept,  with  every- 
body else,  the  existence  of  these  pleural  cysts.  But  if  an  attentive  analysis 
and  a  careful  study  be  made  of  the  cases,  there  will  be  found  reason  to 
believe  that  hydatids  of  the  lung,  which  have  fallen  into  the  pleural 
cavity,  have  often  been  mistaken  for  pleural  hydatids.  This,  you  remem- 
ber, occurred  in  the  case  reported  by  Dupuytren  and  Geoffroy.  Even  M. 
Yigla's  case  is  very  open  to  discussion  from  this  point  of  view,  because  as 
the  patient  fortunately  recovered,  there  was  no  necroscopic  examination 
to  verify  the  diagnosis.  Besides,  if  we  consider,  as  I  remarked  at  the 
beginning  of  this  lecture,  that  hydatids  generally  develop  themselves  in 
parenchvmatous  organs — the  liver,  spleen,  kidneys,  and  ovaries — we  are 
led  to  conclude  that  the  lungs  form  no  exception  to  the  general  law,  and 
that  acephalocysts  are  much  more  frequently  met  with  in  the  lungs,  than 
in  the  pleura.  Dr.  Davaine,  whom  every  one  admits  to  be  an  authority 
on  this  subject,  is  quite  convinced  that  hydatids  of  the  pleura  are  very  rare. 
The  result  of  his  laborious  researches  is  to  the  effect,  that  in  twenty-five 
cases  of  hydatids  which  he  examined,  there  was  only  one  in  which  evidence 
existed  of  the  primitive  development  of  the  hydatids  having  been  in  the 
pleural  cavity. 

The  diagnosis  of  the  precise  seat  of  intrapleural  hydatid  cysts  is  rendered 
all  the  more  difficult  by  the  circumstance,  that  hydatids  of  the  convex  sur- 
face of  the  liver  may  invade  the  chest,  either-  pushing  up  the  diaphragm 
without  perforating  it;  or,  without  bursting,  they  may  make  a  passage  for 
themselves  through  the  distended  attenuated  fibres  of  that  muscle.  It  may 
be  asked,  if  this  be  not  what  happened  in  M.  Vigla's  case — whether  his 
case  be  not  similar  to  that  reported  by  Professor  J.  Cruveilhier,*  in  which 
a  hydatid  cyst  of  the  liver,  which  had  penetrated  into  the  pleural  cavity, 
was  evacuated  by  paracentesis  of  the  chest,  a  cure  taking  place  as  in  M. 
Vigla's  patient.  I  am  aware,  however,  as  I  have  been  careful  to  tell  you, 
that  cases  of  this  description  are  of  exceedingly  rare  occurrence:  that  very 
commonly,  hydatids  of  the  liver  rupture,  and  thereby  cause  a  rapidly 
mortal  pleurisy  ;  or,  as  is  still  more  usual,  adhesions  form  between  the 
diaphragm,  pleura,  and  lung,  so  that  when  the  hydatids  open  into  the  cavity 
which  they  have  formed  by  burrowing  in  the  pulmonary  parenchyma,  they 
empty  themselves  into  the  bronchial  tubes. 

*  Cpa'YKiLHiKR  :  Dictionnaire  de  Medecine  et  de  Chirurgie  en  15  volumes; 
article,  Aceplialoeystes :  Paris,  1829. 


648  HYDATIDS    OF    THE    LUNG. 

"When  the  latter  occurrence  takes  place,  just  as  in  that  which  I  pointed 
out  as  happening  in  hydatids  of  the  lung,  the  elements  for  forming  an 
opinion  possess  an  almost  absolute  degree  of  certainty.  Apart  from  the 
circumstance  of  fragments  of  hydatids,  or  entire  hydatids,  being  found 
mixed  up  with  the  expectorated  matter,  that  matter  presents  peculiar  and 
unmistakable  characters.  In  it  we  find  a  yellow,  thick,  oily  fluid,  which, 
on  the  addition  of  nitric  acid,  assumes  the  color  of  verdigris,  evidently 
dependent  on  the  presence  of  the  coloring  principles  of  the  bile.  The  fluid 
has  sometimes  a  chocolate-brown  color,  due  to  an  admixture  of  a  certain 
quantity  of  blood.  Then,  again,  there  is  a  diminution  of  the  tumor  in  the 
right  hypochondrium  caused  by  the  increased  bulk  of  the  liver;  and  the 
hitherto  impeded  movements  of  the  diaphragm  become  more  easy.  Finallv, 
gurgling,  amphoric  blowing,  and  vocal  resonance  heard  on  applying  the  ear 
or  the  stethoscope  to  the  situation  formerly  occupied  by  the  tumor,  show 
that  a  cavity  exists  which  is  evidently  excavated  partly  in  the  lung  and 
partly  in  the  liver. 

Gentlemen,  when  you  have  diagnosed  an  intrathoracic  hydatid,  be  very 
reserved  as  to  the  prognosis.  While  you  have  a  right  to  hope  that  all  may 
go  on  favorably,  that  the  malady  may  reach  a  happy  issue  by  the  unaided 
efforts  of  nature,  and  through  the  mechanism  which  I  have  explained  to 
you  at  such  length,  you  must  not  forget  that  the  work  of  elimination, 
though  in  itself  favorable,  is  not  unattended  by  danger.  At  its  commence- 
ment, it  may  occasion  suffocative  paroxysms :  the  presence  in  the  air- 
passages  of  the  hydatids  and  of  fluids  which  irritate  the  larynx,  the  trachea, 
and  the  bronchial  mucous  membrane,  may  occasion  fits  of  coughing,  which 
in  their  turn  may  lead  to  mortal  hemorrhages,  an  occurrence  of  which  an 
example  has  been  reported  by  Dr.  Pillon.  You  have  to  dread  hydro- 
pneumothorax,  and  its  disastrous  consequences.  You  have  also  to  dread 
asphyxia,  a  consequence  of  respiration  being  interfered  with  by  the  tumor 
attaining  so  large  a  size  as  to  compress  the  lung:  this  happens  not  only  in 
cases  like  that  of  Dupuytren  and  Geoffroy,  in  which  the  intrathoracic 
tumor  was  double,  but  likewise  when  there  is  only  a  hydatid  on  one  side. 

"When  these  unfavorable  circumstances  do  not  exist,  and  when  the 
hydatids  find  their  way  out  of  the  body  by  the  bronchial  tubes,  you  may  not 
only  hope  for  recovery,  but  also  for  an  early  cure.  The  inflammatory 
symptoms  which  attend  the  process  of  elimination  cease,  the  fever  subsides, 
the  appetite  returns,  and  at  the  end  of  some  weeks,  there  may  be  perhaps  a 
complete  restoration  to  health. 

Ought  there  to  be  any  active  interference  on  the  part  of  the  physician 
with  intrathoracic  hydatids?  It  is  most  prudent  to  abstain  from  BUch 
interference.  Here,  as  in  many  other  circumstances,  we  must  know  how- 
to  wait,  while  we  attentively  wateh  the  patient,  seeking  to  moderate  inflam- 
mation and  sustain  the  vital  powers. 

So  far  am  I  disposed  to  go  in  advising  extreme  caution,  that  1  even 
recommend  yon  to  abstain  from  exploratory  puncture-,  which  there  is  a 
temptation  to  make,  with  a  view  to  elucidate  the  uncertainty  of  the  diag- 
nosis. These  puncture-  may  prove  fatal,  if  adhesions  have  not  been  formed 
between  the  tumor  ainl  the  wall-  of  the  chest,  by  causing  effusion  into  the 
pleura,  the  dangers  of  which  occurrence  I  have  pointed  out  to  you.     Now, 

it    i-    impossible    tor   the   mosl     experienced    physician    to  affirm   that    BUch 

adhesions  exist.  When  circumstances  peremptorily  compel  you  to  inter- 
fere bo  a-  to  ;_;ive  exit  to  the  fluids,  the  fir-t  indication  is  to  excite  adhesive 

inflammation,  the  existence  of  which  i-  absolutely  uecessary  :  this,  however, 
cannot  he  brought  ahout,  unless  the  tumor  is  in  contact  with  the  thoracic 
walls,  and  unless  there  is  no  intervening  portion  of  lung.     This   indication 


PULMONARY    ABSCESSES,    ETC.  649 

will  be  fulfilled  by  making  numerous  acupunctures,  and  repeating  them  on 
Beveral  successive  days. 

When  adhesion  lias  taken  place,  the  pouch  may  he  emptied  by  tapping 
it  with  a  bistoury  or  large  trocar,  after  which  it  has  to  he  injected  with  a 
solution  of  iodine. 

This  is  a  mode  of  treatment  exactly  similar  to  that  which  I  adopt  for 
the  cure  of  hydatid  cysts  of  the  liver,  a  subject  upon  which  I  hold  myself 
in  reserve  till  an  opportunity  occur,  when  I  shall  fully  go  into  it,  I  would 
now  only  add,  in  conclusion,  that  I  have  never  practiced  this  method  for 
the  cure  of  hydatids  of  the  lung,  that  I  do  not  know  whether  it  ever  has 
been  so  employed  ;  and  consequently  I  cannot  say  what  might  be  the  re- 
sults of  having  recourse  to  it, 


LECTUEE  XXXV. 

PULMONARY  ABSCESSES  AND  PERIPNEUMONIC  VOMICiE. 

Rare  affections,  if  we  exclude  from  the  category  Tubercular  Vomicce  and 
Metastatic  Abscesses. — Most  frequent  in  Children,  in  whom  they  are  the 
result  of  Lobidar  Pneumonia. — Diagnosis  of  Peripneumonic  Vomicce  is 
Difficult. — They  may  be  confounded  with  Pleural  Abscesses. 

Gentlemen  :  At  the  close  of  my  last  lecture,  I  showed  you  the  lungs 
of  two  patients  who  died  in  our  wards  of  acute  pneumonia.  At  one  of 
the  autopsies  from  which  these  lungs  were  obtained,  you  may  have  seen 
that  an  immense  pouch  of  pus  occupied  the  anterior  and  lower  portions  of 
the  superior  lobe  of  the  left  lung.  This  cavity  was  large  enough  to  hold  a 
large  egg  of  a  hen  :  it  was  divided  by  incomplete  partitions  into  chambers 
communicating  with  one  another :  the  walls  of  the  cavity  were  formed  by 
gray  indurated  pulmonary  parenchyma.  The  cavity  communicated  with 
the  pleural  cavity  by  a  large  opening,  shaped  like  a  button-hole,  situated 
at  the  anterior  margin  of  this  pulmonary  lobe,  and  probably  measuring 
about  two  centimetres  in  length.  In  every  other  situation,  the  parenchyma 
of  the  lung  seemed  to  be  healthy,  and  to  present  no  trace  of  tubercle.  In 
the  cavity,  there  was  no  trace  of  anything  like  tubercular  matter :  and 
there  was  not  the  slightest  exhalation  of  a  gangrenous  odor.  The  corre- 
sponding pleural  cavity  was  filled  with  a  great  quantity  of  creamy,  inodor- 
ous, white  pus.  The  surface  of  the  visceral  and  parietal  serous  membrane 
was  covered,  in  the  two  lower  thirds,  with  a  layer  of  matter,  pultaceous, 
pseudo-membranous,  thick,  and  of  a  greenish-white  color.  The  lung  ad- 
hered closely  to  the  walls  of  the  chest  along  the  vertebral  column,  as  far 
down  as  the  diaphragm ;  but  on  dragging  the  adhesions,  they  easily  gave 
way,  except  near  the  diaphragm,  where  they  resisted  so  much  that  it  was 
necessary  to  remove  the  diaphragm  with  the  lung.  The  left  lung,  one- 
third  less  voluminous  than  the  right,  had  its  superir  lobe  flattened  upon 
itself,  and  applied  along  the  spine.  An  attempt  to  inflate  it  failed,  in  con- 
sequence of  the  air  escaping  by  the  opening  into  the  cavity  of  which  I 
have  spoken. 

There  was  nothing  abnormal  in  the  condition  of  the  right  lung,  except- 
ing some  old  adhesions,  which  did  not  offer  much  resistance. 


650  PULMONARY    ABSCESSES    AND 

At  the  autopsy  of  the  other  case,  you  also  saw  a  large  purulent  cavity  in 
the  left  lung,  but  it  was  in  a  less  advanced  state,  and  in  fact  was  only  be- 
ginning  to  form.  It  was,  moreover,  the  result  of  a  circumscribed  or  partial 
peripneumonia,  whereas  in  the  other  case,  it  existed  in  the  midst  of  a  lobe 
inflamed  throughout  its  entire  extent. 

The  pulmonary  tissue  presented,  in  fact,  the  consistence  of  hepatic  tissue. 
The  two  lobes  of  the  left  lung  were  completely  involved,  and  had  a  verv 
manifest  gray  color :  when  an  incision  was  made  in  the  condensed  paren- 
chyma of  the  lung,  a  great  quantity  of  a  frothy  grayish  sanies  oozed  out 
from  the  incised  surface.  The  tissue  was  easily  torn  by  the  pressure  of  the 
finger :  at  the  superior  and  posterior  part  of  the  inferior  lobe,  was  situated 
the  purulent  cavity  of  which  I  have  been  speaking.  It  was  as  large  as  the 
abscess  we  met  with  in  our  first  autopsy :  it  was  quite  full  of  putrilaginous 
matter  of  a  lateritious  appearance,  and  only  separated  from  the  interlobular 
fissure  by  a  very  thin  plate  of  pulmonary  tissue.  The  examination  was 
made  with  great  care,  and  without  any  violence,  so  that  it  did  not  seem 
probable  that  there  had  been  any  accidental  breaking  up  of  tissue  by  the 
pressure  of  the  hand  of  the  pupil  who  made  the  necropsy ;  still,  I  must  tell 
you  that  I  have  my  doubts  on  this  point. 

These  two  cases,  gentlemen,  are  examples  of  what  have  been  called  vomica 
— abscesses  of  the  lung :  they  are  phlegmonous  abscesses,  very  different  from 
the  purulent  collections  met  with  in  tuberculous  subjects,  very  different  also 
from  the  abscesses  termed  metastatic,  which  we  meet  with  in  the  bodies  of 
persons  who  have  been  carried  off  by  purulent  infection,  and  which  are  char- 
acteristic of  the  purulent  diathesis. 

These  non-tuberculous,  non-metastatic,  purely  inflammatory  vomica?  are 
very  rare  lesions  in  adults.  I  make  this  limitation,  because  in  young 
children  they  occur  very  frequently.  On  this  point,  I  fully  concur  with 
recent  clinical  observers  who  have  written  on  the  pneumonia  of  children. 
In  a  certain  restricted  sense,  however,  the  general  rule  is  likewise  applicable 
to  children  ;  for  it  is  only  in  lobular  pneumonia  that  pulmonary  abs< 
are  met  with,  and  lobular  is  a  very  different  affection  from  lobar  pneumonia. 

Pulmonary  abscesses  in  children  sometimes  occur  disseminated  in  very 
small  number  throughout  the  pulmonary  parenchyma  :  at  other  times,  they 
are  placed  so  closely  together  as  to  resemble  myriads  of  tubercles.  They  are 
met  with  least  frequently  under  the  latter  aspect.  When  they  are  very  few 
in  number,  they  either  form  small  pouches  on  the  surface  of  the  lung,  pro- 
ducing prominences  under  the  pleura;  or,  having  emptied  themselves  4>v 
the  bronchial  tubes,  they  contain  only  air;  or  possibly,  they  may  contain  a 
mixture  of  air  and  pus.  In  these  different  states,  it  is  difficult  to  say 
whether  the  pouch  has  been  formed  by  a  suppurating  lobule,  or  by  dilata- 
tion of  the  extremity  of  a  bronchial  tube  terminating  in  a  lobule,  the  cells  of 
which  have  been  raptured  :  in  the  latter  ease,  it  would  he  merely  a  variety 
of  vesicular  emphysema.  But  when  the  abscesses  are  very  numerous,  there 
is  something  special  in  the  appearance  of  the  lung  which  require-  to  he  ac- 
curately described. 

Lobular  pneumonia  then  becomes  aggregated  or  pseudo-lobar :  in  other 
words,  the  inflamed  Lobules  unite  in  large  masses,  invading,  it  may  be, 
nearly  or  quite,  the  whole  of  a  lobe,  as  in  the  pneumonia  of  adults. 

Two  young  children  were  attacked  with  acute  pneumonia.  The  elder 
was  taken  to  the  Hopital  des  Enfans  Malades,  where  he  died  altera  resi- 
dence of  :i  fi'U  days:  the  other,  suckled  by  his  mother,  was  taken  to  the 
Hdpital  Necker,  where  he  was  placed  under  my  pare  in  St.  Julia's  Ward. 

The  existence  of  pneumonia  was  unquestionable  :  but  it  seemed  to  be  lim- 
ited to  the  hii  Bide.     There  was  heard  on  that  side  a  very  decided  blowing 


PERIPNEUMONIC    VOMICAE.  651 

sound,  and  also  a  considerable  degree  of  reverberation  of  tbc  cry.  There 
was  a  rather  coarse  subcrepitant  rale,  and  a  little  obscurity  of  the  breath- 
sound.  These  signs  continued  to  the  last.  On  the  right  side,  the  respira- 
tion was  feeble;  and  two  days  before  death,  Ave  began  to  hear  some  sub- 
crepitant rales  unmingled  with  any  blowing.  There,  continued,  however, 
ardent  fever,  and  great  oppression  of  the  breathing. 

At  the  autopsy,  when  the  lungs  were  placed  upon  the  anatomical  table, 
a  multitude  of  yellowish-white  spots  were  seen  shining  through  the  pleura, 
forming  a  striking  contrast  to  the  red  color  of  the  hepatized  parenchyma, 
which  seemed  to  be  stuffed  with  tubercles,  some  in  a  crude  state  and  others 
in  a  state  of  softening.  On  making  a  clean  cut  through  a  large  mass  of 
lung,  a  similar  aspect  was  presented,  with  this  difference,  that  the  appear- 
ance of  the  parts  was  to  a  slight  extent  modified  by  the  gushing  of  pus  from 
the  incised  surfaces.  By  letting  a  small  stream  of  water  fall  on  the  tissues 
thus  altered,  the  water  carried  away  some  of  the  pus,  and  so  disclosed  to 
view  an  irregular  cavity  with  imperfectly  defined  edges.  As  the  little 
stream  of  water  did  not  wash  away  the  whole  of  the  purulent  matter,  there 
remained  a  cavity  not  so  well  defined  as  before,  and  a  very  soft  mass  ad- 
herent to  the  parenchyma.  Finally,  among  the  portions  of  lung  which 
presented  at  a  first  glance  this  general  appearance  of  tubercles,  there  were 
some  portions  from  which,  although  very  friable,  the  water  detached  noth- 
ing.    All  around  this,  the  parenchyma  was  hepatized. 

A  very  little  attention  was  sufficient  to  dispel  the  idea  of  the  existence 
of  tubercles.  We  had  evidently  to  do  with  lobular  pneumonia  in  four 
degrees  :  there  was  red  hepatization,  affecting  the  great  mass  of  the  lobules  ; 
light-colored  hepatization,  corresponding  to  the  third  degree  of  pneumonia 
in  the  adult;  partial  softening  of  the  lobules,  which  had  passed  to  light- 
colored  hepatization  ;  and,  finally,  complete  softening  of  these  same  lobules — 
true  peripneumonic  vomicae. 

It  was  a  somewhat  remarkable  fact,  that  these  four  degrees  were  observed 
in  the  left  lung,  which  was  the  first  as  well  as  the  most  violently  attacked  ; 
while  the  right  lung,  not  attacked  till  two  or  three  days  before  death,  pre- 
sented only  the  first  two  degrees. 

During  the  autopsy,  I  took  care  to  point  out  how  much  these  lesions  differed 
from  tubercles;  and  to  remark,  that  one  could  not  fail  to  recognize  in  the 
inflamed  lobules  the  identical  forms  coexisting  sometimes  in  entire  lobes  of 
the  lungs  of  an  adult. 

Besides,  the  exceedingly  acute  character  of  the  disease  would  indicate 
that  it  was  a  pure  pneumonia;  and  although  it  be  quite  true  that  sometimes 
I  have  seen  acute  attacks  of  pneumonia  prove  fatal,  in  a  few  days,  in  chil- 
dren who  had  hardly  ever  previously  coughed,  and  have,  at  the  autopsy, 
found  the  lungs  full  of  tubercles  in  different  stages,  it  is  not  less  true  that 
pathological  anatomy  furnishes  means  of  distinguishing  cases  of  pneumonia 
complicated  with  tubercles,  from  cases  in  which  the  pulmonary  tissue  is 
studded  with  abscesses.  Quite  recently,  I  showed  to  all  of  you  in  this  am- 
phitheatre the  lungs  of  an  infant  at  the  breast,  in  which  were  thousands  of 
little  pouches  filled  with  perfectly  homogeneous  pus.  The  infant  had  only 
been  ill  for  a  fortnight. 

I  now  return  to  the  consideration  of  what  takes  place  in  the  adult.  In 
adults,  as  I  have  already  said,  non-tuberculous,  non-metastatic,  purely  in- 
flammatory vomicae  are  exceedingly  rare;  indeed,  they  are  so  rare,  that 
during  my  first  twenty-five  years  as  an  hospital  physician,  I  never  met  with 
a  case  of  this  description.  By  one  of  those  strange  coincidences,  however, 
which  sometimes  occur  in  practice,  the  two  cases  which  we  have  seen  to- 
gether presented  themselves  to  my  notice  during  one  week  ;  and  one  of  the 


652  PULMONARY    ABSCESSES    AND 

cases  has  left  some  doubts  in  my  mind.  This  lesion  is  so  rare,  that  Laennec — 
whose  authority  is  of  great  weight  in  such  a  question — affirms  that  in  open- 
ing the  bodies  of  several  hundred  persons  who  had  died  of  peripneumonia 
during  a  period  of  twenty  years,  he  had  only  five  times  met  with  abscesses 
in  inflamed  lungs.  "Moreover,"  adds  the  immortal  author  of  the  Traite  de 
1' Auscultation  Mediate,  "  they  (the  abscesses)  were  inconsiderable,  few  in 
number,  and  scattered  throughout  the  lungs,  which  presented  the  third 
degree  of  inflammation."  Once  only  did  he  meet  with  a  large  abscess,  such 
as  we  found  in  the  first  of  our  autopsies.  Besides  his  own  cases,  Laennec 
says  that  he  only  knew  of  two  other  well-authenticated  cases  of  abscess  of 
the  lung,  notwithstanding  the  zeal  with  which  pathological  anatomy  had 
been  cultivated  in  France  at  the  time  he  made  that  statement:  one  of  the 
cases  was  communicated  to  the  Academy  of  Medicine  in  1823  by  Dr. 
Honore,  and  the  other  was  published  by  Dr.  Andral.*  In  support  of  this 
weighty  testimony,  I  would  adduce  the  statement  of  Professor  Chomel,  who, 
during  twenty-five  years,  only  twice  found,  in  the  pulmonary  parenchyma, 
purulent  collections  which  did  not  seem  to  depend  upon  tearing  by  the 
pressure  of  the  fingers  at  the  moment  of  removal  from  the  thoraxt — an 
occurrence  which  frequently  takes  place  in  a  lung  infiltrated  with  pus. 

A  purely  peripneumonic  vomica  is  consequently  an  exceedingly  rare 
affection  in  adults,  and  under  such  conditions  as  were  present  in  the  cases 
which  have  occurred  in  our  wards.  Bear  clearly  in  your  minds  then  these 
cases,  as  perhaps  ere  long  you  may  finds  others  like  them. 

Let  me  now,  in  a  few  words,  sum  up  the  history  of  our  patients — a  his- 
tory interesting  from  many  points  of  view.  It  is  specially  interesting  in 
relation  to  the  diagnosis  of  pneumonia;  that  is  to  say,  the  real  diagnosis 
of  the  disease,  with  which  the  clinic  can  alone  make  you  acquainted,  and 
which  sometimes  embarrasses  the  most  experienced  physicians — not  that 
ordinary  diagnosis,  so  simple  and  so  easy,  which  may  be  learned  theoreti- 
cally from  text-books. 

The  first  of  our  patients  was  a  young  man  of  robust  constitution,  twenty- 
six  years  of  age.  You  first  saw  him  lying  in  bed  19,  and  then  in  bed  7  of 
St.  Agnes's  Ward.  He  had  been  ill  four  days  when  admitted  to  the  hospital 
on  the  24th  March.  His  illness  had  commenced  with  a  violent  pain  in  the 
left  shoulder,  after  exposure  to  a  sudden  transition  from  heat  to  cold,  OB 
leaving  a  ball.  He,  nevertheless,  went  to  his  work  next  morning;  and 
although  on  the  evening  of  that  day,  there  was  an  increase  of  pain,  and 
though  with  this,  he  also  had  fever,  oppression  of  breathing,  and  cough, 
and  although  he  had  passed  a  sleepless  night,  he  again  returned  to  his 
usual  employment  on  the  23d  March  :  ho  ate  little  :it  his  midday  meal  : 
and  in  the  evening,  he  had  difficulty  in  regaining  his  lodging.  During  the 
night,  the  pain  in  the  shoulder  became  still  mure  seven1,  and  with  it  there 
was  also  pain  in  the  chest  below  the  Left  breast:  this  increase  of  pain  was 
accompanied  by  severe  rigors.  On  the  25th,  as  I  have  already  stated,  be 
entered  the  H6tel-Dieu;  and  I  saw  him  next  morning.  He  bad  intense 
fever;  and  his  countenance  indicated  extreme  anxiety.  He  was  greatly 
excited:  but  the  only  complaint   he  made  was  of  pain  in  the  shoulder, 

which  was  increased  by  i ghing  and  the  exertion  or  breathing,  which  was 

embarrassed  and  difficult.     Although  the  movements  of  the  shoulder-joint 

were    painful,  the    pain  in    that    region  was    not    increased    by  pressure :   he 

made  bul  moderate  complaint   oi  the  Btitch  in  his  side.     There  was  no 
expectoration  accompanying  the  cough.     However,  the  intensity  of  the 

*  Andral:  Clinique  Bffldicale,  t.  ii.  p.  818. 

f  Chomel:  Diction  naire  de  Medecine,     Paris:  1842.     T.  sxv,  p.  161. 


PERIPNEUMONIC    VOMICAE.  653 

fever,  and  the  very  anxious  appearance  of  the  patient,  made  me  think  of  a 
deepseated  pneumonia,  inaccessible  to  our  means  of  investigation ;  while 
mi  the  other  hand,  the  local  pain  suggested  the  commencement  of  an  attack 
of  articular  rheumatism,  which  might  perhaps  declare  itself  next  day. 
Following  the  latter  indication,  I  caused  ten  scarifying  cupping-glasses  to 
!><•  applied  to  the  seat  of  the  pain.  Since  the  evening,  there  had  been 
diminution  in  the  pain  of  the  .shoulder,  but  an  increased  severity  of  the 
stitch  in  the  side,  accompanied  by  extreme  anxiety,  by  considerable  em- 
barrassment in  the  movements  of  respiration  and  coughing.  Next  day, 
these  symptoms  were  very  decided  :  the  fever  was  more  intense,  and  the 
excitement  was  greater.  On  percussion,  ouly  slight  dulness  was  detected 
in  the  region  of  the  heart :  no  morbid  phenomenon  was  revealed  by  auscul- 
tation. The  pulmonary  expansion  was,  it  is  true,  interfered  with,  by  the 
pain  impeding  the  movements  of  the  thorax.  The  sputa,  which  up  to  this 
time  had  been  scanty  and  albuminous,  now  presented  the  yellow  color  of 
barley  sugar :  they  had  a  viscid  cousistence  and  were  expectorated  with 
difficulty.  In  the  evening,  the  sputa  had  additional  characteristics:  they 
were  sanguinolent,  apoplectic,  of  a  bright  red  color,  frothy,  but  still  tena- 
cious. My  diagnosis  of  pneumonia  was  confirmed,  although  the  physical 
signs  were  absent,  except  some  dulness  in  the  region  of  the  heart  detected 
by  percussion  :  this  dulness  was  limited  to  an  extent  of  about  ten  centime- 
tres from  the  nipple  to  the  sternum,  where  a  certain  amount  of  arching 
was  perceptible  :  pressure  in  this  region  occasioned  acute  pain.  I  came  to 
the  conclusion  that  there  was  pericarditis  complicated  with  pneumonia. 
The  autopsy,  to  the  description  of  which  I  shall  return,  showed  me  my 
error  in  diagnosis:  there  was  only  extensive  hypertrophy  of  the  heart. 

On  the  23d,  I  ordered  tweut}r  scarifying  cupping-glasses  to  be  applied  to 
the  region  of  the  heart,  and  at  the  same  time  ordered  a  continuance  of 
the  precipitated  sulphuret  of  antimony,  which  had  been  ordered  on  the 
previous  evening,  one  gramme  [15^  grains]  being  made  up  in  ten  pills. 
The  expectoration,  always  difficult,  had  again  changed  its  character  :  the 
sputa  had  the  color  of  the  juice  of  prunes,  was  somewhat  viscid,  and  ad- 
hered to  the  vessel.  It  was  not  till  the  29th  March,  the  fifth  day  of  resi- 
dence in  hospital,  and  the  ninth  from  the  beginning  of  the  illness,  that  we 
began  to  hear  crepitant  rales ;  but,  when  under  the  ear,  they  sounded  so 
distant,  so  difficult  to  appreciate,  that  even  their  existence  might  be  dis- 
puted. The  general  symptoms  continued,  and,  moreover,  increased  in 
severity. 

On  the  30th  March,  the  sputa  had  assumed  a  chocolate  color,  without 
having  any  fetor.  On  auscultating  the  chest,  there  was  heard  tubal  blow- 
ing of  very  unequivocal  character,  although  it  seemed  distant  from  the 
ear,  and  mixed  with  mucous  rales  of  average  coarseness.  The  resonance 
of  the  voice  was  broncho-segophonic.  The  dulness  in  the  infraspinous  fossa 
was  replaced,  from  the  inferior  angle  of  the  scapula  downwards,  by  exag- 
gerated resonance,  which  could  be  elicited  by  strong  percussion.  This 
exaggerated  resonance  was  so  great  anteriorly,  down  as  far  as  the  mamma, 
even  when  the  percussion  stroke  was  moderate,  that  the  sound  seemed  to 
be  abdominal.  I  therefore  said  :  this  man  has  pneumonia,  a  central  pneu- 
monia, which  invading  the  anterior  part  of  the  lung  has  perforated  the 
parenchyma,  and  determined  an  effusion  of  air  and  pus  into  the  pleural 
cavity,  establishing  a  communication  between  that  cavity  and  the  bron- 
chial tubes.  In  a  word,  I  diagnosed  a  peripneumonic  vomica  and  hydro- 
thorax. 

On  the  31st  March  I  observed  that  the  vesicular  murmur  under  the  left 
clavicle  had  become  weaker,  and  that  towards  the  precordial  region  there 


6-34  PULMONARY    ABSCESSES    AND 

was  heard  distant  amphoric  blowing:  lower  down  the  respiratory  sound 
was  absent.  Behind,  the  vesicular  murmur  was  so  feeble  as  to  be  scarcely 
heard  at  all  in  the  scapular  region:  from  the  inferior  angle  of  that  bone  it 
gave  place  to  very  distant  amphoric  blowing:  there  was  a  somewhat  obscure 
metallic  resonance  of  the  voice,  and  the  sounds  of  the  heart  were  heard 
posteriorly  by  conduction. 

On  the  1st  of  April  the  expectoration,  which  in  the  evening  had  a  choco- 
late color,  beginning  to  mingle  with  greenish  sputa,  became  copious:  it  con- 
sisted of  a  pretty  thick  fluid,  in  which  floated  sputa  which  were  frothy,  not 
viscid,  and  free  from  any  trace  of  blood.  By  auscultation  we  could  -till 
hear  amphoric  blowing,' which  came  and  went  alternately,  to  which  there 
was  added  a  sound  similar  to  that  caused  by  bubbles  of  air  traversing  a 
fluid  in  a  state  of  ebullition. 

On  the  3d  April  the  severity  of  the  general  symptoms  had  so  much  in- 
creased, the  state  of  matters  had  become  so  alarming,  so  desperate,  that  it 
was  quite  out  of  the  question  to  think  of  making  the  patient  change  his 
position  to  examine  the  chest  behind.  Expectoration  was  scanty,  and  in 
the  spittoon  there  were  only  four  or  five  large,  thick,  greenish,  purulent 
sputa.  The  pulse  was  140,  small,  and  intermittent.  The  skin,  which  was 
covered  with  a  viscid  sweat,  presented  a  very  characteristic  cyanosed  appear- 
ance. There  was  extreme  anxiety,  great  oppression  of  the  breathing,  and 
an  almost  complete  extinction  of  the  voice. 

On  the  4th  April  this  young  man  was  in  a  dying  state.  During  the  night 
and  morning  he  had  brought  up  a  great  quantity  of  thick,  creamy,  greenish- 
white,  inodorous  pus,  which  filled  two  spittoons.  In  the  evening  low  de- 
lirium set  in,  and  on  the  morning  of  the  5th  April  he  expired. 

At  the  autopsy  we  found  the  lesions  to  which  I  have  called  your  atten- 
tion: we  likewise  found,  as  I  "have  already  stated,  that  the  pericardium  was 
quite  unaffected;  but  the  heart,  very  bulky,  occupying  the  space  which  I 
had  marked  out  with  the  pleximeter,  rested*  on  the  indurated  lung,  thus,  no 
doubt,  giving  rise  to  the  thoracic  arching  and  precordial  dulness  which  had 
led  me  to  suppose  that  there  was  pericarditis. 

Our  second  patient  was  a  man  of  thirty-three,  and  was  also,  like  the 
former,  of  strong,  vigorous  constitution.  For  six  mouths  lie  had  been  c<>m- 
plaining  of  frequent  headache  and  great  lassitude.  On  the  8th  April,  eight 
days  before  his  admission  to  the  Hotel-Dieu,  he  felt  more  fatigued — more 
foundered  [plus  fourbu] — to  use  his  own  expression,  than  usual.  He  had 
been  attacked  with  fever, unaccompanied  by  decided  rigors, or  stitch  in  the 
side.  He  said  that  at  that  time  he  had  no  oppression  of  the  breathing,  a 
statement  however  of  no  importance,  as  on  admission  he  declared  that  he 
had  liM  oppression,  although  I  could  see  that  it  decidedly. existed,  respira- 
tion being  short,  quick,  and  anxious.  He  had  a  great  deal  of  lever.  <  »n 
percussion  the  sound  was  natural  on  the  right  side  of  the  chest:  on  the  left 
side,  anteriorly,  below  the  clavicle,  the  sound  was  exaggerated,  skodaic. 
Behind  there  was  dulness  from  the  top  to  the  bottom  of  the  chest  The 
vesicular  murmur,  normal  on  (he  right  side,  both  before  and  behind,  was 
likewise  natural  mi  the  left  Bide,  where  we  detected  the  resonance;  hut.  be- 
hind,it  was  replaced  by  very  intense  tubal  blowing  and  In- shophony:  its 

maximum  intensity  was  in  the  infraspinous  fossa. 

On  the  evening  of  the  day  upon  which  he  came  into  hospital,  he  hail  only 
brought  up  one  spit,  which  was  saffron-colored,  frothy,  aerated,  and  non- 
adherent to  the  vessel  in  which  he  expectorated.  On  the  morning  of  the 
9th  his  spittoon  was  tilled  one-third  with  greenish  diffluent  sputa,  some  of 
which  were  brownish,  reminding  one  of  rusty  sputa.  I  directed  two  palets 
[19  fd.  ounces]  of  blood  to  be  taken;  and  at  the  same  time  prescribed  50 


PERIPNEUMONIC    VOMICAE.  655 

centigrammes  [nearly  8  grains]  of  precipitated  sulphuret  of  antimony  in 
five  pills.  In  the  evening  of  the  same  day  the  blood,  which  hail  (lowed 
freely,  presented  a  diffluent  appearance:  the  non-rretracted  crassamentum 
was  covered  with  a  thin  greenish-bufly  coat.  The  pulse  was  compressible 
and  soft,  as  in  the  morning.  It  was  impossible  to  venture  upon  the  farther 
abstract  ion  of  blood. 

On  the  10th  April  the  spittoon  was  still  filled  one-third  with  very  diffluent 
aerated  sputa,  having  the  appearance  of  dirty  gum,  with  a  slight  look  of 
prune-juice.  The  pulse  had  the  same  frequency,  and  the  same  other  char- 
acters, as  on  the  preceding  evening.  There  was  extreme  oppression  of 
breathing,  which  increased  during  the  evening.  The  patient  fell  into  a 
drowsy  state:  his  expectoration  assumed  a  chocolate  color:  his  pulse,  which 
was  very  soft,  beat  136  in  the  miuute.  He  died  on  the  11th  April,  at  four 
o'clock  in  the  morning. 

On  opening  the  body,  there  were  found  the  lesions  of  suppurative  pneu- 
monia, and  perhaps  what  was  an  incipient  vomica,  as  I  stated  to  you. 

To  these  two  cases  of  peripneumonic  abscesses,  I  shall  add  a  third,  nar- 
rated by  Dr.  Graves  in  his  Clinical  Lectures — in  the  lecture  on  "  Abscess 
of  the  Lung. " 

Early  in  the  spring  of  1841,  Dr.  Graves  was  asked  by  Dr.  Brereton  to 
see  with  him  at  Sandford  a  lad  between  fourteen  and  fifteen  years  of  age, 
who,  a  fortnight  previously,  had  suffered  from  the  symptoms  of  pleuropneu- 
monia, with  acute  pain  in  the  side  and  very  violent  cough.  He  had  had 
the  characteristic  expectoration,  as  well  as  sputa  of  the  color  of  prune-juice. 
The  general  symptoms,  as  well  as  the  local  inflammatory  symptoms,  wrere 
very  severe ;  and  did  not  yield  to  the  treatment,  which  was  both  judicious 
and  active.  About  ten  clays  after  Dr.  Graves's  first  visit,  matters  were  pro- 
ceeding from  bad  to  worse,  and  at  that  time  the  pulse  was  nearly  140  :  there 
was  very  great  dyspnoea,  excitement,  jactitation,  insomnia,  and  a  cough 
ceaseless  by  day  and  by  night.  The  case  seemed  desperate,  and,  hour  by 
hour,  death  was  looked  for.  Almost  the  wdiole  of  the  right  lung  was  in- 
volved in  the  pneumonia  ;  and  there  was  great  dulness  on  that  side.  It  is 
noteworthy,  that  in  the  first  stage  of  the  disease,  crepitant  rales  were  heard 
throughout  the  whole  of  both  lungs. 

The  distinguished  clinical  professor  of  Dublin  was  well  aware  that  this 
was  a  case  of  pleural  vomica ;  but  nevertheless,  he  is  careful  to  mention 
the  important  fact  that  at  the  beginning  of  the  illness,  the  patient  had 
crepitant  rales  throughout  the  whole  of  both  lungs,  which  hardly  left  any 
room  for  doubting  the  existence  of  pneumonia.  I  wish  here,  however,  to 
make  a  reservation.  Graves  says  :  "  Crepitant  rales  were  heard :  "  I  should 
have  preferred  that  he  himself  had  heard  them. 

When  matters  were  in  the  gloomy  state  now  described,  the  patient  was 
one  night  affected  with  very  great  difficulty  in  breathing,  anxiety,  and  pain 
in  the  side  :  he  was  supposed  to  be  at  the  point  of  death.  All  at  once,  after 
a  sudden  effort,  he  brought  up  a  large  quantity  of  purulent  matter ;  and 
immediately  afterwards  felt  comparatively  well.  Next  night,  a  similar 
struggle  occurred,  and  was  followed  by  a  similar  result.  In  the  morning, 
when  Dr.  Graves  saw  the  young  man,  he  found  him  better  in  several  re- 
spects ;  but  he  still  had  extreme  debility  with  a  great  deal  of  fever  and 
dyspnoea.  On  examining  the  right  side  of  the  chest,  Dr.  Graves  found 
that  the  anterior  part,  from  the  clavicle  to  the  base,  as  far  down  as  the 
diaphragm,  yielded  a  sound  very  different  from  that  w'hich  it  had  previ- 
ously rendered  on  percussion :  it  was  then  dull — now'  it  was  clear.  This 
side  of  the  thorax  was  evidently  dilated  ;  and,  by  the  stethoscope,  metallic 
tinkling  was  heard  whenever  the  patient  coughed  or  spoke.     This  satisfied 


656  PULMONARY    ABSCESSES    AND 

Dr.  Graves  that  there  was  a  very  large  cavity  in  the  lung,  communicating 
in  one  direction  probably  with  the  bronchial  tubes,  and  in  the  other  with 
the  pleural  cavity.  He  looked  on  the  case  as  hopeless.  Fifteen  days  from 
that  date,  or,  possibly,  a  little  later,  the  expectoration  again  became  puru- 
lent, and  this  recurred:  but  each  time,  the  quantity  was  less,  and  the  state 
manifestly  ameliorated.  In  six  weeks  from  the  occurrence  of  the  first  puru- 
lent expectoration,  convalescence  was  far  advanced  ;  and  ultimately,  the 
young  man  became  strong  and  in  perfect  health. 

The  two  cases  which  we  have  observed  together  in  the  wards,  the  case  of 
Graves  (who  reports  others  of  the  same  kind),  the  cases  observed  by  Laen- 
nec,  by  Honore,  and  by  Professors  Andral  and  Chomel,  incoutestably  prove 
the  possibility  of  a  purely  inflammatory  peripneumonic  vomica.  But  it  is 
not  enough,  gentlemen,  to  detect  a  vomica  at  the  opening  of  the  dead  body  : 
we  must  endeavor  to  diagnose  it  in  the  living  patient.  Let  us  inquire, 
therefore,  whether  there  are  any  other  signs  by  which  recognition  of  this 
diseased  state  can  be  made  during  life. 

The  elements  of  this  diagnosis  are  generally  scanty.  The  signs  indicated 
by  Laennec,  the  coarse,  bubbling,  mucous  rales,  manifestly  cavernous, 
audible  in  the  situation  of  the  abscess :  marked  pectoriloquy  taking  the 
place  of  the  bronchophony  which  previously  existed  ;  the  respiration  and 
the  cough,  previously  bronchial,  becoming  cavernous ;  the  blowing  being  in 
the  ear,  when  the  abscess  is  near  the  surface  of  the  lung,  and  muffled,  when 
a  part  of  the  wall  of  the  abscess  is  thin  and  soft, — these  signs  have  very 
rarely  been  ascertained  to  coexist.  They  are  very  far  from  being  so  easy 
to  distinguish  as  Laennec  alleges :  the  pectoriloquy,  and  particularly  the 
blowing  heard  in  the  ear,  belong  equally  to  pleural  and  peripneumonic 
vomicae:  this  is  the  conviction  which  is  left  on  the  mind  by  reading  the 
chapter  in  Graves's  clinical  lecture  upon  abscess  of  the  lung.  Graves  re- 
ports three  or  four  cases,  occurring  in  the  practice  of  himself  and  Stokes,  of 
pleural  abscesses,  which  opened  into  the  bronchial  tubes.  On  considering, 
however,  what  took  place  in  the  subject  of  our  first  case,  on  considering 
that  the  vomica  was  detected  during  the  life  of  the  patient,  one  is  obliged 
to  admit  that  some  characteristic  signs  do  exist.  But  in  my  opinion,  there 
are  some  signs  of  greater  importance  than  those  pointed  out  by  Laennec. 

There  has  been,  let  us  suppose,  an  acute,  a  very  acute  attack  of  pneu- 
monia: then,  at  a  later  period,  the  individual  expectorates  a  large  quantity 
of  puriform  matter  mingled  with  blood,  and,  in  consequence  of  this  admix- 
ture, presenting  a  chocolate  color:  sometimes,  the  expectoration  is  diffluent, 
at  times  resembling  the  sputa  of  pulmonary  apoplexy,  and  at  other  times 
like  the  fluid  of  certain  hepatic  abscesses  situated  in  the  substance  of  muscles. 
It  is  a  mixture  of  blood  and  pus.  New  stethoseopic  phenomena  become 
observable  at  the  same  time  :  in  a  limited  portion  of  lung,  there  is  amphoric 
resj >i ration,  a  gurgling,  bubbling  sound  ;  and  along  with  this  there  is  Bome- 
times  a  metallic  tinkling  which  passes  into  (he  cavity. 

It  was  not  from  the  expectoration  alone  that  I  formed  my  diagnosis  in 
the  first  case.  The  sputa,  at  first  hemorrhagic,  became,  however,  of  a  choc- 
olate color,  that  is  In  Bay,  mixed  with  pus  and  blood.  On  the  sixth  day 
from  his  admission  t<>  the  hospital,  which  was  the  tenth  day  of  his  illness, 
symptoms  of  hydropneumothorax  all  at  once  showed  themselves  :  then  also 
was  observed  profuse  purulent  expectoration;  and  then,  too,  il  was  that  I 
diagnosed  the  vomica.  To  arrive  at  such  a  conclusion,  however,  it  is  neces- 
sary  to  have  a  conjunction  of  all  these  signs, — a  peculiar  expectoration, 
amphoric  blowing,  and  metallic  tinkling. 

In    the    case  "1    our   second    patient,  in   whom    I    thoughl   a    vomica    \\a- 

beginning  to  form,  in  whom  the  pulmonary  abscess  was  still  tilled  with  the 


PERIPNEUMONIC    VOMICvE.  657 

putrilaginous  matter  which  you  saw  at  the  autopsy,  we  only  discovered  the 

existence  of  pneumonia  in  its  third  stage:  and  you  can  understand  how  dif- 
ficult the  diagnosis  was  in  other  respects,  the  burrow  not  being  as  yet 
empty,  and  neither  communicating  with  the  bronchial  passages,  nor  with 
the  pleural  cavity. 

Therefore,  it  is,  that  the  quantity  of  the  sputa,  the  sudden  increase  in 
their  quantity,  their  special  character,  their  becoming  difiiuent  after  having 
been  viscid,  are  the  circumstances  which  guide  us  to  the  diagnosis  of  an 
open  vomica,  whether  the  opening  be  simply  into  the  bronchial  tubes  (as 
in  our  case  and  in  Graves's  case),  or  into  the  pleural  cavity  as  well  as  into 
the  bronchial  passages.  The  time  at  which  this  communication  is  established 
is  perhaps  the  capital  element  in  the  diagnosis.  It  is  almost  impossible  for 
a  peripneumonia  vomica  to  remain  long  without  opening.  An  abscess 
formed  in  the  parenchyma  of  the  lung  will  try,  like  every  other  purely 
inflammatory  abscess,  to  open  externally,  and  the  pus  will  necessarily  find 
an  exit  by  the  divided  and  ulcerated  bronchial  tubes,  which  correspond  to 
the  cavity  of  the  abscess :  if  at  the  same  time  it  opens  into  the  pleural  sac, 
the  peripneumonic  vomica  does  not  with  less  rapidity  find  an  outlet  by  the 
bronchial  tubes.  Indeed,  there  is  not  on  record  any  case  in  which  the  for- 
mation of  the  opening  has  occurred  later  than  the  twentieth  or  twenty-fifth 
day.  Abscesses  which  open  on  the  fortieth,  fiftieth,  or  sixtieth  day,  are 
abscesses  of  the  great  pleural  cavity,  or  abscesses  between  the  lobes  of  the 
lung.  In  fact,  in  numerous  cases,  we  find  between  the  lobes  of  the  lung  a 
collection  of  fluid  sometimes  serous,  sometimes  sero-purulent,  which  is  im- 
prisoned between  the  lobes  by  false  membranes  closing  in  the  interlobular 
fissure :  these  collections,  to  a  certain  extent  independent  of  the  pleural 
cavity,  nevertheless  belong  to  the  pleura :  like  purulent  collections  in  the 
pleural  cavity,  they  may  find  an  outward  passage  through  the  bronchial 
tubes  by  perforating  the  pulmonary  parenchyma ;  and  when  this  state  of 
matters  exists,  the  patient  presents  all  the  symptoms  of  pleural  vomicae. 
But  as  there  is  necessarily  an  absence  of  the  signs  of  effusion  into  the  great 
cavity,  as  there  is  only  a  dulness  which  seems  to  depend  upon  the  state  of 
the  lung,  the  conclusion  arrived  at  will  be  that  there  is  a  peripneumonic 
vomica.  These  supposed  abscesses  of  the  lung,  however,  are,  I  repeat,  very 
long  in  opening — six  weeks,  two  months,  three  months,  or  sometimes  it  may 
be,  four  months  from  the  commencement  of  the  pleuropneumonia.  This 
original  pleuropneumonia  causes  the  mistake :  it  has  been  followed  in  all 
its  phases,  and  that  which  has  been  ascertained  to  exist  has  appeared  to  be 
its  sequel,  and  to  be  related  to  the  pulmonary  and  not  to  the  pleural  lesion. 
You  are,  under  such  circumstances,  the  more  inclined  to  believe  that  there 
is  pulmonary  vomica — the  sounds  of  gurgling  seeming  to  be  limited  to  the 
lung,  and  not  being  accompanied  by  the  usual  signs  of  hydro  pneumothorax. 

That  which  takes  place  in  interlobar  pneumonia,  occurs  also  in  circum- 
scribed pleurisies  of  the  great  pleural  cavity  itself.  From  the  numerous 
examples  you  have  seen,  you  are  aware  that  under  certain  circumstances 
adhesions  take  place  between  t^he  pulmonary  and  costal  pleura,  that  a 
pleurisy  at  the  base  of  the  lung  terminates  in  resolution,  while  a  pleurisy  at 
the  upper  part  of  the  lung  does  not  enter  upon  resolution,  but  proceeds 
to  suppuration.  There  then  supervenes  a  lesion  difficult  of  recognition. 
Suppose  that  a  pleuropneumonia  has  previously  existed :  the  pulmonary 
inflammation  was  manifested  by  bloody  mucous  expectoration,  and  after- 
wards the  sputa  assumed  a  rusty  color,  and  looked  like  apricot  marmalade  : 
by  the  stethoscope,  pathognomonic  crepitant  rales  were  heard:  the  pleurisy 
itself  had  been  characterized  by  the  violent  stitch  in  the  side,  differing  from 
that  sensation  of  weight  and  pang  which  the  old  authors  connected  more 
vol.  i. — 42 


658  PULMONARY    ABSCESSES    AND 

particularly  with  the  existence  of  peripneumonia.  Adhesions  were  formed 
between  the  inflamed  lung  and  the  costal  pleura.  The  remaining  pleuritic 
effusion  between  the  adhesions  first  became  seropurulent,  and  then  entirely 
purulent.  There  can  still  be  perceived  in  the  situation  corresponding  to 
the  dulness  and  the  blowing,  a  very  considerable  bellows-sound  notwith- 
standing the  great  quantity  of  effusion,  for,  as  you  are  aware,  a  considerable 
amount  of  blowing  is  not  inconsistent  with  great  effusion.  This  then  was 
a  case  of  circumscribed  pleurisy ;  and  in  that  situation,  the  compi 
lung,  becoming  squeezed  on  itself,  was  at  last  completely  flattened  by  the 
effusion. 

It  then  becomes  very  difficult  to  follow  the  evolution,  which  leads  to  the 
belief  that  pulmonary  induration  exists  alone,  in  consequence  of  the  steth- 
oscopic  signs  being  bronchial  blowing,  vocal  resonance,  and  sometimes  even 
coarse  gurgling  rales,  phenomena  which  occur  within  the  as  yet  unflattened 
bronchial  passages,  and  ar.e  transmitted  across  the  condensed  pulmonary 
parenchyma  and  the  effused  fluid  within  the  pleural  cyst.  Under  such 
circumstances,  the  diagnosis  is — pneumonia,  which  has  become  chronic. 
However,  in  two  or  three  months  from  the  beginning  of  the  attack,  the  pa- 
tient brings  up  a  large  quantity  of  pus  by  the  mouth — in  the  literal  mean- 
ing of  the  term,  he  has  a  vomica — he  vomits:  you  then  hear  within  the 
chest,  gurgling  and  the  bursting  of  large  bubbles,  as  well  as  metallic  tink- 
ling; and  you  come  to  the  conclusion  that  in  the  indurated  portion  of  lung, 
a  cavity  has  been  formed,  that  cavity  being  constituted  by  the  pleura.  In 
this  case,  the  sole  element  of  differential  diagnosis  was  the  time  of  the 
opening  of  the  abscess — the  time^f  appearance  of  the  vomica ;  as  I  have 
just  been  saying,  of  all  the  signs  which  have  been  mentioned  as  diagnostic 
of  pulmonary  abscess,  time  of  appearance  is  certainly  the  most  important. 

By  paying  special  attention  to  this  sign,  the  mistaking  pleural  for  pul- 
monary, and  pulmonary  for  pleural  abscesses  may  be  avoided,  particularly 
if  the  patient  has  been  under  observation  from  the  beginning  of  his  attack. 
On  the  other  hand,  wdien  the  patient  is  not  seen  till  an  advanced  period  of 
his  malady,  such  mistakes,  though  much  more  readily  committed,  may  >iill 
be  avoided.  Indeed,  generally  speaking,  pleural  effusion  is  easily  recog- 
nized :  complete  dulness,  and  distension  of  the  chest,  never — absolutely 
never — accompany  pneumonia  ;  and  there  is  nearly  always  absence  of  tho- 
racic vibration:  these  are  phenomena  sufficiently  characteristic.  It  is  true 
that  in  some  exceptional  cases,  thoracic  vibration  is  absent  in  pneumonia  ; 
and  it  is  also  true,  that  thoracic  vibration  may  exist  in  some  cases  of  pleu- 
risy, as,  for  example,  in  pleurisy  accompanied  by  bronchophony.  Bui 
when,  in  addition  to  the  phenomena  now  pointed  out,  we  meet  with  others, 
such  as  the  crushing  up  of  the  mediastinum,  and  the  pushing  over  of  the 
heart  to  the  unaffected  side,  the  pressing  down  of  the  liver  or  spleen,  one 
can  have  no  doubt  as  to  the  existence  of  extensive  pleural  effusion,  nor  will 
there  he  any  chance  of  mistaking  it  for  pneumonia.  Bui  it',  in  these  cases, 
the  patient  has  suddenly  vomited  a  large  quantity  <>t'  pus,  you  may,  with- 
out any  farther  examination  of  the  ch|St,  without  using  stethoscope  01 
pleximeter,  affirm  that  the  pus  comes  from  the  pleura.  Auscultation  will 
generally  confirm  this  diagnosis,  by  enabling  you  to  recognize  the  signs  of 
hydropneumothorax. 

This  is  a  point  upon  which  I  have  insisted,  when  discussing  the  history 
6f  pleurisy   and    pneumothorax.      At    present,   I    shall   only   recall   to  your 

recollection  the  fact  that  these  large  pleural   purulent  collections  may  open 

into  the  bronchial  passages  without   necessarily  causing  anj  greal  harm  to 
t  he  individual. 

Three  years  ago,  Dr.  Hordes  called    me  to  see  with   him  in  consultation 


PERIPNEUMONIC    VOMICAE.  659 

a  fruiterer  of  the  Rue  des  Gravilliers':  our  appointment  was,  to  meet  at  this 

man's  house  at  halt-past  ten  in  the  morning.  Dr.  Hordes  had  detected 
considerable  effusion  in  the  chest,  dating  back  two  months  and  more:  he 
begged  me  to  bring  with  me  the  instruments  necessary  for  performing  para- 
centesis of  the  chest;  and  consequently  I  went  prepared  to  operate.  On 
my  arrival,  the  patient  showed  me  a  salad  dish  containing  five  litres  of 
pus,  which  he  had  vomited  during  the  night.  During  the  day,  he  contin- 
ued to  bring  up  pus  in  large  quantities,  and  within  less  than  a  week,  he 
brought  up  eleven  litres  by  exact  measure.  He  continued  for  three  weeks 
or  a  month  to  vomit  pus,  to  use  his  own  expression.  At  present,  he  is  in 
excellent  health. 

Large  pleural  vomica?,  then,  may,  like  pulmonary  vomica?,  open  into  the 
bronchial  passages ;  but,  irrespective  of  the  signs  which  I  have  given  you, 
the  very  quantity  of  the  pus  brought  up  will  not  allow  the  practitioner  for 
one  moment  to  have  any  doubt  as  to  the  nature  of  the  case.  No  abscess  of 
the  lung  can  contain  a  litre  of  pus  :  that  I  hold  to  be  impossible,  but  a 
pleural  abscess  may  contain  two,  three,  or  four  litres ;  moreover,  as  the  pus 
is  renewed  day  by  day,  the  quantity  brought  up  by  an  individual  may  be 
much  greater.  For  example,  Legroux  mentions  the  case  of  an  individual, 
who — during  a  period,  it  is  true,  of  considerable  duration — brought  up  from 
42  to  43  litres,  actually  measured ;  and  at  a  meeting  of  the  Medical  Society 
of  the  Parisian  Hospitals,  in  1854,  I  read  an  account  of  the  case  of  one  of 
my  patients,  a  girl  six  years  old,  operated  on  for  empyema,  who,  within  a 
period  of  rather  more  than  six  months,  brought  up  pus  estimated  at  200 
grammes  a  clay,  making  the  enormous  total  weight  of  40  kilogrammes. 

The  capital  difference  between  the  quantity  of  pus  expectorated  in  cases 
of  pleural  and  pulmonary  vomica?  simplifies  their  differential  diagnosis. 
The  difference  in  the  quantity  of  pus  expectorated,  and  the  different  period 
at  which  the  vomica  opens,  constitute  the  essential  elements  of  the  diag- 
nosis. In  children,  however,  the  last-mentioned  diagnostic  element  may 
be  wanting. 

In  children,  purulent  collections  in  the  pleura  may  open  very  quickly 
into  the  bronchial  tubes.  Suppose  a  case  of  pleurisy  in  which  the  diag- 
nosis has  been  made  with  exactitude  at  the  beginning  of  the  attack. 
Effusion  has  been  detected,  and  its  increase  observed  :  symptoms  soon  show 
themselves  indicating  that  the  effusion  has  become  purulent :  at  last,  about 
the  fifteenth,  twentieth,  or  eighteenth  day  of  the  attack,  the  patient  brings 
up  pus  in  large  quantities.  The  existence  of  a  pleural  vomica  is  in  such  a 
case  established  beyond  the  possibility  of  mistake.  In  the  adult,  cases  of 
this  description  are  of  exceptional  occurrence  ;  but  they  are  sometimes  met 
with  in  persons  of  suppurative  diathesis.  In  puerperal  women,  for  example, 
you  may  have  rapid  formation  of  pleural  abscesses ;  and  you  may  also 
have  them  opening  into  the  bronchial  tubes  very  rapidly,  much  more 
rapidly  than  in  ordinary  cases.  Under  such  circumstances,  there  might  be 
great  difficulty  in  establishing  the  diagnosis,  owing  to  the  element  of  doubt 
introduced  by  the  expectoration  of  pus  ;  but  if  we  have  seen  the  cases  when 
the  first  symptoms  set  in,  if  we  have  then  perceived  the  presence  of  a  sup- 
purative pleurisy,  the  connection  of  the  suppurative  phenomena  with  the 
puerperal  condition  and  general  symptoms  of'  the  patient,  will  suggest  them- 
selves to  your  minds  ;  and  when  the  vomica  bursts  externally,  you  will 
realize  the  necessity  of  being  guarded  in  your  prognosis. 

To  complete  my  remarks  on  pulmonary  abscesses,  let  me  add  a  few 
words  on  their  pathological  anatomy  and  mode  of  termination.  In  respect 
of  .their  pathological  anatomy,  I  would  call  your  attention  to  the  charac- 


660  TREATMENT  OF  PNEUMONIA. 

ters  which  distinguish  purulent  collections  originating  in  acute  simple 
inflammation  from  the  vomica?  met  with  in  phthisical  subjects.  On  this 
point,  I  cannot  do  better  than  quote  the  exact  words  of  Laenuec.     He  says: 

"  Although  in  some  cases,  the  color  and  aspect  of  tuberculous  matter  are 
very  similar  to  those  of  pus,  tuberculous  matter  generally  differs  from  pus 
by  containing  an  admixture  of  fragments  of  softened  friable  tubercle. 
Moreover,  the  circumscribed  character  of  the  cavities  formed  by  the  softening 
of  tubercle,  the  firm  consistence  of  their  walls,  the  soft  false  membrane  by 
which  they  are  always  lined,  and  the  semi-cartilaginous  membrane  which 
sometimes  succeeds  to  this  false  membrane,  are  sufficient  to  characterize  a 
lesion  very  different  from  the  above-described  abscesses."  I  would  add, 
gentlemen,  to  this  description  of  Laennec,  that  one  never  meets  with  a 
tuberculous  vomica,  without  finding  at  the  same  time  numerous  tubercular 
masses  at  different  stages  in  one  or  both  lungs. 

Regarding  the  prognosis,  I  cannot  speak  from  my  own  experience  alone; 
because,  as  I  have  already  told  you,  I  never  had  a  case  of  pulmonary 
abscess  till  I  met  with  the  two  which  have  given  occasion  to  the  present 
lecture.  Judging  from  these  cases,  and  from  what  has  been  written  on  the 
subject,  I  believe  that  pneumonia  terminating  in  pulmonary  abscess  is 
generally  mortal.  ]So  doubt,  Laennec,  Graves,  and  others,  show  the  pos- 
sibility of  recovery  by  the  abscesses  opening  into  the  bronchial  tubes,  and 
cicatrization  of  the  cavities  taking  place;  but  without  denying  the  possi- 
bility of  cure  in  this  way,  I  agree  in  opinion  with  those  physicians  who  re- 
gard such  cases  as  altogether  exceptional. 

In  the  treatment  of  cases  of  pulmonary  abscess,  as  you  can  understand, 
gentlemen,  there  is  nothing  special  to  be  done.  Up  to  the  time  that  the 
existence  of  the  pulmonary  abscess  is  ascertained,  the  treatment  in  no  re- 
spect differs  from  that  of  ordinary  pneumonia  :  and  when  we  ascertain  that 
the  abscess  is  actually  formed,  intervention  can  avail  nothing,  as  the 
abscess  is  situated  bevond  the  reach  of  our  remedial  resources. 


LECTURE   XXXVI. 

TREATMENT    OF    PNEUMONIA. 

Simj,lr  ]',,,  umonia  withovi  any  Complication. — Expectant  Medicine. —  / 

"//'/  General  Bleeding. — Blisters. — Antimonial  Preparations,  particu- 
larly il"-  Precipitated  Sulphuret  \Kerme8~\  in  large  doses  according  t>> 
Rasori's  Method. 

GENTLEMEN:  1  am  certain  that  in  all  the  differenl  hospitals  which  you 
frequent,  there  are  no  wards  in  which  the  local  and  general  abstraction  of 

blood  is  resorted  to  SO  cautiously  [a/USsi  sobremenf]  a-  in  mine.      This  arises 

from  the  fact  that  as  yei  the  necessity,  the  utility  even,  of  bleeding  does 

not   appear  to  me  to  have  been   made  out  so  clearly  as  is  believed   hy  the 

majority  of  physicians,  to  whom  the  denial  of  the  efficacy  of  abstracting 
blood  in  pneumonia  would  seem  the  denial  of  a  demonstration. 

Even  in  pneumonia,  a  disease  which,  according  to  received  ideas,  demands 
bleeding  more  than  any  other,  you  seldom  hear  me  order  it.  If  I  some- 
times have  recourse  to  it.  it  i-  because  it  seems  to  lie  indicated  by  certain 


TREATMENT  OF  PNEUMONIA.  661 

complications  of  the  case,  rather  than  with  any  view  to  combat  the  ordinary 
inflammatory  clement  of  pneumonia  :  the  cases  in  which  I  resort  to  it  are  too 
few  in  Dumber  to  weaken  in  any  degree  the  general  applicability  of  the  rule 
by  which  I  have  been  guided  in  this  matter  for  many  years. 

Gentlemen,  this  practice  differs  so  essentially  from  that  which  I  may  say 
is  almost  universally  followed — from  that  which  is  followed  by  the  majority 
of  your  teachers,  my  colleagues  as  hospital  physicians,  and  by  the  classical 
authors  whose  works  are  in  your  hands — from  that  which  is  accepted  as 
orthodox  by  non-medical  public  opinion,  which  does  not  recognize  the  pos- 
sibility of  inflammation  of  the  lungs  being  cured  without  the  abstraction  of 
blood — that  I  am  bound  to  explain  myself  to  you  fully  on  this  subject,  and 
to  expound  my  views  on  the  treatment  of  pneumonia. 

But  before  grappling  with  the  merits  of  this  interesting  question,  it  is 
essential  clearly  to  define  the  terms  employed  in  the  discussion. 

Pneumonia  is  not  uniform  in  its  character :  the  forms  which  it  assumes, 
its  greater  or  less  intensity  and  extent — the  influence  of  the  prevailing 
medical  constitution — the  personal  specialties  of  the  patients  in  respect  of 
age,  sex,  temperament,  and  previous  health — the  diseases  which  may  com- 
plicate pulmonary  inflammation,  and  the  unfavorable  conditions  which 
may  supervene  during  its  course — all  demand  particular  inquiry  on  the 
part  of  the  physician.  He  must  take  special  account  of  all  of  them,  for 
they  greatly  modify  the  disease,  and  are  also  the  source  of  much  diversity 
in  the  therapeutic  indications. 

For  the  present,  I  shall  delay  consideration  of  that  particular  form  of 
pneumonia,  which  I  very  willingly  call  catarrhal  pneumonia,  and  which  is 
observed  in  the  early  years  of  infancy  and  childhood,  which' is  in  the  adult 
one  of  the  most  formidable  epiphenomena  of  serious  fevers ;  and  also,  par- 
ticularly, of  measles  and  hooping-cough,  as,  on  former  occasions,  I  have 
pointed  out  to  you. 

I  shall  also,  for  the  present,  say  nothing  of  pneumonia  complicated  with 
symptoms  giving  it  a  special  stamp :  it  will  be  sufficient  for  me  to  name 
bilious  pneumonia,  so  remarkably  described  by  Stoll,  but  which  is  seldom 
met  with  in  the  present  day,  a  circumstance  probably  explained  by  the 
existing  medical  constitutions  differing  from  those  under  which  Stoll  ob- 
served ;  ataxic  and  adynamic  pneumonia,  which  take  their  names  from  the 
predominance  of  nervous  symptoms ;  arthritic  and  rheumatic  pneumonia, 
unquestionably  species  of  pneumonia,  though  their  existence  has  been  denied 
by  some. 

The  kind  of  pneumonia  of  which  I  wish  to  speak  to  you  to-day  is  peri- 
pneumonia vera — simple  legitimate  pneumonia — that  form  of  the  disease 
which  most  frequently  presents  itself  to  our  notice,  and  generally  supervenes 
from  an  accidental  cause,  generally  from  a  chill. 

I  shall  now  rapidly  sketch  its  principal  features.  The  period  of  incuba- 
tion is  either  short,  or  has  had  no  existence.  The  malady  is  generally 
ushered  in  by  a  shivering  fit ;  but  this  phenomenon  is  sometimes  absent.  The 
local  phenomena  generally  open  the  scene.  There  is  a  stitch  in  a  part  of 
the  side  of  variable  extent:  it  is  complained  of  by  the  majority  of  patients 
as  existing  at  the  base  of  the  lung,  more  particularly  under  the  nipple :  it 
is  generally  increased  by  the  inspiratory  movements  and  by  coughing ;  and 
is  intensified  by  pressure.  The  respiratory  movements  become  accelerated ; 
and  there  is  oppression  of  the  breathing — much  more,  however,  in  appear- 
ance than  in  reality.  The  cough,  at  first  dry  and  distressing,  is  almost 
never  absent.  The  local  phenomena  are  accompanied  by  intense  fever ; 
the  skin  is  hot,  having  sometimes  a  burning  dryness,  but  being  more  usually 
covered  with  a  greater  or  less  amount  of  perspiration.     The  patient  com- 


662  TREATMENT    OF    PNEUMONIA. 

plains  of  a  feeling  of  discomfort,  general  bruising,  and  headache  :  the  coun- 
tenance appears  flushed  and  excited  :  the  tongue  is  covered  with  a  white 
saburral  coating,  and  is  sometimes  yellowish  towards  the  base :  there  is  in- 
tense thirst,  and  no  appetite  for  food.  Bilious  vomiting  is  often  the  first 
symptom:  diarrhoea  is  very  common  at  the  beginning  of  the  illness  ;  gener- 
ally, numerous  herpetic  bulla?  appear  on  the  lips  and  around  the  nostrils. 

During  the  first  twenty-four  hours,  the  cough  is  generally  dry,  as  I  have 
just  stated,  or  at  least  the  expectoration  which  accompanies  it  has  as  yet 
nothing  characteristic  of  the  malady ;  but  on  the  following  day,  it  begins 
to  assume  more  and  more  that  appearance  which  is  destined"  to  become  spe- 
cific. Peripneumonic  sputa  are  viscous,  glutinous,  semi-transparent,  and 
minutely  aerated :  although,  as  yet,  they  have  not  much  of  the  rusty  char- 
acter, nor  are  they,  as  a  rule,  very  sanguinolent,  some  of  them  at  least  pre- 
sent occasional  strise,  or  a  small  compact  nucleus,  the  color  of  which  passes 
from  amber-yellow  to  the  tint  of  barley-sugar.  This  coloration,  due  to  the 
.  admixture  of  blood  with  the  mucous  secretion,  becomes  more  and  more 
marked,  presenting  different  shades,  particularly  that  of  apricot  marmalade, 
of  saffron,  and  of  iron  rust.  At  the  same  time  that  the  sputa  undergo  these 
changes,  they  become  more  abundant,  coalesce  into  one  mass  in  the  spit- 
toon, and  form  a  sheet,  semi-transparent  like  the  cornea.  The  sputa  strongly 
adhere  to  the  bottom  of  the  vessel.  They  are  of  themselves  sufficient  to 
enable  us  to  recognize  the  nature  of  the  disease  ;  but  other  physical  signs, 
the  existence  of  which  we  are  able  to  discover  by  auscultation  and  percus- 
sion, are  pathognomonic  of  inflammation  of  the  pulmonary  parenchyma. 

These  signs  do  not  show  themselves  during  the  first  twenty-four  hours : 
at  least,  percussion  furnishes  no  positive  element  of  diagnosis,  thoracic  reso- 
nance not  being  sensibly  modified,  and  auscultation  affording  little  more 
than  negative  results  in  respect  of  changes  in  the  respiratory  sounds.  But 
on  the  second  day,  a  dulness  more  or  less  appreciable  reveals  itself  in  the 
parts  originally  affected ;  and  there  are  also  heard  in  that  situation  anoma- 
lous sounds  which  become  more  and  more  decided. 

The  earliest  of  these  sounds  is  a  fine  and  very  equal  crepitant  rale,  which 
is  heard  during  inspiration:  the  shocks  imparted  by  the  cough,  so  far  from 
causing  it  to  disappear,  make  it  reach  the  ear  of  the  auscultator  in  blasts. 
This  crepitation  tells  us" that  there  is  engorgement  of  the  lung;  and  I  need 
not  here  discuss  the  theories  which  have  been  advanced  to  explain  the  pro- 
duction of  this  crepitation.*  This  rale  is  accompanied  by,  and  soon  after- 
wards replaced  by  bronchial  respiration,  which  has  also  received  the  name 
of  bronchial  blowing.  This  blowing  sound  presents  different  varieties:  some- 
times it  is  distant  from  the  ear;  and  at  other  times,  on  the  contrary,  ii  is 
harsh  and  noisy;  sometimes  it  is  large  and  diffuse,  and  at  other  times  Limited 
and  resounding,  constituting  tubal  blowing.  It  generally  begins  by  replac- 
ing the  sound  of  expiration  only,  but  it  afterwards  invades  that  of  inspira- 
tion, and  then  accompanies  both  expiration  and  inspiration.     The  voice, 

Without  desiring  to  diminish  in  the  smallest  degreee  the  glory  of  Laennec,  to 
whom  belongs  the  whole  of  the  honor  of  having  1  »< > 1 1 1  discovered  auscultation,  and 

of  Ii :i \  i ii lt  at  one  Btroke  as  it  were  brought  it  to  a  very  high  pitch  of  perfection,  it 
will,  I  think,  be  interesting  to  quote  in  this  place  the  following  passage  from  Van 
Swieten,  according  to  whom  it  would  appear,  not  only  that  the  ancients  had  an  idea 
of  the  existence  of  the  crepitant  rale,  hut  likewise  gave  a  theoretical  explanation  of 

it-  cause.      Van  Swieten  Bays  : 

•'  Plerumque  tune  ,-imul  adesi  ingratus  inpectore  Btrepitus,  qui  tit  vel  ab  ocri  muco 
hie  collecto,  irretitio:  vel  a  vesiculis  pulmonum  siccis,  hincq ue  crepitantibua  instar 
corii  rarefacti,  dum  inspirando  eztenduntur." — G.  Vas  Bwibten,  Comment,  in 
II-    ■■    Boerhaavii  Aphor.,  '-,  826,  Peripneumonia  Vera,  t.  ii.  p.  659. 


TREATMENT    OF    PNEUMONIA.  663 

which  has  hitherto  been  only  slightly  resonant,  now  loudly  resounds  in  the 
bronchi,  and  is  transmitted  to  the  <:u'  by  the  hepatized  pulmonary  tissue, 

which,  be  in  g  more  dense  than  the  remainder  of  the  Lung,  Becomes  an  excel- 
lent conductor  of  sound.  This  bronchophony  is  Qever  more  marked  than 
when  it  occupies  the  root  or  summit  of  the  lung,  where  the  bronchial  tubes 
are  larger  than  elsewhere. 

Crepitant  rales  are  also  often  heard  within  the  same  space  in  which  the 
blowing  sound  and  vocal  resonance  are  audible. 

These  characteristic  physical  signs  of  the  disease  which  we  are  now  study- 
ing sometimes  escape  detection,  from  the  inflammation  being  confined  to  a 
central  situation  in  the  lung,  or  to  a  sufficiently  careful  examination  not 
having  been  made.  You  may  be  able  to  hear  the  morbid  sounds  only  in 
the  axilla. 

The  general  symptoms  continue  along  with  the  local  phenomena,  and 
they  never  show  themselves  in  a  more  decided  manner  than  from  the  fifth 
to  the  eighth  day.  The  fever  is  more  intense  at  that  period.  The  flushing 
of  the  face  is  at  its  height,  and  is  greater  over  the  cheek  bones.  The  red- 
ness in  this  situation  was  looked  on  by  our  predecessors  as  one  of  the  char- 
acteristic symptoms  of  pneumonia. 

Physicians,  encouraged  by  the  alleged  success  of  the  Hahnemann  sect  in 
treating  pneumonia,  and  following  also  other  examples,  have  submitted 
their  pneumonic  patients  to  the  expectant  system.  This  method  was  adopted 
long  ago  by  Magendie;  and  there  are  doubtless  some  among  you  who  have 
heard  of  the  recently  published  wTorks  of  MM.  Dietl  of  Vienna,  Xiemeyer 
of  Griefswald,  Schmidt,  &c,  and  of  the  cases  reported  by  Dr.  Laboulbene: 
many  must  have  read  the  posthumous  treatise  of  Legendre,  intituled,  "De 
l'Expectation  dans  la  Pneumonie  Franehe."*  Well,  then,  gentlemen,  these 
experiments  have  made  us  acquainted  with  the  natural  course  run  by  purely 
inflammatory  pneumonia  in  a  great  number  of  cases.  Generally  speaking 
there  is  a  tendency  to  spontaneous  recovery,  'which  usually  occurs  between 
the  ninth  and  eleventh  days. 

According  to  Dr.  Bourgeois  of  Etampes,t  who,  for  twenty-five  years,  has 
abstained  from  all  active  therapeutic  treatment  in  pneumonia  (and  has  pub- 
lished a  short  paper  on  the  subject),  there  is,  at  the  eighth  day,  a  marked 
tendency  to  diminution  in  all  the  symptoms  in  the  cases  which  do  well. 
At  that  period  the  sputa  are  less  colored  and  less  viscid :  respiration  is  a 
little  less  embarrassed:  there  is  no  longer  pain  in  the  side:  there  is  a  dim- 
inution in  the  thickness  of  the  saburral  coating  of  the  tongue:  there  is  a 
return  of  sleep,  which,  during  the  previous  days,  had  been  absent  or  had 
been  replaced  by  a  state  of  constant  drowsiness :  towards  the  close  of  the 
day  the  drowsiness  ceases,  and  the  patient  begins  to  feel  the  want  of  resto- 
rative measures. 

On  the  ninth  day  there  is  almost  always  improvement :  though  there  is 
more  cough,  it  is  looser:  the  sputa,  albuminous  rather  than  gelatinous,  are 
nearly  always  colorless:  the  stitch  in  the  side  has  quite  ceased,  unless  it  be 
that  it  returns  during  severe  coughing  fits,  or  on  taking  a  deep  breath :  the 
tongue  has  become  clean:  there  is  a  decided  appetite  for  food:  the  urine, 
which  was  of  a  scalding  character  and  scanty,  during  the  acute  stage  of  the 
pneumonia,  becomes  abundant,  and  nearly  normal  in  character,  having  no 
deposit,  and  being  devoid  of  turbidity,  appearances  which  rarely  show  them- 
selves except  during  convalescence:  in  a  word,  the  symptoms  of  the  disease 
disappear,  while  its  physical  signs  remain  in  their  plenitude. 

*  Legendre  :  Archives  Generates  de  Medecine,  for  September,  1859. 
f  Bourgeois  (d'Etampes)  :  Union  Medicate,  for  3d  January,  1860. 


664  TREATMENT    OF    PNEUMONIA. 

On  the  tenth  day,  the  patient  enters  upon  complete  convalescence.  At 
the  end  of  the  second  week,  should  nothing  occur  to  impede  the  progress 
of  recovery,  the  patient  is  in  a  state  to  resume  his  ordinary  occupations, 
provided  they  are  not  of  a  fatiguing  nature.  Nevertheless,  upon  ausculta- 
tion at  this  period,  we  still  find  the  dulness,  and  also  the  crepitant  rale 
which  had  replaced  the  tubal  blowing,  but  it  is  the  crepitant  rale  or,  to 
speak  more  correctly,  the  subcrepitant  moist  "rale  de  retour,"  as  it  is  called, 
indicative  of  the  return  of  the  air  into  the  pulmonary  vesicles,  whence  it 
had  been  expelled  by  hepatization.  Several  weeks  will  often  be  required 
for  the  complete  disappearance  of  the  signs  of  engorgement  of  the  lung. 

In  simple  pneumonia  the  temperature  rises  rapidly  after  the  shivering 
fit  which  occurred  at  the  beginning  of  the  attack :  it  often  reaches,  and 
sometimes  goes  above  39°  during  the  early  days  of  the  disease.  It  then 
continues  at  that  point,  with  however  slight  irregular  oscillations.  The 
case  is  serious  when  the  temperature  rises  to  or  ascends  above  40°.  The 
fever  generally  abates  on  the  5th,  7th,  or  9th  day:  this  abatement  takes 
place  abruptly,  and  with  rapidity :  in  twelve  hours,  or  in  thirty-six  hours  at 
the  most,  the  temperature  falls  three  degrees  or  more.  As  soon  as  the 
normal  temperature  is  attained,  resolution  begins,  and  the  patient  may  be 
looked  upon  as  convalescent.  At  defervescence,  it  occasionally  happens  that 
the  temperature  falls  for  a  very  short  time  below  the  natural  standard :  in 
the  cases  in  which  this  occurs,  there  is  a  temporary  collapse. 

These  data,  derived  from  numerous  researches  of  Wunderlich,  you  have 
had  an  opportunity  of  verifying  in  a  patient  who  occupied  bed  20  of  St. 
Agnes's  Ward.  This  man,  aged  27,  addicted  to  drinking  and  affected  with 
alcoholic  tremors,  had  extensive  pneumonia  at  the  upper  part  of  the  right 
lung.  From  the  first  days  of  his  attack,  the  urine  was  found  to  contain  a 
considerable  quantity  of  albumen :  he  was  delirious  on  the  night  of  the 
sixth  day  of  the  disease,  and  during  the  seventh  and  eighth  days  the  de- 
lirium continued.  On  the  ninth  day,  however,  a  complete  convalescence 
set  in  ;  and  by  the  eleventh  day,  there  was  no  longer  any  albumen  in  the 
urine.  Here  is  what  occurred  in  respect  of  temperature :  On  the  fourth 
day,  the  day  on  which  the  patient  was  admitted  to  the  hospital,  his  tem- 
perature was  39°  :  on  the  morning  of  the  fifth  day,  it  had  risen  to  40.2°, 
and  in  the  evening  of  that  day  it  fell  to  39.6°,  under  the  influence  of  anti- 
phlogistic treatment:  on  the  sixth  day,  during  the  whole  day,  morning 
and  evening,  it  kept  at  40.4°:  on  the  evening  of  the  eighth  day,  it  fell  to 
39.8°,  then  on  the  morning  of  the  tenth  clay,  it  fell  to  thirty-six  degrees  <m>l 
six-tenths — which  is  below  the  normal  standard,  to  rise  again  to  37°  and 
37.2°,  where  it  definitively  remained. 

I  am  unwilling  to  quit  this  interesting  subject  of  temperature,  without 
pointing  out  to  you  an  important  clinical  peculiarity.  At  the  beginning 
of  an  inflammatory  affection  of  the  chest,  when  there  is  stitch  in  the  side, 
it  is  occasionally  very  difficult  by  unaided  physical  signs  and  the  reaction 
to   ascertain  whether  the   inflammation   is   pneumonia   or   pleurisy:   well.it' 

from  the  first  days  of  the  attack,  the  temperature  rises  rapidly,  reaching  39  , 

or,  u  fortiori,  if  it  rise  to  a  higher  figure,  pleurisy  may  be  excluded,  and 
pneumonia  diagnosed:  and  likewise,  (lie  continuance  of  a  relatively  low 
temperature  makes  it  probable  thai  there  is  pleurisy,  or,  at  all  event-,  it 
excludes  the  idea  of  the  existence  of  simple  pneumonia. 

Axe  we  obliged  to  conclude,   that  the  treatment   of  pneumonia    ought    to 

he  expectant,  because  recovery  takes  place  spontaneously  in  a  certain  num- 
ber of  cases?  I  think  not:  and,  moreover,  when  1  find  myself  Confronted 
with  this  disease,  I  cannot  remain  an  inactive  spectator.     Whenever  I  am 


TREATMENT    OF    PNEUMONIA.  665 

called  in  to  a  patient  suffering  from  pure  and  absolutely  uncomplicated 
pneumonia,  I  lose  no  time  in  intervening  by  antiphlogistic  treatment. 

As  I  stated  at  the  beginning  of  this  lecture,  I  very  rarely  have  recourse 
to  the  abstraction  of  blood,  local  or  general.  When  there  are  symptoms  of 
great  general  plethora,  threatening  to  complicate  the  progress  of  the  disease, 
I  sometimes,  though  very  rarely,  cause  a  vein  to  be  opened.  After  a  single 
bleeding,  however,  of  from  four  hundred  to  five  hundred  grammes,  I  seldom 
require  to  repeat  the  proceeding.  To  remove  or  moderate  the  stitch  in  the 
side,  when  the  pain  is  excessive,  I  prescribe  cupping-glasses  to  be  applied 
to  the  seat  of  pain,  abstracting  or  not  abstracting  blood  as  the  case  may 
be;  or  I  inject  some  drops  of  a  solution  of  atropine  into  the  subcutaneous 
cellular  tissue :  but  that  is  the  limit  within  which  I  bleed  in  pneumonia. 
Bleeding,  once  extolled  by  physicians  of  the  highest  repute,  employed  for- 
merly in  one  form  or  another  by  almost  all  practitioners,  is  energetically 
objected  to  in  the  present  day.  Some  clinical  physicians  not  only  deny  its 
efficacy,  but  even  regard  it  as  generally  injurious.  The  only  cases  in  which 
they  do  not  regard  it  as  objectionable  are  those  in  which  the  inflammatory 
symptoms  are  accompanied  by  excessive  reaction,  such  as  intense  headache, 
somnolence,  and  great  dyspnoea.  In  such  circumstances,  even,  though  they 
sanction  bleeding  as  a  means  of  affording  temporary  relief,  they  insist  on 
the  necessity  of  drawing  blood  in  moderation.  Though  in  these  cases,  they 
admit  that  bleeding  may  prove  palliative,  they  deny  that  it  is  ever  a  means 
of  cure,  far  less  do  they  admit  that  it  ever  has  the  power  which  has  been 
assigned  to  it  of  cutting  short  the  disease.  And  again,  the  physicians  to 
whom  I  refer,  looking  to  the  statistics  which  have  been  drawn  up  to  elu- 
cidate this  question,  have  come  to  the  conclusion  that  there  has  been  a 
greater  mortality  in  pneumonia  among  those  who  have  been  bled,  than 
among  those  who  have  not  been  bled:  and  consequently,  they  say  that 
bleeding  has  been  the  cause  of  the  numerous  deaths  from  pneumonia,  not- 
withstanding the  immediate  temporary  benefit  which  it  affords. 

You  have  heard  Dr.  Beau,*  in  his  clinical  lectures,  develop  these  ideas 
regarding  the  unfavorable  effects  which  bleeding  produces  upon  pneumonic 
patients.  In  citing  to  you  cases  from  his  own  practice,  in  supporting  his 
views  by  other  cases  quoted  from  the  works  of  numerous  French  and  foreign 
physicians,  my  honorable  colleague  of  the  Hopital  de  la  Charite  has  en- 
deavored to  explain  them  to  you  by  entering  into  physiologico-pathological 
considerations. 

Although  I  also  call  in  question  the  advantages  of  the  abstraction  of 
blood,  the  usefulness  of  which,  particularly  in  the  treatment  of  pneumonia, 
seems  to  me  to  have  been  vaunted  beyond  measure,  I  cannot  agree  with 
those  who  are  the  detractors  of  bleeding.  Although  I  do  not  admit  its 
utility  in  the  majority  of  cases,  allowance  being  made  for  the  peculiar 
medical  constitutions  through  which  we  have  passed  in  recent  years,  yet,  at 
the  same  time,  I  deny  that  it  brings  in  its  train  the  disastrous  consequences 
ascribed  to  it,  provided  it  be  practiced  with  due  moderation.  If,  as  a 
general  rule,  I  abstain  from  prescribing  bleeding,  it  is  not  because  I  believe 
it  to  be  the  cause  of  the  frequent  deaths  which  have  been  attributed  to  it, 
but  because  my  experience  has  taught  me  that  it  seldom  shortens  the 
duration  of  the  disease,  and  frequently  retards  complete  return  to  health, 
by  weakening  the  patients,  and  prolonging  the  period  of  their  convales- 
cence. 

Antimonials  have  not  these  drawbacks.  Their  antiphlogistic  properties 
are  as  unquestionable  as  those  of  bleeding  :  the  only  difference  is  that  they 

*  Beau  :  Gazette  des  Hopitaux,  for  the  6th  and  8th  September,  1859. 


666  TREATMENT    OF    PNEUMONIA. 

act  in  a  different  manner.  While  sanguineous  evacuations  suppress  in- 
flammatory  action  by  removing  the  materials  which  constitute  its  aliment, 
while  they  exhaust  the  disease  by  exhausting  the  patient,  antimonial 
preparations  act  in  a  wholly  different  manner,  and  never  bring  along  with 
them  the  extreme  prostration  which  often  accompanies  the  convalescence 
from  pneumonia  treated  by  repeated  bleedings. 

This  action  of  antimonials  has  been  explained  in  many  different  ways. 
Rasori  explained  it  by  saying  that  these  medicines  exhausted  the  diathesis  of 
the  stimulus  ;  but  he  did  not  define  very  well  the  meaning  which  he  attached 
to  that  expression.  According  to  Dance  and  Chomel,  antimony  does  not 
possess  any  specific  property.  When  there  is  a  complete  tolerance  for  it, 
they  say  that  it  is  inert;  and  when  it  acts  as  an  emetic  or  purgative,  they 
hold  that  its  action  differs  in  no  respect  from  that  of  any  other  evacuant. 
This  opinion  comes  very  near  to  that  of  Broussais,  the  eminent  professor  of 
the  Yal-de-Grace,  who  says  that  antimonials  ought  to  be  regarded  as 
revulsives  even  more  powerful  than  the  blisters  and  the  sinapisms,  which 
are  applied  to  the  skin,  inasmuch  as  they  act  upon  a  larger  surface,  and 
moreover  often  excite  profuse  discharge  from  the  gastro-intestinal  mucous 
membrane. 

Gentlemen,  this  is  not  the  place  to  repeat  a  discussiou  which  you  will 
find  given  very  fully  in  the  article  on  antimony  in  my  treatise  on  therapeu- 
tics. I  nevertheless  ask  you  to  allow  me  to  add  what  is  there  said  on  this 
head.  As  a  general  rule,  I  attach  very  little  importance  to  explanations 
of  the  therapeutic  action  of  medicines.  In  therapeutics,  I  only  see  two 
things — the  administration  of  the  medicine,  and  the  result  of  that  adminis- 
tration. As  for  the  intermediate  phenomena,  they  escape  our  observation, 
and  perhaps  will  always  continue  to  do  so.  Notwithstanding,  I  have 
hazarded  my  theory  as  to  the  mode  in  which  antimonial  preparations  act; 
holding  it,  however,  as  very  cheap,  and  being  quite  willing  to  abandon 
it  for  any  other  which  may  appear  to  me  to  be  more  in  conformity  with 
facts.  I  asked  myself  whether  we  might  not  grant  that  antimony  exercised 
a  special  toxic  action  on  the  heart  and  respiratory  organs,  either  directly 
or  through  the  medium  of  the  nervous  centres,  just  as  many  medicinal 
substances  have  unquestionably  a  special  action  on  certain  organs.  The 
existence  of  this  specific  action  of  antimony  appeared  to  me  to  he  demon- 
strated by  its  physiological  effects  as  manifested  by  the  pulse  becoming 
slower  and  weaker,  and  by  the  breathing  becoming  slower.  This  fact  being 
established,  the  therapeutic  effects  of  antimonials  in  pneumonia  may  be 
ascribed  to  a  diminution  in  the  quantity  of  blood  sent  to  the  inflamed 
lungs,  which,  by  having  a  less  degree  of  activity,  are  in  a  state  analogous 
to  that  in  which  the  Burgeon  places  a  fractured  limb — that  i-  t"  say,  in  a 
state  < » t'  relative  if  not  in  a  state  of  absolute  repose. 

Experiments  on  animals  confirmed  the  views  which  1  had  formed  as  to 
the  toxic  action  of  antimonials  upon  the  heart  and  organs  of  respiration. 
I  had  long  previously  enunciated  the  opinion  I  have  now  stated,  when — in 
[856 — the  experiments  of  Ackerman,  and  afterwards  those  of  Pecholier, 
demonstrated  its  correctness.  If,  a- ha-  been  done  quite  recently  in  con- 
firmatory vivisections,  by  my  learned  colleague,  Professor  S6» — if  a  solution 
of  tartar  emetic  be  injected  into  the  veins  of  rabbits  or  of  guinea-pigs, 
there  are  soon  observed  ;i  decided  lowering  of  the  pulse,  diminished  ar- 
terial pressure,  ami  frequently,  likewise,  irregularity  in  the  pulsations. 
Along  with  this  condition  of  the  pulse  there  is  a  great  depression  of  the 
vital  powers.  The  lowering  of  the  pulse  and  the  diminution  of  arterial 
pre—ure  are  due  to  diminished  frequency  and  diminished  energy  in  the  con- 
tractions of  the  lean  ;  and  this  may  be  attributed  to  a  direct,  and  to  a 


TREATMENT  OF  PNEUMONIA.  667 

certain  extent  paralyzing  actios  of  the  tartar  emetic  upon  the  cardiac 
ganglia,  which  are  the  automotor  ganglia  of  the  organ. 

Whatever  may  be  the  explanation  of  their  action,  the  utility  of  anti- 
moniala  in  the  treatment  of  pneumonia  is  now  generally  admitted.  Violently 
and  unfairly  attacked  by  many,  and  inordinately  extolled  by  others,  the 
tartar  emetic  treatment  has  at  last  taken  its  place  in  the  domain  of  thera- 
peutics. But  if  even  persons  who  were  the  most  incredulous  have  become 
convinced  of  the  efficacy  in  pneumonia  of  tartar  emetic  in  large  doses,  it  is 
not  so  with  some  other  preparations  of  antimony.  The  kermes,  which  you 
see  me  prefer  to  tartar  emetic  (for  reasons  which  I  am  about  to  state ),  and 
the  white  oxide  of  antimony,  which  some  believe  to  be  inert,  have  not  as 
yet  acquired  the  same  rights  of  citizenship. 

Nevertheless,  there  is  evidence  to  show  that,  in  the  treatment  of  peri- 
pneumonia, the  kermes  is  in  no  degree  inferior  to  tartar  emetic.  It  has, 
moreover,  this  advantage  over  tartar  emetic,  that  it  is  much  less  irritating, 
and  much  more  rarely  produces  the  inflammatory  affections  of  the  throat 
and  gastro-intestinal  canal  which  prevent  the  continuance  of  the  tartar 
emetic  for  a  period  sufficiently  long  to  bring  about  resolution  of  the  pul- 
monary inflammation,  and  particulary  to  prevent  its  recurrence. 

In  respect  of  the  white  oxide  of  antimomj,  numerous  cases  have  demon- 
strated to  me  its  beneficial  influence,  particularly  in  the  treatment  of  the 
pneumonia  of  children.  There  is,  however,  a  necessity  for  giving  it  in 
large  doses ;  and  the  actual  good  results  may  unquestionably  be  obtained 
by  smaller  doses  of  the  kermes. 

Some  persons  have  seemed  surprised — their  surprise,  however,  being 
more  seeming  than  real — that  I  have  appeared  to  abandon  the  use  of  cer- 
tain antimonial  preparations  which  I  lauded  at  a  previous  period  of  my 
professional  career :  narrow-minded  and  ill-natured  individuals  have  made 
this  circumstance  the  ground  of  bitter  and  insulting  criticism.  They  might 
have  spared  me,  had  they  remembered  a  great  law  of  therapeutics,  to  the 
effect,  that  the  medical  constitution  has  an  immense  influence  on  the  action  of 
remedies. 

This  grave  question  approaches  too  near  the  domain  of  clinical  medicine 
not  to  be  here  discussed,  just  as  in  former  times  I  discussed  it  before  my 
classes  at  the  Faculte  de  Medecine,  and  as  Dr.  Pidoux  and  I  have  discussed 
it  in  our  Traite  de  Therapeutique. 

Medicinal  substances,  when  administered  to  human  beings,  may  be  cor- 
rectly regarded  as  morbific  agents  similar  to  those  which  commonly  beset 
us.  Have  the  ordinary  morbific  agents  always  the  same  mode  of  action  ? 
To  experience  we  must  refer  this  question  for  a  reply. 

A  man,  during  a  particular  epidemic  constitution,  is  exposed  to  the  in- 
clemency of  the  atmosphere ;  he  takes  pneumonia,  and,  at  a  later  period, 
articular  rheumatism,  pleurisy,  or  colitis.  Here,  therefore,  there  is  the 
same  cause  determining  an  inflammation  to  different  organs.  This  happens 
so  frequently,  that  it  is  impossible  for  any  one  to  deny  that  it  is  a  common 
occurrence.  During  the  cholera  epidemic  of  1832,  causes  apparently  the 
least  calculated  to  disturb  the  digestive  functions  produced  diarrhoea,  and 
sometimes  a  sudden  invasion  of  cholera.  Two  years  later,  during  the  in- 
fluenza epidemic,  the  same  cause  which  had  before  produced  cholera  gave 
rise  to  a  special  form  of  catarrh.  No  change  had  taken  place  in  the  cause; 
it  was  identically  the  same.  Why,  then,  did  it  not  produce  the  same 
effects? 

In  considering  the  way  in  which  a  cause  acts,  two  things  of  equal  impor- 
tance have  to  be  borne  in  mind  :  first,  there  is  the  nature  of  the  cause,  which 
is  always  the  same  :  and  second,  there  is  the  support  of  the  cause,  that 


668  TREATMENT  OF  PNEUMONIA. 

is  to  say,  the  economy  within  which  the  cause  operates,  which  is  subject  to 
infinite  variety,  and  reacts  in  virtue  of  idiosyncrasy,  and  also  in  virtue  of 
an  accidental  tendency  which  exercises  an  immense  influence.  It  is  this 
accidental  tendency  [disposition  uccidentelle]  which,  when  distributed  at  the 
same  time  to  a  great  number  of  persons  in  the  same  district  is  called  the 
epidemic  constitution:  it  bears  the  same  relation  to  the  general  population 
that  idiosyncrasy,  or  special  constitution,  bears  to  the  individual. 

When,  therefore,  the  whole,  or  nearly  the  whole  of  a  population  have  one 
common  accidental  constitution,  called  medical  or  epidemic  constitution,  the 
same  cause  which  but  for  this  constitution  would  have  produced  certain 
known  effects,  will  produce  very  different  effects,  because  the  support  of  the 
cause — the  economy — has  a  different  bias,  in  virtue  of  which  its  reaction  is 
different. 

The  medicine  administered  to  the  sick  man  not  only  finds  him  suffering 
from  the  particular  ailment  for  which  it  is  prescribed,  but  also,  finds  him 
under  the  influence  of  the  common  or  epidemic  constitution,  which  neces- 
sarily modifies  the  effects  of  the  ailment.  Suppose,  for  example,  that  a 
choleraic  constitution  prevails  in  a  district.  If  mercurial  frictions  are  em- 
ployed within  that  district,  in  puerperal  fever,  or  articular  rheumatism, 
exceedingly  serious  gastro-intestinal  symptoms  may  supervene  ;  and  the  mer- 
cury, diverted  from  its  normal  action,  irritates  the  intestine  before  manifest- 
ing its  ordinary  effects. 

The  aptitude  of  the  illustration  now  given  is  palpably  evident :  but  the 
influence  of  the  medical  constitution  is  not  less  constant  in  a  host  of  other 
circumstances  in  which  the  manifestations  are  less  clear.  Testimony  to 
that  effect  can  easily  be  collected  from  the  writings  of  all  intelligent  medi- 
cal observers  of  the  times  anterior  to  our  own. 

In  the  present  day,  a  physician  makes  himself  the  champion  of  a  thera- 
peutic idea,  or  rather  of  an  experimental  idea,  which  is  not  the  same  thing. 
He  goes  on  for  many  years  submitting  all  his  patients,  irrespective  of  age, 
sex,  temperament,  and  medical  constitution,  to  identically  the  same  treat- 
ment: and  month  by  month,  and  year  by  year,  gravely  registering  the 
numbers  of  the  deaths  and  recoveries,  he  finally  deduces  from  these  statis- 
tics therapeutic  laws  which  he  looks  upon  as  irrefragable.  It  matters  little 
to  him  that  one  year  he  had  a  frightful  mortality  to  deplore,  and  that  in 
another  he  had  to  congratulate  himself  upon  a  great  number  of  recoveries. 
To  him  it  is  simply  a  cmestion  of  figures :  he  adds  up,  and  calls  the  result — 
a  law ! 

If  you  ask  him  how  it  is  that  fifteen  years  ago,  he  lost  one  out  of  three 
patients,  while  now  he  only  loses  one  out  of  ten.  In-  is  scarcely  at  all  dis- 
concerted  ;  and  with  assurance  concludes  that  the  disease  was  much  more 
serious  then  than  now.  This  conclusion  would  have  been  legitimate  had 
he  left  his  patients  to  the  unaided  powers  of  nature;  hut  he  does  not  take 
into  account  his  treatment,  and  he  does  not  perceive  that  possibly  the  year 
in  which  he  lost  the  greatest  number  of  patients  was  that  in  winch  the 
mortality  might  have  been  least,  had  any  other  treatment  been  adopted. 

<  )n  reading  with  attention  what  has  been  so  beautifully  written  by  Syden- 
ham and  Btoll  upon  the  modifications  necessitated  in  therapeutics  by  the 
epidemic  constitutions  which  have  been   observed  with  mi  much  care,  there 

is  produced,  on  the  one  hand,  the  conviction  that  the  physicians  who  go  on 
continually  pursuing  the  Bame  treatment,  notwithstanding  a  change  in  the 
epidemic  constitution,  are  men  of  narrow  views ;  and,  on  the  other  hand, 
that  there  is  a  very  greal  influence  exerted  by  the  epidemic  constitution 

upon  the  action  of  the  same  medicines  in  diseases  of  which  the  local  mani- 
festations are  the  Bame. 


TREATMENT    OF    PNEUMONIA.  6G9 

You  can  now  understand,  gentlemen,  why  in  saying,  at  the  beginning  of 
this  lecture,  that  the  necessity,  the  utility  even  of  bleeding  in  pneumonia, 
did  not  appear  to  me  to  have  been  clearly  demonstrated,  I  took  care  to  add, 
in  respect  of  the  present  time.  In  fact,  for  years  past,  we  have  been  travers- 
ing medical  constitutions  which  do  not  necessitate  recourse  to  that  treatment, 
jusl  as  in  the  past,  there  have  been  medical  constitutions  which  required  it, 
and  as  there  may  be  others  in  the  future  also  demanding  it. 

So  also,  when  Stoll,  and  still  more  when  Riviere  lauded  the  tartar  emetic 
treatment,  that  treatment  responded  to  the  indications  of  a  then  dominant 
medical  constitution.  For  a  long  time  past,  that  constitution  has  not  shown 
itself,  and  the  bilious  symptoms,  these  which  specially  demand  evacuant 
treatment,  have  not  been  recently  observed. 

Let  me  now  resume  consideration  of  the  subject  of  antimoniak-  adminis- 
tered in  large  doses. 

To  enable  you  to  estimate  correctly  the  immense  difference  which  has 
been  found  to  exist  between  their  action  as  studied  at  different  periods,  it 
will  be  sufficient  to  glance  at  their  immediate  effects :  and  this  will  enable 
you  to  judge  as  to  what  may  be  their  secondary  influence.  You  will  readily 
admit,  that  if  it  be  possible  to  form  an  erroneous  opinion  regarding  the 
secondary  results  of  a  particular  treatment,  there  is  never  any  room  for 
mistake  as  to  the  immediate  action.  Though  during  a  particular  period, 
both  in  hospital  and  private  practice,  I  could  not  prescribe  for  adults  more 
than  a  gramme  a  day  of  the  white  oxide  of  antimony  without  exciting  vom- 
iting and  diarrhoea — though  during  the  same  period  I  could  not  give  in  a 
day  more  than  from  30  to  50  centigrammes  of  kermes,  and  that  too,  only 
when  tolerance  was  secured — by  administering  along  with  it,  a  considerable 
dose  of  opium — though  in  fact,  during  the  period  I  refer  to,  I  was  obliged 
to  discontinue  the  use  of  the  tartar  emetic  from  the  patients  being  unable 
to  bear  it,  and  from  its  always  leading  to  serious  symptoms — at  another 
time,  I  have  fearlessly  given  to  an  adult  as  his  first  dose  16  grammes  of  the 
white  oxide  of  antimony  in  twenty-four  hours,  without  the  patient  experi- 
encing even  the  slightest  nausea.  I  have  at  another  time  carried  the  dose 
of  the  kermes  up  to  two  or  three  grammes,  without  its  being  necessary  to 
combine  it  with  opium  :  and  have  without  hesitation  prescribed  a  gramme 
of  tartar  emetic,  this  large  dose  hardly  inducing  vomiting  more  than  once 
or  twice. 

The  immediate  effects  being  so  different,  are  we  not  justified  in  asking, 
whether  the  secondary  effects  do  not  vary  as  much  ?  The  fact  ought  to  be 
recognized,  that  there  is  no  ground  for  giving  an  absolute  preference  to  any 
one  of  these  preparations  over  the  others ;  and  it  ought  also  to  be  under- 
stood that  the  dose  in  which  they  ought  to  be  prescribed  is  subordinate  to 
the  influence  of  the  prevailing  medical  constitution. 

You  perceive  from  what  I  have  said,  that  the  self-contradiction  with 
which  I  am  taunted  in  respect  of  the  therapeutic  properties  of  these  prepa- 
rations of  antimony  is  more  apparent  than  real. 

Finally,  that  which  seems  to  me  at  present  to  succeed  best  in  the  treatment 
of  pneumonia — simple  and  perfectly  uncomplicated  pneumonia — is  the  con- 
tra-stimulant treatment,  to  use  Rasori's  expression — that  is  to  say,  the  admin- 
istration of  antimonials,  among  which  kermes  ought  to  have  the  preference.- 

The  efficacy  of  bleeding,  I  repeat,  appears  to  me,  for  the  present,  very 
open  to  be  disputed.  In  respect  of  blisters,  the  employment  of  which  has 
been  very  general,  from  an  impression  that  they  greatly  accelerate  resolu- 
tion of  the  inflammation,  I  concur  with  a  large  number  of  my  professional 
brethren  in  thinking  that,  when  the  disease  is  at  its  height,  they  may  in- 
crease the  febrile  excitement,  and  that  when  it  is  in  a  more  advanced  stage, 


670  TREATMENT  OF  PNEUMONIA. 

they  are  useless.  Moreover,  during  certain  medical  constitutions,  a  blister 
may  be  the  starting-point  of  very  severe  erysipelas. 

It  is,  therefore,  my  practice  to  have  recourse  to  kermes,  or  to  kermes 
combined  with  digitalis.  Not  a  week — indeed,  I  may  say,  not  a  day — 
passes,  without  your  hearing  me  prescribe  this  medicine.  Consequently, 
you  are  acquainted  with  my  method  of  administering  it. 

To  avoid  a  drawback  incident  to  its  use  when  prescribed  in  the  form  of 
potion,  a  drawback  depending  upon  its  locally  irritant  properties,  its  caus- 
ing a  pustular  inflammation  of  the  tongue,  pharynx,  and  oesophagus,  similar 
to  that  produced  by  rubbing  the  skin  with  tartar  emetic,  I  give  it  in  pills. 
I  order  a  mass  to  be  made  of  kermes,  extract  of  digitalis,  and  medicinal 
soap  \_savon  medicinal*"],  dividing  it  so  that  each  pill  contains  ten  centi- 
grammes of  kermes  and  one  centigramme  of  the  extract  of  digitalis.  The 
patient  ought  to  take  from  ten  to  twenty-five  of  these  pills  during  the  day, 
at  intervals  as  nearly  equal  as  possible.  When  they  produce  vomiting  and 
diarrhoea,  I  take  care  to  give  a  drop  of  the  laudanum  of  Sydenham  with 
each  pill,  so  as  to  establish  a  tolerance  for  the  kermes.  I  continue  this 
treatment  during  the  whole  of  the  acute  period  of  the  disease :  when  the 
febrile  symptoms  are  subdued,  I  diminish  the  dose,  but  do  not  discontinue 
the  medicine. 

From  my  adopting  this  method  of  administration,  you  never  see  a  pus- 
tular eruption  produced  by  the  kermes.  Here,  gentlemen,  we  are  brought 
into  collision  with  the  opinion  of  those  who  hold,  with  Laennec,  that  the 
appearance  of  pustules  is  indicative  of  saturation  of  the  system  with  anti- 
monials,  just  as  salivation  and  mercurial  stomatitis  are  the  results  of  satura- 
tion, infection  of  the  whole  economy,  with  mercury.  Supposing  that  this 
opinion,  from  which  I  dissent,  were  a  real  expression  of  the  tacts,  you  would 
obtain  this  saturation  as  quickly  by  administering  the  remedy  in  pills  as  in 
potion ;  and  again,  mercurial  stomatitis  is  quite  as  apt  to  supervene  after 
mercurial  frictions  or  baths,  as  after  the  internal  administration  of  mercury. 
I  again  repeat — what  you  can  daily  verify  for  yourselves — that  antimonials 
given  in  pills,  be  the  dose  what  it  may,  never  produce  inflammation  of  the 
mouth,  pharynx,  and  oesophagus,  as  they  do  in  the  form  of  potion,  when 
they  remain  long  in  contact  with  the  mucous  membrane. 


Erysipelato-Phlegmonous  Pneumonia. 

Gentlemen:  I  place  before  you  the  lungs  of  a  patient  who  died  from  a 
special  form  of  pneumonia,  which  I  have  called  erysipelato-phlegmonous 
pneumonia.  Let  me  tell  you  why  I  have  given  this  name  to  the  disease. 
Generally,  as  you  know,  simple  inflammation  of  the  pulmonary  parenchyma 
runs  a  course  precisely  similar  to  that  of  a  boil — in  (his  sense,  (hat  attack- 
ing a  greater  or  less  portion  of  the  organ,  it  is  at  once  that  which  ii  is 
destined  to  be,  or,  at  least,  it  remains  localized  in  the  parts  which  it  first 
seized,  exactly  as  a  boil  in  the  cellular  tissue  is  limited  to  its  original  situa- 
tion. This  form  of  simple  pneumonia  accomplishes  its  entire  Course  of  evo- 
lution, passing  from  the  first  to  the  second  stage,  and  sometimes  to  the 
third:  after  which,  resolution  may  lake  place,  the  patient  recovering  after 
having  expectorated  sputa  to  which  pus  imparls  a  characteristic  aspect :  or 

*  Savon  mtdicinal  is  made  of  two  parts  (by  weigh!  |  of  "il  of  sweel  almonds  and 
one  part  of  caustic  alkali  Oaatile  soap  [aavon  dur],  made  of  olive  oil  and  Boda,  is 
also  designated  '•  buvod  medicinal." — Tkanm.  \  rOR. 


TREATMENT  OF  PNEUMONTA.  ■  G71 

the  pus  may  collect,  forming  a  real  abscess,  which  may  burst  suddenly  into 
the  bronchial  tubes. 

But  the  other  form  of  pneumonia,  which  carried  off  the  person  whose 
autopsy  we  are  now  making,  has  not  these  simple  characters.  The  paren- 
chymatous phlegmasia,  instead  of  remaining  confined  to  the  situation  in 
which  it  is  originally  developed,  has  a  peculiar  tendency  to  invade  other 
parts;  it  migrates  like  phlegmonous  erysipelas  of  the  cellular  tissue. 

In  two  words,  here  is  what  occurred  in  the  case  of  our  patient !  Ten 
days  ago,  he  entered  the  clinical  wards  complaining  of  a  violent  stitch  in 
the  right  side,  quite  at  the  base  of  the  chest.  In  the  spittoon,  we  observed 
peripneumonia  sputa  of  a  slightly  viscid  character.  The  breathing  was 
greatly  oppressed,  and  there  was  high  fever.  Although  these  diagnostic 
data  left  no  room  for  doubt  as  to  the  existence  of  pneumonia,  I  could  not 
find,  on  auscultation,  any  physical  sign  of  that  disease.  In  no  part,  though 
the  examination  was  made  with  the  utmost  care,  could  I  hear  rales  or  blow- 
ing. I  then  thought  that  it  might  be  a  case  of  pneumonia  affecting  a  cen- 
tral portion  of  the  lung,  and  foresaw  that  when  the  hepatization  reached 
the  surface  of  the  organ,  there  would  be  produced  the  stethoscopic  phenom- 
ena previously  in  vain  sought  for.  In  fact,  at  my  second  visit,  I  heard  fine 
crepitation,  in  front,  about  the  tenth  rib.  From  that  time,  no  characteristic 
sign  of  the  lesion  was  wanting. 

On  the  following  days,  the  physical  signs  indicated  that  the  pulmonary 
inflammation  was  extending:  it  at  first  advanced  to  the  middle  of  the  axil- 
lary hollow,  where  it  seemed  to  stop  in  its  progress,  there  being  at  the  same 
time  observable  a  real  amelioration  in  the  totality  of  the  patient's  symptoms. 
The  fever  had  abated,  and  he  had  even  begun  to  feel  some  inclination  for  food, 
when  the  posterior  part  of  the  inferior  lobe  was  attacked ;  and  soon  after- 
wards, the  superior  lobe  became  involved.  The  general  symptoms,  at  the 
same  time,  became  very  severe :  ataxic  phenomena  with  delirium  super- 
vened :  and  the  patient  died. 

Here,  then,  gentlemen,  you  have  a  pneumonia,  apparently  not  at  all 
serious  at  its  commencement,  very  circumscribed,  seeming  on  the  first  day 
to  confine  itself  to  a  minute  space,  and  even  to  show  signs  of  incipient  reso- 
lution :  you  have  this  pneumonia  all  at  once  redeveloping  itself  with  more 
than  its  original  violence,  and  within  nine  or  ten  days  invading  progres- 
sively the  entire  lung,  exactly  as  we  see  phlegmonous  erysipelas,  at  first 
limited  to  the  extremity  of  a  limb,  progressively  attack  the  whole  member, 
and  give  rise  to  most  formidable  symptoms. 

This  is  one  of  the  worst  forms  of  pneumonia,  one  of  the  forms  which 
baffles  our  means  of  treatment,  in  consequence  of  the  constitution  of  the 
patient,  exhausted  by  the  successive  shocks  of  the  malady,  being  unable  to 
respond  to  remedies  otherwise  most  useful. 


Treatment  of  Pneumonia  complicated  with  Delirium,  by 
-     Preparations  of  Musk. 

Mush  not  indicated  in  all  cases  of  Pneumonia  accompanied  by  Delirium. — 
Distinctions  Essential  to  establish  in  relation  to  this  point. 

Gentlemen  :  You  have  seen  me  prescribe  musk  a  second  time  for  a 
patient,  occupying  bed  24  of  our  ward  for  women,  who  had  a  relapse  of 
pneumonia.  I  must  state  why  I  have  done  so ;  and  explain  to  you  the 
circumstances  in  which  I  consider  this  medicine  to  be  useful. 

In  the  first  place,  gentlemen,  let  me  remark  that  musk  is  a  medicine 


672  TREATMENT    OF    PNEUMONIA. 

which  I  seldom  employ  in  the  treatment  of  pneumonia.  Many  months 
will  probably  elapse  before  a  case  occurs  in  which  its  use  is  indicated  ;  but 
rare  though  these  cases  be,  as  they  may  present  themselves  and  greatly 
embarrass  you,  it  is  necessary  to  make  you  familiar  with  them.  It  is  in 
the  forms  of  pneumonia  accompanied  by  delirium,  which  were  called  ataxie 
and  malignant  by  the  old  writers,  that  this  treatment  takes  an  important 
part.  To  Recamier  belongs  the  credit  of  having  in  these  later  times 
assigned  to  it  this  honorable  place. 

What  ought  we  to  understand  by  the  expression  ataxic  pneumonia ;  or, 
to  speak  more  accurately,  what  is  ataxia  in  pneumonia  ? 

Nervous  disorders,  delirium  in  particular,  supervening  in  the  course  of 
diseases  are  insufficient  to  constitute  ataxia.  To  have  an  accurate  under- 
standing on  this  point,  it  is  indispensable  to  distinguish  several  kinds  of 
delirium  in  the  pneumonia  with  the  consideration  of  which  we  are  now 
occupied. 

In  the  first  place,  there  is  that  delirium  which  is  dependent  upon  the 
intensitv  of  the  peripneumonic  fever,  and  which  only  indicates  that  the 
brain  participates  in  the  febrile  excitement  of  the  entire  organism.  It  is 
not  of  common  occurrence,  except  during  the  night,  when  the  patients  are 
in  a  drowsy  state  ;  it  is,  or  may  be,  observed  in  all  acute  diseases  accom- 
panied bv  fever,  and  it  has  no  special  character.  Musk  certainly  would 
not  produce  any  beneficial  effect  upon  this  kind  of  delirium,  inasmuch  as 
it  has  no  power  over  the  inflammatory  peripneumonic  fever  itself,  and 
because  the  delirium  will  only  yield  to  the  means  which  stop  the  fever.  It 
is  also  necessary  to  recollect  that  there  is  a  form  of  delirium  occurring  in 
persons  of  highly  nervous  temperament,  which  is  not  amenable  to  musk. 
It  is  well  known  that  the  persons  who  become  delirious  under  the  least 
febrile  excitement  are  those  in  whom,  a  fortiori,  inflammation  of  the  lung 
excites  very  intense  fever. 

Secondly,  there  is  delirium  connected  with  suppuration  of  the  pulmonary 
parenchyma,  probably  similar  in  kind  to  all  forms  of  delirium  produced 
by  purulent  infection,  and  which  is  of  evil  augury — "a  peripneumonia 
phrenitis  malum"  to  use  the  words  of  Hippocrates.  It  is  always  unpropi- 
tious,  irrespective  of  the  extent  of  the  pneumonia.  It  is  not  amenable  to 
musk. 

Thirdly,  there  is  delirium  caused  by  one  or  several  inflammatory  com- 
plications situated  in  other  parts  than  the  lungs,  and  apt  to  be  mistaken 
by  the  practitioner.     It  belongs  to  the  first  variety. 

Fourthly,  there  is  a  delirium  more  dependent  upon  the  malignity  of  the 
cause  than*  upon  the  pneumonia  itself.  It  is  met  with  in  pneumonia  pro- 
duced by  poisoning,  both  in  cases  resulting  from  poisoning  by  articles  of 
the  Materia  Mediea  or  from  morbific  atmospheric  miasmata,  and  by  morbid 
poisons  engendered  within  the  economy.  In  all  such  cases,  the  pneumonia 
and  the  delirium  are  effects  of  the  -aim-  cause.  This  is  apparent  in  the 
pneumonia  which  complicate-  putrid  fever.-,  acute  glanders,  &C,  &C.,  and 
poisoning  with  acrid  substances.  In  this  class  of  cases,  there  is  do  indica- 
tion for  the  use  of  musk. 

Finally,  there  i-  a  specii  -  of  low  delirium,  attended  by  a  want  of  harmony 
between  the  different  symptoms,  and  a  predominance  of  nervous  phenomena 
bearing  do  evident  relation  to  the  inflammation  of  the  lung.  Under  the 
influence  of  antiphlogistics  or  antimonials,  this  ataxic  state  increases. 
Were  we  to  judge  only  by  the  diagnostic  signs  derived  from  stethoscopic 
and  plessimetric  examination,  we  should  say  that  the  pneumonia  is  not 
serious,  and  vet  the  vital  power,  prostrate  and  disorganized,  collapses  sud- 
denly, and  the  patient  die-.     Thi-  is  ataxia — this  is  malignity. 


TREATMENT  OF  PNEUMONIA.  G73 

The  characteristic  of  this  species  of  delirium  is  the  impossibility  of  asso- 
ciating it  with  any  known  material  condition  of  the  solids  or  fluids.  In 
Cases  of  this  description,  it  would  be  a  loss  of  time  to  seek  for  the  <;iuse. 

This  kind  of  ataxia  shows  itself,  I  repeat,  by  want  of  harmony  between 
the  local  and  general  symptoms,  and  also  by  want  of  harmony  between 
the  different  functional  disorders,  which  ordinarily  progress  parallel  with 
one  another,  or  are  correlatives.     Let  me  explain  myself. 

An  individual  has  a  very  slight  attack  of  pneumonia:  let  us  suppose  that 
the  disease  is  prevailing  as  an  epidemic,  so  that  a  certain  number  of  per- 
sons become  affected  in  a  manner  similar  to  him.  While  in  none  of  those 
seized,  excepting  the  first  mentioned,  do  nervous  symptoms  supervene,  or 
at  least  if  present,  are  proportionate  to  the  extent  of  the  lesion,  in  the  in- 
dividual first  mentioned,  there  is  delirium  from  the  very  first,  without  the 
inflammation  having  attained  such  a  height  as  to  justify  one  in  supposing 
that  the  intensity  of  the  inflammation  is  the  cause  of  the  nervous  symptoms, 
and  without  the  phlegmasia  reaching  the  stage  of  suppuration,  which  if 
present,  as  I  have  just  said,  would  explain  the  delirium.  It  thus  becomes 
necessary  to  admit  that  in  the  individual  first  mentioned,  there  was  a  pecu- 
liar modality  of  the  nervous  system  in  virtue  of  which  the  nervous  centres 
showed  evidence  of  disorder  not  explainable  by  the  slight  local  lesion. 
This  is  a  point  of  the  first  importance. 

In  the  second  place,  there  is  want  of  harmony,  parallel  or  correlative, 
between  the  functional  disorders.  In  pneumonia — in  peripneumonia  fever 
— proceeding  regularly,  at  the  same  time  that  the  pulse  becomes  very  quick, 
respiration  becomes  relatively  accelerated.  For  example,  while  the  pulse 
rises  to  120  in  the  minute,  the  respirations  are  from  36  to  40 :  here  the  dis- 
orders of  respiration  respond  to  those  of  the  circulation.  This  is  what  takes 
place  in  ataxic  pneumonia. 

In  the  woman  whose  case  is  the  subject  of  the  present  lecture,  I  insist 
upon  this  point,  and  beseech  you  not  to  forget  it :  while  the  pulse  was  84 
in  the  minute,  the  respiratory  movements  rose  to  88.  Respiration,  conse- 
quently, had  a  frequency  quite  out  of  proportion  to  that  which  it  generally 
bears  to  the  arterial  pulse.  In  place  of  being  about  one-third  slower  than 
the  pulse,  it  was  quicker  than  the  pulse.  There  was  consequently  a  want 
of  harmony  between  the  functional  disorders,  which  generally  proceed  in  a 
parallel  course. 

It  may  also  happen,  gentlemen,  that  the  want  of  harmony  which  char- 
acterizes ataxia  is  not  so  great  in  respect  of  the  respiratory  or  circulatory 
functions  viewed  in  relation  to  one  another,  as  in  respect  of  the  two  when 
compared  with  the  nervous  symptoms.  Thus,  along  with  the  delirium, 
there  may  be  no  great  frequency  in  the  respi rations,  and — judging  by  the 
pulse  and  the  temperature  of  the  skin — the  fever  may  be  very  moderate. 
Under  what  circumstances,  and  in  what  class  of  patients,  is  this  peculiar 
form  of  delirium  met  with  ? 

It  is  met  with  more  frequently  in  women  than  in  men,  which  is  easily 
explained  by  the  fact  that  disorder  of  the  nervous  system  is  more  common 
in  the  former  than  in  the  latter.  In  men  addicted  to  alcoholic  liquors,  or 
who  drink  stimulants  to  excess,  it  is  also  more  usual  than  in  others.  In 
this  class  of  patients,  the  nervous  symptoms  of  which  I  speak  occur  not  only 
in  connection  with  an  inflammatory  affection  such  as  pneumonia,  but  like- 
wise as  a  consequence  of  severe  traumatic  lesions,  such  as  a  compound 
fracture  of  one  of  the  extremities,  a  serious  injury  of  a  joint,  or,  it  may  be, 
after  even  a  slight  surgical  operation.  In  telling  you  this,  I  am  not  stating 
anything  which  you  have  not  already  learned  from  your  surgical  teachers. 
Have  you  not  heard  them  say  a  hundred  times,  that  persons  who  have  re- 
vol.  i. — 43 


674  TREATMENT  OF  PNEUMONIA. 

ceived  wounds,  have  been  surgically  operated  on,  or  have  abused  alcoholic 
liquors,  are  liable  to  a  peculiar  form  of  delirium  tremens.'  Now,  thisjjelirium 
is  analogous  to  the  nervous  symptoms  to  which  I  am  at  present  directing 
your  attention.  It  is  liable  to  occur  in  the  same  persons  in  the  course  of  a 
pneumonia,  just  as  in  the  course  of  any  other  inflammation,  or  during  a 
fever. 

This  delirium  of  drunkards,  however,  differs  in  its  nature  from  the  delirium 
which  more  specially  characterizes  malignity.  It  is  a  purely  nervous 
delirium:  the  brain  is  in  a  state  of  violent  excitement:  the  patients  are 
restless,  they  wish  to  get  out  of  bed,  they  talk  nonsense  with  furious  vivacity, 
just  as  if  they  were  in  the  excitement  stage  of  alcoholic  intoxication ;  but 
there  is  no  prostration  of  the  vital  powers  as  in  ataxia. 

If  you  employ  musk  to  subdue  the  delirium  of  fever,  or  of  suppurative 
pneumonia,  if  you  employ  it  in  cases  in  which  the  nervous  symptoms  de- 
pend upon  the  malignity  of  the  cause  which  dominates  the  pulmonary  in- 
flammation itself,  you  mistake  the  indication,  and  your  treatment  is  inevit- 
ably a  failure.  The  consequences  of  your  error  will  be  disastrous.  You 
will  be  prevented  from  recognizing  in  musk  the  beneficial  effects,  which, 
when  given  in  suitable  cases,  it  is  capable  of  producing;  and  will,  therefore, 
not  administer  it  in  cases  in  which  you  ought  to  give  it  and  obtain  from  it 
the  best  possible  results. 

Michael  Sarcone  proved  the  reality  of  these  marvellous  results,  when,  by 
the  treatment  I  now  commend,  he  checked  delirium  and  disastrous  excita- 
bility in  some  of  his  patients  during  the  terrible  Neapolitan  epidemic  of 
which  he  has  left  us  a  history  remarkable  from  many  points  of  view.  He 
says: 

"  When  there  was  a  threatening  of  delirium,  and  when  in  the  aggregate 
of  symptoms,  there  was  a  manifest  sensitiveness,  along  with  insomnia  and 
great  disorder  of  the  nervous  system,  the  only  appropriate  remedies  were 
those  which  afforded  quiet  and  repose  to  the  patient.  It  is  impossible  to 
speak  too  strongly  of  the  advantage  obtained  in  these  cases  by  the  use  of 
gentle  calmatives  and  narcotics,  when  judiciously  given.  Musk  was 
especially  remarkable  for  its  great  efficacy  in  calming  and  subduing  a 
tendency  to  convulsions  which  was  dominant  in  a  very  marked  degree  in 
some  of  the  patients.  They  at  once  fell  into  an  agreeable  and  unhoped  for 
torpor,  and  then  by  degrees  passed  into  a  state  of  repose,  into  drowsiness, 
and  into  sleep.  The  pulse  acquired  a  more  equal  volume  ;  and  the  respi- 
ration became  less  sighing.  In  cases  in  which  delirium  was  not  prevented, 
it  was  certainly  less  violent  than  had  been  threatened  by  the  severity  of 
the  symptoms:  and  it  never  attained  such  dangerous  manifestations  in 
those  to  whom  this  drug  was  administered,  as  in  other  patients  from  whom 
it  was  withheld,  or  too  long  delayed,  owing  to  1  know  not  what  preju- 
dices."* 

Gentlemen,  let  us  have  no  misunderstanding  on  this  point.  I  do  not 
give  mink  indiscriminately  in  the  delirium  of  pneumonia  any  more  than  1 
iln  so,  in  that  of  scarlatina  or  .-mall-pox:  1  only  give  il  in  thai  peculiar 
form,  which,  manifesting  itself  in  maladies  characterized  by  nervous  dis- 
order, are  yet  not  of  a  serious  nature.  In  these  cases,  musk  becomes  a 
sorl  of  regulator  of  the  nervous  system,  which  then  responds  in  a  regular 

manner  to  tin'  assaults  of  the  disease. 

What  occurred  in  the  case  of  our  patient  of  bed  24  St.  Bernard's  Ward  ? 
From  the  second  day  of  her  pneumonia,  this  woman  was  delirious,  though 

the  local    affection    remained  \ery  limited    in    situation,   and    did    Qol    |>a  — 
Sarcone:   EListoire  dea  Maladies  Observes  a  Naples,  t.  ii,  p.  240. 


TREATMENT  OF  PNEUMONIA.  675 

beyond  the  second  degree.  The  respirations  rose  to  88  in  the  minute, 
although  the  pulse  was  only  84.  The  ataxia  was  evident  :  the  indication 
for  giving  musk  was  precise.  Whilst  I  administered  it,  however,  I  did  not 
discontinue  giving  the  kermes.  With  kermes  I  combated  the  inflam- 
mation, while  1  at  the  same  time  directed  the  antispasmodic  remedy  against 
the  nervous  element  of  the  disease. 

You  have  seen  the  results  of  this  treatment.  No  doubt,  on  auscultating 
the  chest,  you  have  satisfied  yourselves  that  it  has  not  stopped  in  any  de- 
gree the  inflammation  of  the  lung.  I  made  no  such  pretension;  for,  treat- 
ing the  ease  by  antimonials,  or  by  bleedings,  the  indications  for  employing 
which  are,  as  I  have  already  said  subordinate  to  the  dominant  medical 
constitution,  we  may  conduct  the  pneumonia  to  its  termination  in  resolution, 
but  we  cannot  cut  it  short  in  twenty-four,  thirty-six,  or  forty-eight  hours, 
as  has  been  supposed  possible  by  some  physicians.  I  therefore  waited  to 
see  the  local  affection  run  its  course ;  but  I  also  waited  to  see  the  cessation 
of  the  nervous  symptoms.  The  respirations  fell  from  88  to  44  in  the 
minute,  although  the  pulmonary  lesion,  being  a  little  more  extensive  than 
before,  one  might  on  the  contrary  have  expected  acceleration  of  the  breath- 
ing, had  that  been  dependent  upon  the  state  of  the  lung.  Although  the 
number  of  the  respirations  had  not  yet  come  down  to  the  normal  standard, 
there  was  every  reason  to  hope  that  this  diminution  would  take  place  on 
the  following  day. 

The  very  violent  delirium,  which  might  have  caused  anxiety,  had  calmed 
down :  during  the  night  there  wTas  only  a  little  restlessness,  and  in  the 
morning,  the  patient  answered  questions  with  precision.  The  musk  had 
induced  this  sedative  effect,  though  I  had  not  had  occasion  to  give  more 
than  50  centigrammes  in  the  twenty-four  hours.  I  still  continue  to  use  it. 
As  the  patient  has  been  entirely  without  sleep  during  the  last  three  days, 
and  as  this  insomnia  is  a  phenomenon  pertaining  to  ataxia,  I  shall,  if  it 
continue,  combine  small  doses  of  opium  with  the  musk,  or  1  shall  give  the 
opium  by  itself.  The  combination  of  musk  and  opium  is  also  recommended 
by  Sarcone,  when  there  is  exhausting  obstinate  sleeplessness  in  addition  to 
the  other  nervous  symptoms. 

But  it  is  not  enough  to  be  able  to  recognize  the  indications  for  giving 
musk  in  pneumonia  accompanied  by  delirium — there  are  certain  rules 
connected  with  its  administration,  which  it  is  indispensable  to  know.  It 
may  be  prescribed  to  the  extent  of  a  gramme  a  day  divided  into  ten  doses 
given  in  the  form  of  pills,  one  pill  being  taken  every  hour  till  there  is  a 
remission  in  the  ataxic  symptoms,  which  generally  occurs  within  eight  or 
ten  hours.  At  the  end  of  that  time,  according  to  Recamier,  if  no  benefit 
has  been  obtained,  we  need  not  look  for  results,  as  they  are  either  obtained 
promptly  or  not  at  all. 

I  have  still  a  word  to  say,  in  conclusion,  regarding  our  patient.  Her 
pneumonia  is  not  extensive,  and  the  reactional  symptoms,  separated  from 
the  nervous  symptoms,  also  indicate  that  the  case  is  not  serious.  Under 
the  circumstances,  therefore,  I  consider  that  in  this  case  recovery  will  take 
place.* 

Gentlemen,  I  think  it  very  important  to  bring  these  points  under  your 
notice,  and  to  state  with  precision  the  indications  for  the  treatment  which 
you  have  seen  me  employ,  because  I  have  often  heard  its  efficacy  called  in 
question  by  very  wrorthy  persons,  who  have  unsuccessfully  employed  musk 
in  pneumonia  with  delirium.     Their  failure  did  not  depend  on  the  remedy 

*  After  having  been  under  treatment  for  some  days,  this  woman  made  a  com- 
plete recovery,  and  was  able  to  leave  the  hospital. 


676  TREATMENT    OF    PNEUMONIA. 

being  bad,  but  on  its  having  been  given  in  unsuitable  cases,  in  very  different 
forms  of  delirium  from  that  now  under  our  consideration.  By  such  errors 
in  diagnosis  the  character  of  the  best  therapeutic  agents  is  compromised. 
When  you  confound  with  one  another  the  different  phenomena  which  may 
supervene  in  the  course  of  a  disease,  you  inevitably  fail,  through  attacking 
symptoms  which  are  not  the  same  by  the  same  remedy.  The  remedy  hav- 
ing failed,  from  its  employment  not  having  been  indicated,  you  cannot  see 
its  utility,  and  you  deprive  yourselves  of  a  powerful  agent,  which  in  appro- 
priate circumstances  is  of  real  service. 

Pneumonia  of  the  Summit. 

Not  necessarily  accompanied  by  Delirium. — Delirium  may  also  occur  in  Pneu- 
monia situated  in  the  Centre  or  Base  of  a  Lobe. — Pneumonia  of  the  Sum- 
mit is  not  necessarily  more  dangerous  nor  more  tedious;  but  this  statement 
requires  limitation  in  respect  of  Tuberculous  Patients. 

Gentlemen  :  In  beds  4  and  1 8  of  St.  Agnes's  Ward  you  have  seen  two 
men  with  acute  simple  pneumonia.  Both  these  men,  Avho  are  of  good  con- 
stitution, in  the  prime  of  life  and  under  thirty,  took  the  disease  which 
brought  them  to  the  hospital,  in  the  way  which  is  most  usual,  that  is  to  say, 
in  consequence  of  a  chill.  In  both  there  was  this  peculiarity,  that  the 
pneumonia  occupied  the  summit  of  the  lung.  Both  recovered  completely 
and  rapidly :  no  complication  arose  to  impede  the  cure.  Let  me  briefly 
recapitulate  the  facts. 

The  first  subject  had  been  ill  for  seven  days :  a  violent  shivering  fit  and 
a  stitch  in  the  side  announced  the  beginning  of  the  morbid  symptoms: 
almost  immediately  afterwards  there  supervened  cough,  accompanied  by 
expectoration.  The  fever,  which  forthwith  declared  itself,  has  continued 
ever  since.  When  this  patient  came  into  hospital  on  the  third  day  of  the 
disease,  we  found  him  expectorating  characteristic  sputa  of  a  saffron  yellow 
color,  aerated,  viscid,  adherent  to  the  vessel,  and  leaving  no  room  for  doubt 
as  to  the  diagnosis.  The  harshness  of  the  sound  elicited  on  percussing  the 
left  side  of  the  chest  over  the  infraspinous  fossa  of  the  scapula  and  under 
the  clavicle,  the  crepitant  rales  and  the  blowing  sound  of  expiration  per- 
ceived on  auscultation  of  these  regions,  confirmed  the  view  already  satis- 
factorily arrived  at,  as  to  the  nature  of  the  case,  from  an  inspection  of  the 
sputa  and  the  symptoms  complained  of  by  the  patient.  We  had  pneumo- 
nia, and  that  pneumonia  was  situated  in  the  summit  of  the  left  lung, 

Next  day  the  blowing  expiratory  sound  had  given  place  to  tubal  blow- 
ing, and  numerous  pulls  of  fine  crepitation  were  heard  throughout  a  space 
more  extended  than  on  the  previous  evening.  On  the  sixth  day  the  stetho- 
scopic  signs  were  still  more  decided. 

Contrary  to  what  I  have  frequently  observed  this  year,  the  patient  com- 
plained of  obstinate  constipation,  although  he  had  been  taking  kermes  in 
large  daily  doses.  I  found  it  necessary  to  give  him  two  calomel  pills,  each 
pill  containing  five  centigrammes ;  and  in  addition  to  this,  two  grammes  of 
powder  of  jalap.    These  remedies  produced  the  desired  effects. 

This  morning — the  eighth  from  the  beginning  of  the  malady  I  find  the 
patient  without  fever,  the  Bkin  is  in  a  good  state,  the  pulse  is  full  and  nol 
quick, its  amplitude  being  proportionate  to  the  constitution  and  Btrength  of 

the   subject.      The  BtetflOSCOpic  signs  are   modified,  and    we    now    hear    the 

vesicular  murmur,  accompanied  it  is  true  by  fine  subcrepitanl  mucous  rales, 


TREATMENT  OF  PNEUMONIA.  677 

in  situations  where,  forty-eight  hours  previously,  we  heard  tuhal  blowing 
and  crepitant  rales. 

The  resolution  of  the  pneumonia  has,  therefore,  fairly  begun.  Yesterday, 
however,  a  circumstance  arrested  my  attention,  although  the  condition  of 
the  patient  seemed  satisfactory.  I  refer  to  the  character  of  the  sputa.  The 
saffron  color  which  they  presented  during  the  first  days  of  the  illness  had 
become  of  a  deeper  shade;  and  yesterday,  though  still  retaining  their  viscid 
character,  they  had  assumed  the  aspect  of  wine  lees,  or  prune-juice,  gener- 
ally an  evil  omen.  As,  however,  the  sputa  were  still  viscid,  I  was  less 
alarmed  by  their  change  of  color.  In  point  of  fact,  it  is  not  so  much  the 
sputa  assuming  the  prune-juice  color  in  peripneumonia,  as  their  ceasing  to 
be  viscid,  and  assuming  a  peculiar  diffluent  character, which  constitutes  the 
unfavorable  prognostic.  This  morning  we  observed  that  the  sputa  had  re- 
assumed  a  slight  saffron  tint,  and  were  not  profuse. 

The  history  of  our  second  patient  is  nearly  identical  with  that  of  the  first. 
His  peripneumonia,  contracted  under  similar  circumstances,  occupied  the 
same  situation,  ran  the  same  course,  and  likewise  terminated  as  rapidly  in 
recovery. 

In  both  cases,  my  treatment  was  the  same  :  I  employed  antimonials  :  I 
had  recourse  to  kermes. 

These  cases  form  an  appropriate  secjiiel  to  what  I  have  been  saying  on 
the  use  of  musk  in  pneumonia.  In  fact,  gentlemen,  the  form  of  delirium 
so  remarkably  subdued  by  that  remedy,  is  perhaps  most  frequently  met 
with  in  pneumonia  of  the  summit.  The  reason  of  this  I  cannot  tell ;  but 
the  fact  is  generally  admitted.  It  is  evident,  however,  that  pneumonia  of 
the  summit  does  not  necessarily  induce  nervous  symptoms  ;  as  is  proved  by 
the  cases  of  the  two  men  of  St.  Agnes's  Ward.  You  also  learn  from  these 
two  cases  that  pneumonia  of  the  summit  is  not  inevitably  more  serious  than 
pneumomia  of  the  base. 

I  do  not  deny  that  in  persons  of  the  tuberculous  diathesis,  pneumonia  of 
the  summit  is  a  more  serious  affection  than  in  those  not  under  that  diathesic 
influence.  This  dbes  not  depend  upon  the  pneumonia  itself,  but  upon  the 
risk  there  is  that  its  presence  may  hasten  the  development  of  phthisis,  by 
calling  forth  the  manifestation  of  the  diathesis  by  accelerating  the  evolu- 
tion of  tuberculous  products  in  their  favorite  seat — the  summit  of  the  lung. 
With  this  limitation,  I  maintain  that  pneumonia  of  the  summit  is  not  more 
dangerous  than  pneumonia  of  the  base  or  centre.  The  gravity  of  the 
inflammation  does  not  depend  upon  its  situation,  but  upon  its  extent  and 
nature.  With  regard  to  extent :  a  pneumonia  which  simultaneously  invades 
an  entire  lung  is,  if  other  conditions  are  equal,  more  grave  than  inflamma- 
tion limited  to  one  lobe,  and  double  is  always  more  dangerous  than  single 
pneumonia.  With  regard  to  nature :  the  relative  gravity,  I  should  say, 
depends  on  the  specialty  of  the  nature,  which  varies  with  the  epidemic 
constitution,  the  previous  condition  of  the  patient,  as  well  as  with  certain 
other  influences,  an  intimate  acquaintance  with  which  we  are  unable  to 
obtain,  and  which  we  know  only  by  their  effects. 


678  PARACENTESIS    OF    THE    PERICARDIUM. 


LECTURE  XXXVII. 

PARACENTESIS    OF    THE    PERICARDIUM. 

Cases. — Historical  Summary. — Harmlessness  of  Tapping  the  Pericardium  and 
injecting  Solutions  of  Iodine. — Better  to  make  the  opening  ivith  the  Bis- 
toury than  with  the  Trocar. — Dropsy  of  the  Pericardium  almost  always 
associated  with  some  other  diseased  state,  particularly  ivith  the  Tubercu- 
lous Diathesis. — Paracentesis  affords  relief  and  prolongs  life  placed  in 
immediate  jeopardy. 

Gentlemen  :  In  your  presence,  I  performed  paracentesis  of  the  pericar- 
dium upon  a  patient  who  lay  in  bed  2  of  St.  Agnes's  "Ward.  The  man 
died  five  days  after  the  operation  ;  and  I  placed  before  you  the  morbid 
structures  found  at  the  autopsy. 

This  patient  was  a  young  man  of  27,  who  came  into  our  clinical  wards 
on  the  2d  June,  1856  :  he  dated  the  commencement  of  his  illness  from  a 
few  clays  prior  to  his  coming  into  hospital.  I  observed  at  my  first  visit, 
that  there  was  great  oppression  of  the  breathing:  throughout  nearly  the 
whole  of  the  chest,  I  heard  sibilant,  mucous,  and  subcrepitant  rales — in 
fact,  all  the  signs  of  capillary  bronchitis.  The  intensity  of  the  fever  quite 
corresponded  with  the  severity  of  the  local  symptoms.  This  young  mau 
told  us  that  two  years  previously  he  had  had  a  severe  pulmonary  affection, 
for  which  he  had  taken  cocl-liver  oil. 

I  prescribed  preparations  of  antimony  and  digitalis:  I  administered  pur- 
gatives :  speedy  improvement  was  the  result. 

I  did  not,  however,  take  into  account  the  persistence  of  the  fever,  still 
less  the  persistence  of  the  peculiar  anxiety  experienced  by  the  patient. 
Upon  afterwards  carefully  examining  the  heart,  I  heard  a  blowing  sound  ; 
and  also  a  friction-sound  accompanying  both  sounds  of  the  heart,  a  little 
more  marked  at  the  apex,  which  is  not  usual  in  pericarditis,  in  that  disease 
the  double  friction-sounds  being  heard  around  the  base  of  the  heart:  in 
other  respects,  the  pulsations  were  perfectly  distinct. 

This  young  man  had  never  had  rheumatism. 

My  opinion  was  that  there  existed  endocarditis,  and  a  lesion  of  the  mitral 
valve  complicating  the  pulmonary  catarrh. 

Once  my  attention  was  called  to  this  point,  I  carefully  auscultated  the 
heart  every  day.  A  week  had  scarcely  elapsed,  when  the  stethoscopic 
phenomena  presented  a  strange  modification.  I  distinctly  heard  a  double- 
bellows  sound  at  the  apex,  and  some  days  later  there  was  a  reduplication 
of  the  second  sound,  80  a-  to  constitute  a  third  sound,  called  the  bruit  de 
rappel  or  bruit  de  gait, p. 

The  precordial  dulness  increased  greatly,  the  blowing  sound-  became 
more  and  i 'edistanl  from  the  em-,  and  at  last  were  hardly  audible.    The 

pulsations  of  the   heart    became  very  obscure,  ami  then  ceased  I"  he  heard. 

The  pulse  at  thewrisl  continued  to  De  rapid,  bul  it  was  regular,  and  of  fair 
strength. 

There  was  no  doubl  as  to   the   existence  of  the   pericarditis,  the   proj 

of  which  I  followed.     The  arching  of  the  precordial  region,  the  limits  of 


PARACENTESIS    OF    THE    PERICARDIUM.  679 

the  dulness — extending  to  the  right  beyond  the  median  line,  and  reaching 
on  the  left  to  two  or  three  centimetres  externa]  to  the  nipple,  descending  as 
far  down  as  the  diaphragm,  ascending  to  the  third  rib,  thus  circumscribing 
:i  space  of  about  twenty  centimetres — clearly  indicated  the  existence  of 
extensive  effusion  into  the  pericardium. 

The  anxiety  of  the  patient  increased  proportionately  to  the  increase  of 
the  pericardial  dropsy,  although  in  respect  of  the  cough  there  was  a  great 
change  for  the  better. 

No  amelioration  of  symptoms  was  obtained  by  the  administration  of 
digitalis,  calomel,  and  purgatives,  and  the  application  of  blisters  to  the 
region  of  the  heart. 

Matters  had  been  going  on  in  this  way,  or  getting  worse,  for  six  weeks, 
when  I  perceived  oedema  of  the  extremities,  puffiness  of  the  face,  and  great 
paleness  of  the  skin.  These  symptoms  suggested  that  there  was  probably 
albuminuria;  but  upon  analysis  of  the  urine  it  was  found  not  to  contain 
any  albumen.  I  then  concluded  that  the  anasarca,  oppression,  and  anxiety 
were  all  dependent  upon  obstructed  circulation.  The  pulse  had  become 
small  and  very  rapid. 

Under  the  circumstances,  I  considered  that  paracentesis  of  the  pericar- 
dium was  indicated.  I  nevertheless  allowed  a  fortnight  to  elapse ;  for 
although  two  years  previously,  in  my  wards,  I  had  operated  successfully  in 
a  similar  case,  I  hesitated  to  have  recourse  to  an  operation  which  one  never 
without  trembling  decides  upon  performing.  The  symptoms,  however, 
became  so  urgent,  and  death  appeared  so  imminent,  that  I  determined  to 
delay  no  longer.  On  the  1st  August,  I  invited  my  colleagues  of  the  Hotel- 
Dieu  to  meet  me  in  consultation  on  the  case. 

I  submitted  to  my  colleagues  the  triple  question  of  diagnosis,  prognosis, 
and  treatment.  They  were  all  of  opinion  that  there  was  pericarditis  with 
effusion,  which  was  estimated  at  less  than  a  litre.  They  all  thought,  that, 
looking  to  the  anxiety  of  the  patient,  the  general  puffiness,  and  the  ex- 
treme paleness  of  the  tissues,  death  would  occur  within  a  few  clays.  They 
likewise  all  thought,  that  although  the  operation  offered  but  little  chance 
of  success,  that  the  treatment  which  afforded  the  greatest  chance  was  the 
prompt  evacuation  of  the  fluid  by  tapping. 

Paracentesis  having  been  decided  on,  I  forthwith  proceeded  to  perform 
it.  I  employed  a  bistoury  in  opening  into  the  chest.  The  incision  was 
made  in  the  centre  of  the  circumference  marked  out  by  dulness,  below  the 
nipple,  and  in  the  nearest  intercostal  space.  After  cutting  in  succession, 
with  the  utmost  caution,  the  skin  and  muscles,  I  reached  the  pleura.  This 
membrane  was  next  cut  through.  Upon  introducing  my  finger  into  the 
cavity  of  the  chest,  I  encountered  resistance  from  the  distended  pericardium. 
I  did  not  feel  the  heart  beating  under  my  finger.  I  then  cut  through  the 
successive  layers  of  tissue,  separating  them  by  means  of  a  grooved  director. 
At  last,  the  point  of  the  bistoury  having  penetrated  a  little  too  far,  some 
slightly  red  serosity  spurted  along  the  blade.  Using  the  grooved  director, 
I  enlarged  the  incision  only  to  the  extent  of  half  a  centimetre  :  a  gush  of 
similar  fluid  then  issued  from  the  wound,  and  in  part  spread  under  the 
layers  of  tissue:  nearly  100  grammes  were  collected  in  a  pallet.  This  fluid 
immediately  coagulated  like  currant  jelly :  the  flow  then  ceased.  I  intro- 
duced several  gum-elastic  sounds,  but  by  so  doing  did  not  succeed  in  ob- 
taining any  more  fluid.  By  causing  the  patient  to  be  placed  on  his  left 
side,  nearly  200  grammes  of  yellow-colored  serosity  is.-ued  from  the  open- 
ing; this,  therefore,  was  very  different  from  the  first-drawn  serosity,  which, 
when  received  in  the  same  pallet,  coagulated  but  imperfectly,  and  con- 


680  PARACENTESIS    OF    THE    PERICARDIUM. 

trasted  by  its  amber  color  with  the  appearance  of  red  currant  jelly  pre- 
sented by  the  other. 

Gentlemen,  it  was  seen,  at  the  autopsy,  that  one  of  these  fluids  must  have- 
come  from  the  pericardium,  and  the  other  from  the  pleura. 

From  the  cessation  of  the  flow,  I  thought  that  the  pericardium  was  occu- 
pied by  false  membranes,  which  retained  the  fluid  within  inclosures.  I 
tried  to  inject  a  solution  of  iodine,  but  none  of  it  passed  into  the  cavity  of 
the  pericardium  :  perhaps  about  a  tablespoonful  penetrated  into  the  pleura. 
The  wound  was  then  closed  by  means  of  diachylon  plaster. 

Notwithstanding  the  small  quantity  of  fluid  withdrawn,  certainly  not 
more  than  400  grammes,  including  both  that  which  came  from  the  peri- 
cardium and  the  pleura,  the  patient  was  decidedly  relieved  by  the  operation. 
The  pulse  became  slower  and  fuller. 

Some  air  entered  the  chest  during  the  operation:  and, mixing  with  the 
serous  fluid  which  was  withdrawn,  gave  it  a  frothy  appearance.  On  aus- 
cultating the  patient  after  the  dressing,  we  heard  the  sounds  of  the  heart 
unaccompanied  by  the  mill-wheel  sound  [bruit  de  roue  de  mouliri\,  which 
has  been  given  as  a  characteristic  sign  of  hydropneumo-pericardial  disease. 

The  young  man,  who  formerly  could  only  lie  on  the  left  side,  now  found 
that  he  was  most  comfortable  when  on  the  right  side.  Matters  went  on 
pretty  well  till  the  afternoon  :  but  when  M.  Beylard  and  I  saw  the  patient 
about  four  o'clock,  we  found  him  in  a  very  excited  state,  with  high  fever, 
and  a  pulse  of  124.  About  three  hours  after  our  visit,  he  was  suddenly  seized 
with  an  attack  of  eclampsia :  the  convulsions  were  confined  to  the  right 
side  of  the  body.     During  the  night,  the  attacks  recurred  every  half  hour. 

On  the  following  morning,  the  right  side  of  the  body  and  the  tongue 
were  completely  paralyzed  ;  but,  strange  to  say !  during  the  attacks  which 
I  witnessed,  consciousness  remained  to  a  certain  extent.  The  patient  tried 
to  answer  questions ;  and  with  the  left  hand  he  pressed  the  convulsed  mus- 
cles of  the  right  cheek,  to  restrain  their  disorderly  movements. 

Gentlemen,  before  I  go  any  further,  let  me  try  to  explain  these  attacks 
of  eclampsia.  Ought  they  to  be  attributed  to  the  operation  ?  Let  us  for 
the  present  leave  out  of  view  the  question  of  the  advisability  of  the  opera- 
tion— a  question  resolved  in  the  affirmative  by  my  colleagues  in  the  H6tel- 
Dieu  and  myself.  Let  it  be  granted  that  surgical  interference  was  as  rash 
a  proceeding  as  could  have  been  adopted,  still,  it  was  not  one  of  those 
great  surgical  operations — those  serious  traumatisms — which  sometimes  in- 
duce nervous  symptoms. 

Again,  in  the  convulsions  of  our  young  man,  there  was  nothing  like  the 
phenomena  of  tetanus.  Let  it  be  granted  that  the  paracentesis  increased  the 
intensity  of  the  inflammation  of  the  pericardium  :  but  then,  do  inflamma- 
tions of  the  serous  membranes,  be  they  ever  so  violent,  or  whatever  may 
be  the  extent  of  the  membranes  involved — do  they  usually  had  to  such 
symptoms?  The  answer  is  obtained  by  an  appeal  to  clinical  facts.  Never 
does  the  most  violent  pleurisy,  never  does  the  most  acute  peritonitis  fol- 
lowing perforation  or  Strangulation  of  the  intestine.  Induce  convulsions — 
not  at  least  in  adults.  Have  you  ever  heard  thai  it  was  otherwire  in  peri- 
carditis? 

The  circumstances  in  which  the  patient  was  placed  gave  US  a  better  ex- 
planation of  his  symptoms.      You   are  aware   that    general   anasarca,  even 

w  hen  there  is  no  albuminuria,  produces  a  peculiar  predisposition  to  eclamp- 
sia. This  is  observed  principally  in  pregnant  women  and  ill  children.  A 
feverish  attack  or  a  menial  emotion  may  he  the  immediately  exciting  cause. 

You  know  also  how  much  an  amende  condition  conduces  to  the  occurrence 
of  convulsions.    In  our  young  man,  two  predisposing  causes,  anasarca  and 


PARACENTESIS    OF    THE    PERICARDIUM.  G81 

anaemia,  existing  in  a  high  degree,  it  is  not  surprising  that  mental  emotion 
occasioned  by  the  dread  of  the  operation — for  he  was  much  alarmed  by  the 
meeting  in  consultation  held  around  him — should  have  induced  the  nervous 
symptoms  of  which  I  speak. 

I  prescribed  preparations  of  musk  and  valerian  ;  and  for  the  time,  they 
seemed  to  subdue  the  symptoms.  I  was  beginning  to  hope  that  matters 
were  taking  a  favorable  turn,  and  no  new  heart  symptoms  had  occurred, 
when  the  respiratory  organs  were  again  attacked.  On  August  4th,  the 
fourth  day  after  the  operation,  I  observed  more  oppression  of  the  breathing, 
as  well  as  some  cough  accompanied  by  profuse  expectoration  of  slightly 
viscid  matter  ;  and  I  heard  subcrepitant  rales.  Next  morning,  these  symp- 
toms had  become  still  more  alarming,  and  caused  me  much  more  anxiety 
than  those  referable  to  the  heart. 

From  the  very  wTeak  state  of  the  patient,  I  was  unable  to  examine  the 
chest  as  carefully  as  I  should  have  wished.  However,  the  dulness  of  the 
precordial  region  indicated  that  there  was  still  a  very  considerable  amount 
of  effusion,  though  much  less  than  before  the  tapping.  The  patient  died  on 
the  evening  of  Tuesday,  5th  March,  five  days  after  the  operation. 

The  autopsy  was  performed  with  the  greatest  possible  care.  The  ribs 
on  the  left  side,  from  the  axilla  to  the  base  of  the  chest,  were  sawn  through  : 
on  the  right,  the  sternum  was  separated  from  the  costal  cartilages,  then  the 
sternum  and  anterior  part  of  the  chest  were  detached  in  such  a  way  as  to 
remove  the  trachea,  the  lungs,  and  the  heart  intact  within  the  pericardium. 
In  the  left  pleura,  I  found  a  citrine-colored  fluid  similar  to  that  which 
flowed  during  the  second  period  of  the  operation.  There  were  neither  false 
membranes,  fibrinous  flocculi,  nor  adhesions. 

The  pericardium  was  reddish  in  color,  and  resembled  an  enormous  globe 
as  large  as  a  man's  head.  It  had  no  adhesions  with  the  ribs,  and  was  only 
in  its  upper  part  covered  by  a  thin  portion  of  the  left  lung,  which  was 
firmly  attached  to  it  by  an  adhesion  of  old  date.  Situated  in  the  anterior 
mediastinum,  which  it  had  separated,  it  resembled  a  fruit  planted  behind 
the  sternum  on  a  large  base,  and  floating  in  the  pleural  cavity  which  it 
had  opened.  Almost  opposite  the  point  at  which  the  opening  had  been 
made  in  the  intercostal  space,  a  violet  spot  was  observed  on  the  inside  of 
the  pericardium — the  mark  left  by  the  cut  of  the  bistoury.  The  blunt  end 
of  a  probe  entered  it  easily.  The  false  membrane  which  lined  the  serous 
membrane  in  the  situation  of  this  opening  was  red,  apparently  from  recent 
sanguineous  effusion.  On  opening  the  pericardium,  there  flowed  out  nearly 
a  litre  of  a  reddish  fluid,  identical  with  that  collected  in  the  pallet  during 
the  first  part  of  the  operation.  A  very  few  fibrinous  flocculi  were  observed 
floating  in  this  fluid. 

The  heart  was  at  the  bottom  of  this  sac,  at  least  ten  centimetres  from  the 
wall  of  the  cyst,  and  from  the  point  where  the  puncture  had  been  made. 
It  was  covered  by  a  thick,  reticular,  dirty-yellow  false  membrane,  as  was 
likewise  the  whole  of  the  interior  of  the  sac.  The  thickness  of  the  wTall  of 
the  cyst  might  be  about  five  millimetres. 

On  cutting  the  heart,  it  was  found  that  below  the  serous  coat  there  was 
a  thick  lardaceous  cellular  tissue,  resembling  a  layer  of  fat. 

The  heart  was  of  rather  more  than  the  natural  volume :  but  the  hyper- 
trophy was  concentric,  the  cavities  being  narrower  than  normal.  The  flap 
of  the  valve  was  supple,  thin,  and  without  appreciable  change  of  structure. 

The  orifices,  however,  allowed  the  finger  to  pass  less  easily  than  in  a 
healthy  heart. 

In  the  lungs  and  bronchial  glands,  there  were  disseminated  both  crude 
and  softening  tubercles.     Near  the  pancreas,  there  was  a  mass  of  softened 


682  PARACENTESIS    OF    THE    PEHIC ARDIUM. 

tuberculous  glands.  The  mesenteric  glands  were  engorged.  There  were 
some  intestinal  adhesions. 

In  the  encephalon,  the  only  morbid  appearance  seen  was  a  little  soften- 
ing of  the  falx  cerebelli.  It  ought,  however,  to  be  stated,  that  the  autopsy 
was  made  during  very  hot  weather. 

The  post-mortem  examination  gave  us  complete  information  as  to  what 
took  place  during  life,  and  during  the  operation.  There  was  pleural  as 
well  as  pericardiac  effusion.  The  stoppage  in  the  flow  of  the  pericardiac 
fluid  was  produced  by  a  mechanical  cause  which  is  easily  explained.  Once 
I  had  penetrated  the  pleura,  I  was  afraid  to  go  farther,  and  consequently 
only  made  a  very  small  opening  in  the  pericardium  opposite  the  opening 
in  the  thoracic  walls.  The  parallelism  between  the  two  openings  was  soon 
destroyed,  and  the  result  was  the  flow  of  the  pericardiac  effusion  into  the 
pleural  cavity. 

Could  I  have  avoided  this  accident  by  at  once  introducing  a  sound  into 
the  pericardium  through  the  opening  made  by  the  bistoury,  or  by  punc- 
turing with  a  trocar  so  as  to  enable  the  fluid  to  flow  through  the  canula  ? 
But  even  then,  there  would  have  been  difficulty  in  avoiding  the  inconveni- 
ence which  arose  from  the  fluid  oozing  out  between  the  lips  of  the  wound 
and  the  sides  of  the  canula  :  as  soon  as  the  canula  was  withdrawn,  the  parts 
resumed  the  vicious  position  which  it  was  supposed  could  have  been  pre- 
vented. 

When  I  come  to  discuss  the  mode  of  performing  paracentesis  of  the  peri- 
cardium, I  shall  return  to  this  question,  to  explain  how  it  is  that  the  incon- 
venience referred  to  is,  in  my  opinion,  a  matter  of  small  importance.  Then, 
I  shall  also  tell  you,  why  I  prefer  to  operate  with  the  bistoury,  and  not  with 
the  trocar  employed  by  others,  and  in  particular  as  you  have  seen  it  used 
even  in  my  wards,  in  the  case  regarding  which  I  have  now  been  speaking. 
Finally,  I  shall  have  to  tell  you  that  I  reject  Riolan's  operation,  adopted 
by  Skielderup  and  recommended  by  Laennec,  which,  consisting  in  pene- 
trating into  the  pericardium  by  trepanning  the  sternum,  is  a  proceeding 
which  seems  to  me  at  the  least  to  be  useless. 

Gentlemen,  as  I  have  just  mentioned,  I  have  had  occasion  to  perform 
paracentesis  of  the  pericardium  in  the  case  of  a  young  man  in  our  wards. 
This  first  case  (published  by  my  friend  Dr.  Lasegue  and  me  in  the  Archives 
Gcnerales  de  Medecine  for  November,  1854)  might  have  been  considered 
as  encouraging. 

The  patient,  a  lad  of  sixteen,  was  admitted  to  St.  Agnes's  Ward  on  the 
2d  February,  1854.  He  was  pale  and  weak  ;  but  lie  declared  that  he  had 
never  had  any  serious  illness.  Four  or  five  days  before  he  came  into  the 
hospital,  he  had  suffered  from  very  severe  frontal  headache,  which  was 
soon  followed  by  extreme  lassitude  and  pain  in  the  precordial  region. 

On  admission, he  had  intense  dyspnoea:  his  pulse  was  L5Q:  lie  had  a  little 
cough:  and  there  was  an  expression  of  suffering  in  his  countenance.  On 
percussion,  1  found  greal  dulness  in  the  region  of  the  heart,  reaching  as 
high  up  as  the  second  rili,  and  extending  from  the  right  margin  of  the 
sternum  to  very  Car  forward  in  the  left  side  of  the  chest,  in  which  direction, 
however,  its  limits  could  not  be  exactly  defined :  posteriorly,  the  left  was 
less  Bonorous  than  the  righl  side  of  the  chesl  :  the  sound  of  the  pulsations 
of  the  heart  was  ob.-cure  and  distant.  The  patienl  had  uever  completely 
fainted;  bul  had  a  constant  feeling  that  syncope  was  imminent.  I  ordered 
a  large  blister  to  he  applied  to  the  precordial  region;  and  prescribed  an 
infusion  of  digitalis  as  a  tisane. 

During  the    month   of  February,  while   the  pulse   continued    very  rapid, 

the  pulsations  of  the  In  an  were  better  heard  at  intervals,  becoming,  how- 


PARACENTESIS    OF    THE    PERICARDIUM.  683 

ever,  indistinct  at  other  times.  The  dulness  in  the  precordial  region  occu- 
pied  almost  uninterruptedly  a  space  extending  upwards  and  downwards  of 
seventeen  centimetres,  and  transversely  of  eighteen  centimetres:  during  two 
day-  only — from  the  18th  to  the  20th — did  it  appear  to  diminish.  At  this 
time,  there  was  a  double  cardiac  friction-sound,  which  was  most  appreciable 
at  the  base  of  the  heart.  The  arching  of  the  precordial  region  became  more 
and  more  marked  on  the  left  side  of  the  chest:  the  signs  of  pleural  effusion 
became  more  and  more  distinct,  there  being  posteriorly,  below  the  scapula, 
segophony  and  a  bellows-sound. 

On  the  17th  March,  it  was  noted  that  the  arching  had  been  greater  for 
eight  days,  and  that  profuse  diarrhoea  had  supervened.  The  patient  was 
losing  strength  and  flesh,  and  could  no  longer  move  in  bed  without  induc- 
ing a  tendency  to  faint.  The  face  was  pale  and  livid :  the  oppression  of 
breathing  was  extreme:  respiration  was  short  and  sighing:  percussion,  and 
even  the  simple  application  of  the  hand  over  the  precordial  region,  produced 
pain  and  pang :  the  pulse,  small  and  feeble,  was  120 :  the  dulness  extended 
up  to  the  clavicle. 

Next  day,  in  consequence  of  the  symptoms  having  become  more  serious, 
and  death  threatening,  I  resolved  to  have  recourse  to  paracentesis  of  the 
pericardium.  Professor  Jobert  (of  Lamballe)  operated.  In  the  fifth  inter- 
costal space,  at  about  three  centimetres  from  the  left  margin  of  the  sternum, 
he  made  an  incision  through  the  skin  and  cellular  tissue  to  the  intercostal 
muscles.  He  then  introduced  slowly,  steadily,  by  continuous  pressure,  ob- 
liquely from  right  to  left,  a  trocar  provided  with  a  piece  of  membranous 
material.  On  withdrawing  the  stem  of  the  instrument,  some  drops  of  reddish 
serosity  flowed  through  the  canula.  When  the  canula  was  left  free  in  the 
wound,  it  was  moved  about  by  the  action  of  the  heart,  being  raised  up  by 
each  contraction  of  the  organ. 

During  the  operation,  the  patient  (who  had  requested  its  performance  but 
was  alarmed  by  the  preparations)  was  pale,  and  groaned,  His  pulse,  very 
slow  and  almost  imperceptible,  ere  long  regained  its  usual  strength  and 
quickness.  He  had  no  feelings  of  general  discomfort,  no  great  amount  of 
oppression,  and  no  faintness. 

At  first,  the  fluid  flowed  pretty  freely,  although  it  did  not  spurt  out  in  a 
jet.  When  about  sixty  grammes  had  been  collected,  the  flow  became  slower : 
the  canula  was  then  fixed  in  the  wound,  whereupon,  without  favoring  the 
flow  by  any  manoeuvre,  the  fluid  dribbled  out.  The  operation  was  per- 
formed at  nine  in  the  morning :  at  half  past  nine,  the  patient  stated  that 
he  neither  experienced  any  relief,  nor  felt  increased  oppression.  The  canula 
was  removed  at  half-past  ten :  by  that  time,  the  flow  amounted  to  400 
grammes.  About  noon,  the  young  man  felt  a  little  better.  At  my  evening 
visit,  he  expressed  himself  as  having  obtained  great  relief.  He  breathed 
quietly.  His  pulse  was  134,  and  full.  The  dulness  only  extended  upwards 
to  within  four  finger-breadths  below  the  clavicle,  and  did  not  go  more  than 
two  centimetres  to  the  right  of  the  middle  of  the  sternum  :  on  the  left,  it 
extended  to  a  line  drawn  vertically  downwards  from  the  anterior  boundary 
of  the  axilla.  The  pulsations  of  the  heart  were  much  more  distinct;  and 
the  apex  of  the  heart  was  appreciably  raised. 

Forty-eight  hours  later,  the  report  made  was  to  the  following  effect :  the 
ameliorated  condition  is  maintained:  there  is  increased — almost  tympanitic 
— resonance  anteriorly  in  the  left  summit:  the  respiratory  murmur  is  audi- 
ble from  the  clavicle  to  the  fourth  rib,  where  dulness  commences :  the  sounds 
of  the  heart  are  becoming  more  and  more  distinct :  on  the  left  side,  poste- 
riorly, there  is  dulness,  bellows-sound,  and  aegophony:  there  is  little  cough, 
and  almost  no  oppression  of  the  breathing;  there  is  not  much  fever. 


684  PARACENTESIS    OF    THE    PERICARDIUM. 

On  the  22d  March,  the  pleuritic  effusion  was  progressing:  the  heart  was 
pushed  over  to  the  right  side,  and  there  was  great  distension  of  the  left  side 
of  the  chest.  The  patient  lay  on  the  right  side,  and  complained  of  an 
exceedingly  painful  stitch. 

Up  to  the  end  of  the  month,  the  pleuritic  effusion  went  on  increasing ; 
the  fever  augmented ;  and  the  cough,  more  frequent,  was  accompanied  by 
the  expectoration  of  thick  white  matter.  Mucous  rales  were  heard  at  the 
summit  of  the  left  lung.  The  oppression  of  the  breathing  had  become 
more  decided,  but  still  it  was  not  nearly  so  urgent  as  it  had  been  before 
the  operation.  There  was  some  diarrhoea,  which  was  moderated  by  the 
administration  of  nitrate  of  silver. 

On  the  30th,  seeing  that  there  was  effusion  occupying  the  entire  left  pleura 
of  an  individual  already  exhausted  by  his  disease,  I  did  not  hesitate  to  per- 
form paracentesis  of  the  chest.  A  first  opening  made  in  the  sixth  inter- 
costal space,  in  the  axilla,  did  not  afford  exit  to  one  drop  of  fluid :  the 
trocar  had  been  arrested  by  a  very  tough  false  membrane.  A  second 
opening,  made  a  little  more  posteriorly,  and  lower  down,  allowed  about  500 
grammes  of  fluid  to  flow  out.  The  operation  was  not  followed  by  any  par- 
ticular occurrence,  and  did  not  occasion  any  untoward  symptoms. 

On  the  2d  April,  some  subcrepitant  rales  were  heard  in  the  lower  part  of 
the  left  lung ;  but  there  was  neither  blowing  sound,  jegophony,  nor  any 
appreciable  embarrassment  of  breathing.  The  diarrhoea  continued.  The 
patient  had  insomnia. 

From  the  first  days  of  April,  up  to  the  28th  May,  the  day  on  which  the 
patient  left  the  hospital,  there  was  no  reproduction  of  the  pleuritic  or  peri- 
cardiac effusion.  The  pulsations  of  the  heart  could  be  felt  by  the  hand : 
the  sounds  of  the  heart  were  not  accompanied  by  any  blowing  or  friction- 
sounds.  The  extent  of  dulness  was  greater  than  in  the  normal  state :  the 
arching  was  quite  obliterated  ;  respiration  was  fairly  free,  and  the  young 
man  made  no  complaint  of  dyspnoea.  He  sat  up  in  bed  to  play,  had  appe- 
tite for  food,  and  declared  that  he  was  very  much  pleased  with  his  improved 
position. 

His  general  state,  however,  was  far  from  satisfactory :  his  cough  was 
more  frequent :  he  had  recurrence  of  the  fever,  particularly  towards  even- 
ing: the  diarrhoea,  more  moderate  it  is  true,  was  not  yet  checked  :  and  he 
did  not  regain  strength,  notwithstanding  the  use  of  medicinal  tonics  and 
a  strengthening  regimen. 

As  he  was  weary  of  the  hospital,  and  attributed  the  slowness  of  his  con- 
valescence to  his  remaining  so  long,  he  asked  to  be  allowed  to  leave.  The 
signs  of  tuberculization,  which  had  been  becoming  more  evident  for  a 
month,  were  quite  decided  at  the  date  of  his  leaving  the  hospital.  The 
symptoms  then  noted  were  the  following:  At  the  summit  of  the  left  lung, 
anteriorly,  there  were  observed  dulness,  sibilant  rales,  gurgling  during 
forcible  inspiration,  and  an  absence  of  the  bellows-sound;  posteriorly,  at 
the  summit,  there  existed  subcrepitant  rales,  and  at  the  lower  parte  of  the 

lung  there  were  mucous  rales.  On  the  righl  side,  respiration  was  puerile 
in  front  :  behind,  expiration  was  blowing,  the  voice  resonant,  the  rales  dry 
and  sonorous,  and  the  pulsations  of  the  heart  were  Strong  and  distinct. 
The  fits  of  Coughing  recurred  unaccompanied  by  anv  special  expectoration. 

The  patient  had  dyspnoea,  obstinate  diarrhoea,  emaciation,  and  1  Eippocratic 
deformity  of  the  fingers. 

Notwithstanding  his  feeble  state,  he  was  able  to  be  taken  home  in  a  car- 
riage to  his  family,  in  the  department  of  Eure-et-Loir.     During  the  first 

fortnighl  of  June,  We  heard  thai  his  state  continued  very  much  as  when  he 
left  the  hospital.     Since  then  I  do  not  know  what  has  become  of  him. 


PARACENTESIS    OF    THE    PERICARDIUM.  685 

This  case,  gentlemen,  as  I  have  already  said,  is  an  encouragement  to  per- 
form paracentesis  of  the  pericardium,  because  it  is  an  example  of  the  opera- 
tion preventing  death  otherwise  imminent. 

In  one  of  my  recent  lectures,  when  giving  you  a  rapid  historical  sketch 
of  paracentesis  of  the  chest  in  pleuritic  effusions,  I  showed  you  that  although 
the  indications  for  operating  had  not  been  formulated  with  precision,  the 
operation  had  been  performed  at  different  periods  anterior  to  our  own. 
Long  before  any  one  ventured  to  perform  it,  it  had  been  considered  from  a 
theoretical  point  of  view,  and  supported  by  sound  arguments,  as  a  proceed- 
ing likely  to  be  useful  and  quite  free  from  danger.  It  was  not  so  in  respect 
of  paracentesis  of  the  pericardium.  .  A  long  period  elapsed  before  it  was 
advocated  on  speculative  grounds ;  and  while  some  expressed  an  opinion 
that  it  might  be  possible  to  operate  for  effusions  into  the  pericardium  as 
had  been  done  successfully  for  effusions  into  the  pleura,  the  proposal  to 
bring  a  cutting  instrument  near  so  delicate  an  organ  as  the  heart  was  re- 
jected as  inexcusably  rash. 

To  Senac  is  generally  attributed  the  honor  of  having  pointed  out  the 
possibility  of  successful  paracentesis  of  the  pericardium  ;*  but  a  century 
previously,  Biolan  had  formulated  the  indications  for  resorting  to  that 
operation.f  Senac  certainly  never  performed  the  operation,  though  some 
compilers  have  made  a  statement  to  the  opposite  effect.  Several  authors 
cited  by  Sprengel,  taught  that  the  operation  ought  to  be  tried,  as,  if  left  to 
itself,  dropsy  of  the  pericardium  must  prove  fatal;  but  they  did  not  venture 
to  set  the  example  of  performing  it.  Bicter,  while  he  admitted  its  utility, 
exclaimed:  "Intrepido  opus  est  animo  ad  talem  operationem  instituendam;" 
and  Van  Swieten,  who  was  not  overtimid  in  employing  remedies  of  risk  in 
extreme  cases,  does  not  speak  more  confidently :  he  says,  "  Quam  audax 
facinus  debet  videri  omnibus  si  quis  cogitaret  de  pertundendo  pericardia  dum 
hydrope  target."  However,  notwithstanding  the  difficulties  with  which  the 
diagnosis  of  dropsy  of  the  pericardium  was  surrounded,  although  experience 
had  not  yet  pronounced  its  decision,  he  recognized  that  it  was  allowable, 
rather  than  leave  the  patient  to  the  cruel  alternative  of  death,  to  afford  by 
operation  an  outlet  for  the  effused  fluid:  his  words  are,  "Interim  generate 
axioma  practicum  omnibus  probatur :  tentandum  esse  potvus  anceps  remedium 
quam  nullum,  dam  certa  pernicies  imminet."  He  concludes  his  remarks  by 
describing  the  manner  in  which  the  operation  ought  to  be  performed. 

About  the  same  period,  Benjamin  Bell,  Camper,  Arneman,  and  Conradi 
all  recommended  the  operation  to  be  tried,  while  they  proposed  different 
methods  of  operating,  to  the  consideration  of  which  I  shall  afterwards  re- 
turn :j  the  counsels  which  they  give  are,  however,  purely  theoretical.  At 
a  later  date,  Desault,  who  originally  regarded  paracentesis  of  the  pericar- 
dium as  almost  impracticable  on  account  of  the  difficulty  of  determining 
the  indications,  found  a  case  in  which  he  thought  he  had  a  good  oppor- 
tunity of  carrying  out  practically  the  precepts  of  his  contemporaries :  but 
his  first  operative  attempt  was  far  from  being  a  success.  The  effusion,  in 
fact,  which  he  had  desired  to  evacuate  by  tapping,  was  not  contained  in  the 
pericardium,  as  appears  by  his  account  of  the  case,  which  is  given  with  the 
most  perfect  simplicity^and  candor.§ 

This  case,  then,  usually  quoted  as  the  first  in  which  paracentesis  of  the 
pericardium  was  performed,  has  no  claim  to  figure  in  the  history  of  that 

*  Senac:  Traite  de  la  Structure  du  Coeur  et  de  Ses  Maladies.     Paris,  1749. 
f  Riolan  :  Enchiridion  Anat.     Lib.  III.     Lugduni  Batavorura,  1049. 
X  Van  Swieten  :  Comment,  in  Aphorismos  Boerhaavii.    Parisiis  :  T.  iv,  p.  122. 
\  Desault:  (Euvres  Chirurgicales  recueillies  par  Bichat.     T.  ii.     1798. 


686  PARACENTESIS    OP    THE    PERICARDIUM. 

operation,  and  cannot  be  appealed  to,  except  as  an  argument  to  show  the 
obscurity  of  the  diagnosis.  Larrey's  case  is  not  more  conclusive,  although 
it  has  also  been  often  appealed  to.* 

These  two  cases  of  alleged  paracentesis  of  the  pericardium,  both  origi- 
nating in  errors  of  diagnosis  and  both  terminating  in  death,  hardly  advanced 
the  question  :  they  may  be  considered  as  leaving  matters  as  they  were.  With 
the  exception  of  an  interesting  essay  in  which  Skielderup  defends  tapping 
the  pericardium,  without,  however,  citing  cases  in  support  of  his  views, f  the 
operation  was  either  forgotten  or  very  severely  criticized. 

Corvisart,J  who  in  the  first  edition  of  his  work,  which  appeared  in  1806, 
was  satisfied  to  report  Desault's  case,  proposed  paracentesis  of  the  pericar- 
dium in  a  subsequent  edition  published  in  1818 :  he  recommended  an  in- 
cision with  the  bistoury,  as  preferable  to  a  puncture  with  the  trocar.  He 
stated,  however,  that  he  thought  the  possible  advantages  of  the  operation 
would  rarely  counterbalance  the  danger  to  which  it  exposed  the  patient. 

The  opinion  then  held  in  Germany  was  similar  to  that  of  Corvisart:  and 
Kreysig,  in  a  work  which  he  published  in  Berlin  in  1816,  on  paracentesis 
of  the  pericardium,  holds  that  it  would  be  very  difficult  to  apply  the  opera- 
tion usefully  in  practice.  Besides,  he  said,  the  disease  being  of  such  a 
nature  as  to  render  tapping  of  little  avail,  there  is  always  the  fear  of  consec- 
utive inflammation  of  the  heart  with  its  inevitable  results.  The  introduc- 
tion of  air  would  induce  suppuration  leading  to  death.  In  harmony  with 
the  opinion  of  his  contemporaries,  he  added,  that  the  means  of  diagnosis 
were  not  sufficient  to  excuse  the  temerity  of  resorting  to  such  an  operation. 

In  France,  Laennec,  adopting  the  views  of  Senac,  thought  that  there 
might  be  a  possibility  of  curing  dropsy  of  the  pericardium  by  a  surgical 
operation.     He  only  supported  this  opinion,  however,  by  presumptions. 

Richerand  went  farther  than  Laennec,  by  proposing  as  a  means  of  radical 
cure,  a  treatment  by  astringent  injections»similar  to  that  pursued  in  dropsy 
of  the  tunica  vaginalis.  Such  was  the  position  of  the-  question  as  one  of 
science,  when,  in  1839,  Schuh,  one  of  the  principal  physicians  of  Vienna, 
published  a  remarkable  work  entitled:  "  De  l'lnfluence  que  la  Percussion 
et  l'Auscultation  sont  appelees  a  exercer  sur  la  Pratique  Chirurgicale."  He 
therein  reviewed  the  services  rendered  by  both  the  new  means  of  diagnosis, 
and  specially  applied  himself  to  show  the  reliability  of  surgical  diagnosis 
based  upon  signs  which  were  almost  certainties.  Pleuritic  effusions,  for  the 
treatment  of  which  he  invented  (as  I  have  told  you)  a  special  apparatus, 
and  pericardiac  effusions  were  cited  as  the  most  convincing  examples  in 
support  of  his  opinion;  and  he  summed  up  by  stating  that,  suitable  cases 
presenting,  he  should  not  hesitate  to  perform  one  or  other  of  these  paracen- 
teses as  the  case  might  require.  An  opportunity  soon  presented  itself.  In 
the  following  year,  paracentesis  of  the  pericardium  was  practiced  lor  the 
first  time.  Tin;  operation  was  performed  in  tin'  wards  of  Professor  Skoda, 
and  Schuh  was  the  operator. 

Notwithstanding  the  interest,  which  attaches  to  the  case  published  by 
Skoda,  and  which  Dr.  Lasegue  and  I  have  reported  inextemo, in  the  paper 
which  we  contributed  to  the  Archives  Ge"n6rales  de  Medecine,  it  would  be 
occupying  your  time  unnecessarily  to  repeal  tin' details  upon  the  present 
occasion;  particularly,  because  when  considered  from  the  special  point  of 

*  Larrey :  Sur  une  Blessure  du  Pericarde  suivie  d'Hydro-pericarde.  [Bulletin 
dee  Sciences  Midicales:   lslO.] 

f  Skm.i  deri  p:  !><•  Trepanatione  ossis  Sterni,  et  A.pertura  Pericardii.  [Acta 
Jfova  Societatia  Medicince  Hafnienaia:   1S18.] 

J  Corvisart:  Maladies  et  Lesions  Organiquea  duOceuretdes  Gros  Vaisseaux. 
Paris:   1806. 


PARACENTESIS    OF    THE    PERICARDIUM.  687 

view  now  engaging  our  attention,  this  first  attempt  at  paracentesis  of  the 
pericardium  was  not  very  encouraging.  In  fact,  upon  two  occasions,  the 
attempt  to  make  the  puncture  was  a  failure.  On  the  firsl  occasion,  the  in- 
strument penetrated  a  heterologous  mass  six  indies  thick  occupying  the 
mediastinum:  this  mass  impinged  upon  and  altered  the  sternum:  the  inner 
Burface  of  the  clavicle  and  upper  four  ribs  were  attached  to  the  vertebrae, 
adhered  strongly  to  the  lungs,  and  encircled  the  large  vessels  and  the  wind? 
pipe.  From  this  first  puncture,  there  came  only  a  very  small  quantity  of 
sanguinolent  serosity  of  the  consistence  of  syrup.  After  prolonged  and  in- 
effectual attempts  to  obtain  more  fluid,  the  canula  was  withdrawn;  and  it 
was  resolved  that  a  second  puncture  should  be  made  in  the  intercostal  space 
immediately  under  that  first  perforated.  A  certain  quantity  of  reddish  se- 
rosity was  obtained  by  this  second  puncture;  but  the  relief  which  the 
patient  experienced  was  of  short  duration.  Nevertheless,  this  case  afforded 
valuable  instruction  ;  for  it  was  a  decisive  experiment  to  show  that  para- 
centesis of  the  pericardium  ought  not  to  be  looked  upon  as  one  of  those  bold 
proceedings  which  are  hardly  justified  even  by  success. 

In  the  following  year,  Dr.  Heger,  a  pupil  of  the  learned  professor  of 
Vienna,  operated  in  a  case  of  dropsy  of  the  pericardium,  which  though  not 
complicated  with  conditions  so  unusual  as  those  met  with  in  the  former 
case,  was  associated  with  other  pathological  states,  which,  as  I  shall  forth- 
with tell  you,  and  as  Dr.  Aran  has  shown,  generally  coexist  with  this  dis- 
ease. 

Dr.  Heger's  case  published  in  a  German  journal  deserves  to  be  reported 
to  you. 

The  patient  was  a  shoemaker  aged  nineteen.  He  stated  that  on  admis- 
sion to  the  hospital  he  had  had  the  disease  for  about  six  weeks  which  brought 
him  thither.  He  complained  of  dyspnoea,  which  at  first  was  not  alarming, 
but  afterwards  became  so  severe  that  on  the  1st  July,  1841,  the  day  of  his 
coming  into  the  hospital,  suffocation  seemed  imminent. 

On  admission,  his  countenance  was  anxious,  pale,  and  somewhat  ©edema- 
tous :  respiration  was  short,  quick,  painful,  and  panting.  The  patient  kept 
in  a  half-sitting  position.  When  he  tried  to  turn  on  the  left  side,  he  felt 
an  acute  pain  accompanied  by  great  dyspnoea.  The  expectoration  consisted 
of  a  thick  yellowish  mucus.  There  was  found  complete  dulness  on  per- 
cussing over  the  whole  of  the  sternum  from  its  right  margin  to  the  anterior 
portion  of  the  left  side  of  the  chest,  from  the  second  rib  to  the  epigastric 
region,  and  laterally  from  the  left  margin  of  the  sternum  for  six  inches. 
Below  the  left  clavicle,  along  the  scapula,  and  in  the  axilla,  the  sound  was 
clear ;  behind,  on  the  same  side,  it  was  tympanitic.  The  whole  of  the  front 
of  the  chest  was  clear  on  the  right  side  to  the  sixth  rib :  from  the  fourth 
rib  laterally,  the  sound  was  obscure.  Behind,  there  was  dulness  increasing 
from  above  downwards :  on  the  left  side,  there  was  tympanitic  resonance. 
The  liver  was  prominent  and  descended  two  finger-breadths  into  the  hypo- 
chondrium.     There  was  ai'ching  of  the  precordial  region. 

The  impulse  of  the  heart  was  imperceptible,  and  its  sounds  were  very 
obscure.  In  the  inferior  sternal  region,  a  friction-sound  was  heard  which 
it  was  difficult  to  distinguish  amidst  the  noise  of  the  mucous  rattles.  On 
the  right  side,  below  and  in  front,  large  mucous  rales  were  audible,  while 
behind,  no  respiratory  sound  could  be  heard. 

The  patient  had  some  appetite  for  food ;  and  had  almost  no  thirst.  The 
heat  of  the  skin  was  normal.  The  pulse  was  small,  irregular,  and  112. 
There  was  neither  diarrhoea  nor  constipation.  The  urine  was  of  a  deep 
red  color.     The  patient  complained  of  a  feeling  of  pressure  over  the  epi- 


PARACENTESIS    OF    THE    PERICARDIUM. 

gastriura,  and  of  pains  in  the  precordial  regions,  when  he  leaned  against 
the  left  side. 

The  diagnosis  was :  extensive  effusion  into  the  pericardium,  consequent 
upon  an  attack  of  pericarditis,  compressing  the  lower  part  of  the  left  lung, 
slight  effusion  into  the  right  pleura,  accompanied  by  infiltration  of  the  pul- 
monary parenchyma,  following  pleuropneumonia  and  general  bronchial 
catarrh. 

Some  relief  was  afforded  by  very  active  measures  employed  to  promote 
absorption  of  the  fluid  :  the  pulse  became  less  irregular.  Percussion  showed 
that  the  infiltration  of  the  inferior  lobe  of  the  right  lung  was  less,  but  that 
there  was  no  diminution  in  the  effusion  into  the  pericardium.  The  patient 
was  losing  flesh.  Mercurial  preparations,  from  which  most  excellent  results 
had  been  obtained,  were  uselessly  pushed  to  larger  doses,  without  producing 
diarrhoea  or  salivation. 

On  the  3d  August,  three  months  after  the  date  of  this  man's  admission 
to  hospital,  incipient  ascites  was  detected.  It  was  then  resolved  to  perform 
paracentesis  of  the  pericardium ;  and,  on  the  following  day,  Dr.  Heger 
operated.  The  place  selected  for  the  puncture  was  in  the  fifth  intercostal 
space,  and  at  a  point  about  two  inches  from  the  left  margin  of  the  sternum, 
where  the  friction-sound  was  not  heard,  and  where  there  was  less  risk  of 
wounding  the  internal  mammary  artery  and  large  vessels.  In  the  first  in- 
stance there  flowed  about  twelve  grammes  of  reddish  serosity.  Unsuccess- 
ful attempts  were  made  to  render  the  flow  continuous  by  using  in  the  first 
instance  a  catheter,  and  then  a  suction-pump:  a  freer  discharge,  however, 
was  obtained  by  getting  the  patient  to  hold  in  his  breath  and  make  an  ex- 
pulsive effort,  strong  pressure  being  made  at  the  same  time  over  the  epigas- 
trium. The  fluid  only  came  in  jets  under  the  influence  of  the  systole.  The 
serosity  obtained  was  brownish-red :  at  first  it  was  clear,  and  then  it  was 
flaky:  in  quantity  it  was  above  1500  grammes.  During  the  operation  the 
pulse  was  112  and  small.  At  intervals  the  friction  of  the  heart  upon  the 
canula  was  heard.  Not  one  bubble  of  air  penetrated  into  the  pericardium. 
Almost  immediately  after  the  paracentesis  marked  relief  was  experienced. 
The  diaphragm  regained  its  natural  position,  and  the  arching  of  the  chest 
became  less  :  the  sound  was  clearer  in  the  second  intercostal  space  and  along 
the  outer  margin  of  the  scapula:  the  friction-sound  had  disappeard.  The 
extent  of  the  dulness,  however,  led  to  the  conclusion  that  there  existed  from 
seven  hundred  to  eight  hundred  grammes  of  fluid  within  the  pericardium, 
The  wound  was  covered  with  a  piece  of  diachylon  plaster;  and  compresses 
soaked  in  iced  water  were  placed  on  the  side,  to  prevent  the  reaction  being 
excessive. 

At  3  r.M.  the  patient  had  a  shivering  fit,  and  increased  rapidity  of  breath- 
ing, but  no  cough.  The  pulse  was  104.  He  passed  a  restless  night,  bad 
sonic  cough,  and  slight  pain  in  the  wound. 

Next  day  there  was  observed  short  rapid  breathing,  fits  of  coughing, 
mucous  expectoration,  a  pulse  of  112,  constipation,  dulness  in  the  lower 
third  of  the  left  side  of  the  chest,  numerous  subcrcpitant  rales,  and  a  fric- 
tion-sound at  the  bottom  of  the  sternum.  With  a  view  to  check  the  pneu- 
monia in  the  left  lung  the  patient  was  bled:   the  blood  was  very  hull'v. 

Till  August  loth  the  pericardiac  effusion  went  on  increasing:  the  sound 
on  percussion  had  again  became  dull  in  the  second  intercostal  space:  the 

friction-sound  was  no  longer  audible:  the  sounds  of  the  heart  were  more 
obscure:  t  here  was  an  increase  in  t  he  intensity  of  the  fever  :  the  loss  of  flesh 
was  becoming  a  greater  cause  of  anxiety:  ana  it  was  feared  thai  then  was  <i 

(lrrc/i>/>i)irnt  of  tnhcrcle. 

During  the  following  week  there  was  an  amelioration  in  the  general 


PARACENTESIS    OF    THE    PERICARDIUM. 

state  of  the  patient:  the  pneumonia  of  the  left  Bide  was  undergoing  resolu- 
tion, but  there  was  effusion  into  the  pleura  of  the  same  side. 

On  the  17th  there  was  diminution  of  the  effusion  on  the  right,  and  in- 
crease of  the  effusion  on  the  left  side.  The  pulse,  which  was  small  and 
irregular,  ranged  between  120  and  124.  There  was  oedema  of  both  malleoli 
and  of  the  left  leg.  The  dyspnoea  was  increasing  and  becoming  complicated 
with  excitement.  Four  days  later  this  (edema  had  become  very  great ;  and 
the  local  condition  of  the  patient  was  the  same  as  on  his  admission  to  hos- 
pital, but  the  cachexia  was  much  more  threatening. 

On  the  22d  the  pericardium  was  punctured :  the  result  was  the  flow  in 
drops  of  deep  red  fluid:  every  effort  failed  to  render  the  flow7  continuous. 
The  patient,  with  the  canula  in  situ,  lay  on  the  edge  of  the  bed  for  fully 
two  hours,  so  that  the  serosity  might  be  collected.  In  all  there  was  hardly 
obtained  400  grammes  of  a  turbid  bluish-red  fluid.  For  the  canula  there 
was  then  substituted  a  caoutchouc  tube  firmly  fixed,  and  closed  at  its  free 
extremity  by  a  movable  valve  of  pig's  bladder.  The  liquid  continued  to 
flow  through  this  tube  from  eleven  in  the  forenoon  to  three  in  the  afternoon ; 
and  the  quantity  may  approximately  be  estimated  at  500  grammes.  The 
dulness  continued  after  the  puncture,  but  the  movements  and  sounds  of 
the  heart  became  more  distinct.  The  patient,  exhausted  by  the  long  time 
occupied  by  the  operation,  experienced  no  relief  from  it.  The  pulse  was 
116.  At  five  in  the  evening  the  patient  had  a  shivering  fit.  The  tube  was 
then  removed,  when  there  was  again  detected  a  pneumonia  of  the  left  side 
with  bronchophony,  bellows-sound,  rales,  and  characteristic  sputa.  Forty- 
eight  hours  later  this  pneumonia  j)assed  into  the  stage  of  resolution,  but  the 
respiration  still  remained  harsh. 

On  the  29th,  there  was  a  notable  diminution  in  the  amount  of  effusion  : 
and  there  was  a  gradual  progress  in  its  absorption  up  to  the  1st  September. 
At  that  date,  the  pericardial  friction-sound,  which  had  returned,  had  ceased. 
The  sound  on  percussion  was  almost  normal  up  to  the  left  nipple,  and  in  the 
axilla :  it  was  perfectly  clear  anteriorly  in  the  first  two  intercostal  spaces. 
The  amount  of  oedema  wTas  insignificant:  the  cough  was  moderate,  and  the 
respiration  was  nearly  natural :  still,  the  patient  continued  to  lose  flesh. 

On  the  4th  September,  there  were  diarrhoea,  oedema  of  the  lower  extrem- 
ities and  face,  particularly  on  the  left  side.  The  sound  on  percussion  on 
the  upper  and  front  part  of  the  same  side  of  the  chest  had  again  become 
tympanitic. 

On  the  11th,  the  left  pleural  effusion  had  made  very  great  progress. 
There  was  complete  dulness  as  high  up  as  the  axilla.  Behind,  there  was 
enormous  bronchial  respiration;  in  front,  respiration  was  harsh  and  whis- 
tling. It  was  impossible  to  measure  with  precision  the  extent  of  the  peri- 
cardiac effusion.  There  was  general  anasarca  up  to  within  half  an  inch  of 
the  umbilicus,  and  there  was  ascites.  The  dyspnoea  was  extreme  :  the  skin 
was  cold  and  livid  ;  asphyxia  was  becoming  more  and  more  threatening  ; 
and  the  pulse  was  too  rapid  to  be  counted.  These  symptoms  increased  in 
severity,  and  next  day  the  patient  sunk  under  them. 

At  the  autopsy,  the  left  lung  was  found  free  in  the  thoracic  cavity,  and 
the  right  was  fixed  by  strong  cellulo-fibrous  adhesions.  The  left  pleura 
contained  from  eight  to  nine  pounds  [pints],  and  the  right  five  pounds  of 
brownish  serosity.  The  right  lung,  pushed  back  along  the  spinal  column, 
was  slightly  compressed ;  its  inferior  lobe  was  dry  and  bluish,  and  the  su- 
perior lobe  was  infiltrated  with  serosity,  which  was  partly  frothy  and  partly 
unmixed  with  air.  The  left  lung,  also  pushed  back  and  compressed,  had 
undergone  similar  changes,  with  this  exception,  that  there  was  a  tuberculous 
cavity  surrounded  by  a  deposit  of  crude  tubercle.  The  pericardium  adhered 
vol.  i. — 44 


690  PARACENTESIS    OF    THE    PERICARDIUM. 

to  the  ribs  by  its  anterior  surface  from  the  second  to  the  sixth  rib.  There 
were  tuberculous  glands  in  the  anterior  mediastinum.  The  pericardium 
was  several  lines  in  thickness ;  it  adhered  to  the  heart  throughout  the  greater 
part  of  its  anterior  and  posterior  surface,  and  contained  several  ounces  of 
yellowish  flocculent  fluid.  By  careful  examination  three  layers  of  deposit 
on  the  pericardium  could  be  distinguished;  and  the  middle  layer  had  un- 
dergone tuberculous  degeneration.  The  heart  was  large  and  flaccid.  Its 
dilated  ventricles  contained  a  black,  soft  coagulum.  There  was  an  ascitic 
effusion.     The  liver  was  of  a  brownish  color,  and  hypertrophied. 

Gentlemen,  the  remarkable  feature  in  this  case  is  the  pleural  and  peri- 
cardiac effusions  progressing  almost  simultaneously :  this  happened  also  in 
the  young  man  in  whom  I  was  obliged  to  perform  in  succession  paracentesis 
of  the  chest  and  of  the  pericardium.  The  pericarditis  developed  itself  slowly, 
almost  without  any  acute  stage,  and  without  any  violent  inflammatory  symp- 
toms at  the  beginning  of  the  attack.  To  make  up  for  the  absence  of  acute 
svmptoms,  there  was  extensive  effusion,  as  in  dropsy  of  the  pericardium  and 
in  hvdrothorax.  Chronic  oedema  of  the  lung,  anasarca  limited  at  first  to 
the  lower  extremities,  and  ascitic  effusion,  are  almost  necessary  consequences 
of  disturbance  of  the  circulation ;  and  therefore,  in  this  case,  we  have  no 
ground  for  being  surprised  eit]ier  at  their  occurrence  or  duration. 

I  have  intentionally  dwelt  upon  the  symptoms  of  tuberculization  existing 
during  life,  and  upon  the  lesious  characteristic  of  that  condition  being 
found  after  death.  These,  in  fact,  are  the  complications  to  which  I  for- 
merly alluded,  wheu  I  said  that  they  were  generally  coincident  with  dropsy 
of  the  pericardium.  You  recollect,  that  in  my  lectures  on  hvdrothorax,  I 
pointed  out  to  you  that  extensive  pleuritic  effusions  of  a  chronic  and  latent 
character  are  frequently  manifestations  of  the  tuberculous  diathesis,  in  this 
sense,  that  they  affect  individuals  who,  although  they  have  not  as  yet  any 
sign  of  tuberculization,  ultimately  succumb  to  a  tuberculous  affection,  which 
may  or  may  not  be  an  affection  of  the  respiratory  organs.  In  relation  to 
this  point  I  cited  the  case  of  the  son  of  my  colleague,  Dr.  Thillaye,  who 
died  of  tuberculous  meningitis  some  months  after  having  been  successfully 
treated  by  paracentesis  of  the  chest  for  extensive  pleuritic  effusion.  Well 
then,  gentlemen,  it  appears  that  a  similar  rule  applies  to  dropsy  of  the 
pericardium.  This,  at  least,  was  an  opinion  expressed  by  my  lamented 
colleague,  Dr.  Aran.  His  personal  experience,  and  attentive  study  of  cases 
published  by  others,  led  my  accomplished  colleague  to  conclude  that  dropsy 
of  the  pericardium,  when  chronic  and  latent,  generally  coexists  with  tuber- 
culous disease,  and  that  these  pericardiac  effusions,  which  may  be  called 
symptomatic,  are  also  generally  those  which  assume  such  proportion-  as  to 
necessitate  paracentesis. 

To  conclude  this  historical  review  of  paracentesis  of  the  pericardium,  lei 
me  remind  you  that  Dr.  Meral  mentions  two  successful  cases  of  Dr.  Remero 
of  Barcelona;*  and  let  me  also  quote  from  memory  the  practice  of  Dr. 
Bowditcb  of  Boston,  who,  in  desperate  cases,  has  also  performed  thi>  opera- 
tion with  success.  1  would  also  add,  that  in  a  discussion  which  arose  in 
the  Societo  de  Meclecine  des  Qdpitaux  de  Paris  in  relation  to  a  case  brought 
forward  by  Dr.  Be'hier,  it  was  stated  by  Dr.  Henri  Roger  that  during  his 
visit  to  Germany  he  had  -ecu  Professor  Skoda  puncture  the  pericardium 
without  a  successful  result. 

Gentlemen,  Dr.  Aran  had  twice  occasion  to  perform  this  operation. 

( )n  a  previous  occasion,  at  the  end  of  1  s").'}  or  beginning  of  1 85  1,  prior  to 
my  operation  upon  the  second  patient  to  whom  I  referred  at  the  COmmenCC- 

*  Dictionnnire  des  Sciences  Medicates, 


PARACENTESIS    OF    THE    PERICARDIUM.  691 

ment  of  this  lecture,  he  attempted  the  operation,  but  had  not  the  courage 
to  complete  it.  After  carrying  an  incision  through  the  thoracic  walls,  and 
reaching  the  pericardium,  he  stopped  short.  When  he  felt  the  heart  beat- 
ing immediately  under  his  finger,  carried  deep  into  the  wound  made  by 
the  bistoury,  he  was  afraid  to  touch  it,  and  so  renounced  the  operation. 

Who  can  blame  the  physician  for  showing  such  an  excess  of  prudence 
under  the  circumstances?  The  operation  had  only  in  rare  cases  been 
brought  to  the  test  of  experience ;  and  the  operations  performed  in  France 
were  but  little  encouraging.  Notwithstanding  the  comparative  certainty 
which  has  in  our  day  been  attained  in  the  diagnosis  of  effusion  into  the 
pericardium,  the  diagnosis  is  still  sufficiently  difficult  to  leave  room  for  the 
physician  being  deceived  ;  and  the  special  form  of  the  dulness  in  peri- 
carditis, very  different  from  the  rounded  dulness  due  to  hypertrophy  of  the 
heart,  is  a  very  uncertain  sign.  May  it  not  be  well  to  carry  in  the  mind 
a  case  which,  among  many  others,  is  well  calculated  to  show  that  even  with 
men  the  most  able,  errors  are  sometimes  inevitable  ? 

In  1841  or  1842,  Dr.  Vigla,  now  physician  to  the  Hotel-Dieu,  when 
doing  duty  for  Professor  Rostan,  found  a  young  man  in  his  wards  suffering 
from  dyspnoea  approaching  to  asphyxia.  He  was  unable  to  give  any 
account  of  himself;  and  all  that  was  known  of  him  was  that  he  had  come 
out  of  the  Hopital  du  Midi.  Over  the  precordial  region,  he  bore  the  cica- 
trices of  recent  cupping.  His  general  appearance  and  physiognomy  indi- 
cated that  he  had  recently  had  an  illness. 

On  examining  this  young  man  as  minutely  as  the  circumstances  per- 
mitted, Dr.  Vigla  found  that  the  lungs  were  free  from  appreciable  lesions  ; 
but  that  in  the  region  of  the  heart,  there  was  extensive  dulness,  with 
absence  of  normal  or  abnormal  sounds;  the  pulse  was  very  small  and 
rapid.  All  who  saw  the  patient  concurred  in  diagnosing  great  effusion 
into  the  pericardium,  recent  in  its  origin,  and  the  result  of  inflammation. 

Certain  death  being  imminent,  prompt  and  decisive  action  was  impera- 
tive. Under  the  circumstances,  paracentesis  seemed  the  only  proceeding 
which  fulfilled  the  indication  ;  and  Roux  was  asked  to  perform  that  opera- 
tion. Roux  proceeded  with  extreme  caution,  and  made  the  opening  by 
incision  in  preference  to  puncture :  the  result  testified  to  his  sagacity  in  so 
acting.  When  he  reached  the  pericardium,  and  introduced  his  finger  into 
the  wound,  he  felt  the  heart  beating,  and  recognized  a  slight  friction 
between  it  and  the  pericardium,  without,  however,  detecting  the  slightest 
degree  of  fluctuation.  The  operation  was  suspended,  and  inevitable  death 
was  expected. 

The  patient,  without  having  inhaled  ether  or  chloroform — the  properties 
of  Which  were  not  then  known — was  almost  unconscious  of  what  was  done 
to  him,  and  quietly  sunk  from  asphyxia. 

At  the  autopsy,  there  was  found  dilatation,  Avhich  was  quite  a  phenomenon 
[dilatation  phenomenale]  to  use  Dr.  Vigla's  expression,  with  attenuation  of 
the  walls  of  the  heart :  there  were  no  valvular  lesions,  and  no  serosity  in 
the  pericardium. 

The  following  case,  which  occurred  under  your  own  observation,  corrobo- 
rates still  farther  the  point  which  I  at  present  wish  to  establish  :  A  young 
woman,  in  November,  1862,  came  into  my  wards  in  the  Hotel-Dieu  and 
occupied  bed  12  of  St.  Bernard's  Ward.  She  had  been  recently  confined  of 
her  fourth  child.  She  complained  of  breathing  with  difficulty.  The  symp- 
toms were  dyspnoea,  pale  countenance,  blue  lips,  anxious  expression,  oedema 
of  the  inferior  extremities,  and  a  small  though  regular  pulse.  The  extent 
of  the  dulness  in  the  precordial  region,  and  the  acute  pain  experienced 
when  that  region  was  percussed,  testified  to  the  existence  of  heart  disease. 


692  PARACENTESIS    OF    THE    PERICARDIUM. 

This  young  woman  had  been  suffering  for  a  long  time  from  palpitation  of 
the  heart,  and.  the  slightest  exertion  brought  on  difficulty  of  breathing. 
She  stated  that  she  had  had  several  attacks  of  acute  articular  rheumatism. 
The  cardiac  affection  was  of  a  complex  character.  The  great  extent  of  the 
precordial  dulness,  the  sounds  of  the  heart  seeming  muffled,  and  as  if  dis- 
tant, there  being  moreover  a  rasping  bellows-murmur  accompanying  the 
first  sound,  heard  at  the  base  of  the  heart,  and  extending  into  the  vessels 
of  the  neck,  and  the  smallness  of  the  pulse,  justified  me  in  concluding  that 
there  was  serous  effusion  into  the  pericardium,  and  contraction  of  the  aortic 
orifice.  Dr.  Barth,  who  examined  the  patient  at  my  request,  concurred  in 
my  diagnosis :  he  also  thought,  that  perhaps  there  were  clots  in  the  heart. 
In  addition  to  the  cardiac  disease,  we  found  the  signs  of  general  bronchitis, 
and  slight  effusion  into  the  left  pleura.  Ought  paracentesis  of  the  peri- 
cardium to  be  performed  ?  I  hesitated.  Next  day,  there  was  less  oppres- 
sion of  the  breathing,  a  diminution  in  the  'extent  of  the  dulness,  and  less 
pain  on  percussion.  After  the  lapse  of  some  days,  the  pleuritic  effusion 
was  to  a  great  extent  absorbed,  and  by  degrees  the  amelioration  in  the 
general  state  of  the  patient  became  so  great  that  in  opposition  to  my  advice 
she  left  the  hospital  at  the  beginning  of  December,  that  is  to  say,  in  rather 
less  than  a  month  after  admission. 

After  eight  days'  absence,  however,  she  returned  to  the  Hotel-Dieu. 
Consequent  upon  slight  fatigue,  her  difficulty  of  breathing  had  returned  in 
an  aggravated  degree :  her  pulse  was  small  and  irregular,  and  although 
there  was  still  great  cardiac  dulness,  the  bellows-murmur  at  the  base,  ac- 
companying the  first  sound  of  the  heart,  appeared  more  superficial :  the 
dyspnoea  soon  increased,  and  the  oedema  of  the  inferior  extremities  also 
made  progress :  the  pulse  could  not  be  felt  in  the  radial  arteries,  and  was 
hardly  appreciable  in  the  carotids :  the  extremities  were  cold.  The  op- 
pression became  greater  and  greater ;  and  after  a  continuance  for  two  days 
of  symptoms  of  immediately  impending  death,  the  patient  expired  in  a 
faint. 

At  the  autopsy,  the  appearances  found  demonstrated  that  pericarditis 
had  existed :  false  membranes  of  recent  formation  were  found  floating  in  a 
small  quantity  of  serosity.  There  was  great  hypertrophy  of  the  heart ; 
and  this  was  of  itself  sufficient  to  explain  the  extent  of  the  precordial  dul- 
ness. The  aortic  orifice  was  so  contracted  by  calcareous  deposits  as  hardly 
to  allow  the  passage  of  a  goosequill.  The  left  pleura  contained  a  small 
quantity  of  effusion,  and  some  cellular  false  membranes.  Both  lungs  were 
oedematous  in  their  posterior  and  inferior  parts  :  the  bronchi  were  gorged 
with  mucus,  but  the  bronchial  mucous  membrane  did  not  present  any 
traces  of  recent  inflammation. 

The  important  point  to  remark  in  this  case  is  that  the  effusion  into  the 
pericardium  was  never  so  great  as  hail  been  supposed;  for  the  extent  of 
the  precordial  dulness  nearly  corresponded  to  the  enormous  hypertrophy  of 
the  heart.  The  feebleness  ami  seemingly  distant  BOUnd  of  thi'  pulsations 
of  the  heart  resulted  from  the  feeble  contractions  of  that  organ,  ami  not 
from  a  thick  layer  of  serosity  being  interposed  between  the  heart  ami  the 
walls  of  the  chest. 

1'hc    tWO    cases    which    1    have  just    related   prove   then,  that  \vc   cannot 

always  affirm  that  the  pericardium  contains  a  large  quantity  of  effusion, 

even  when  the  majority  "f  the  BignS  of  effusion  are  present;  and  conse- 
quently, it  is  always  accessary  to  proceed  with  extreme  caution  iii  perform' 
ingthe  manual  operation,,  when  it  is  supposed  thai  paracentesis  is  indicated. 
Dr.  Aian'-  patienl  died  from  asphyxia,  occasioned  by  dropsy  of  the 
pericardium..    On  opening  the  body  after  death,  there  was  found  the  effU- 


PARACENTESIS    OF    THE    PERICARDIUM.  693 

sion  diagnosed  during  life — effusion  sufficient  in  quantity  to  obviate  the  fear 
of  wounding  the  heart  when  making  the  opening  into  the  pericardium  :  and 
the  only  concomitant  lesions  were  some  tuberculous  granulations  on  the 
pleura.  The  operation  evidently  offered  great  chances  of  success  in  such  a 
ease;  and  Aran  was  resolved  not  to  let  the  opportunity  slip  should  a  simi- 
lar case  present  itself.     He  did  not  require  to  wait  long. 

On  the  6th  November,  1855,  my  lamented  colleague  read  to  the  Academy 
of  Medicine  "  a  case  of  pericarditis  with  effusion  treated  successfully  hy 
tapping  and  iodinous  injections."  I  shall  now  read  this  case  to  you  in  the 
form  in  which  it  was  published  at  the  time.* 

"  The  patient  was  a  smelter  of  metals,  a  young  man  of  twenty-three  or 
twenty-four  years  of  age.  Though  of  a  miserably  delicate  constitution,  he 
had  never  suffered  from  serious  illness,  except  when  he  was  for  a  month  in 
my  wards,  at  the  close  of  1854,  for  a  pleurisy  of  the  left  side  with  exten- 
sive effusion.  He  left  the  Hopital  Saint-Antoine  in  fair  health  on  the  21st 
of  last  November.  A  month  afterwards,  he  perceived  a  pain  in  the  chest, 
near  the  third  or  fourth  rib,  accompanied,  when  at  his  work,  by  a  little 
difficulty  of  breathing  and  some  'palpitation  of  the  heart.  The  pain  con- 
tinued till  the  fine  season  set  in,  but  with  the  warm  weather  it  disappeared. 
This  young  man  was  consequently  in  very  good  health,  when  towards  the 
middle  of  last  July,  he  was  seized  with  fever,  cephalalgia,  shivering,  pains 
in  the  back,  decided  pain  under  the  left  nipple,  palpitation,  and  dyspnoea. 

"  On  the  27th  July,  the  date  at  which  he  came  into  my  wards,  there 
could  be  no  doubt  of  the  existence  of  pericarditis  with  extensive  effusion. 
On  the  one  hand,  the  patient  had  high  fever,  marked  by  intense  heat  of 
skin,  cephalalgia,  urgent  thirst,  and  a  pulse  of  116  :  on  the  other  hand,  the 
local  signs  were  more  characteristic — there  were  lancinating  pains  in  the 
fourth  and  fifth  intercostal  spaces  on  the  left  side,  in  front,  which  were 
increased  by  pressure  :  there  was  also  very  great  sensitiveness  over  the  epi- 
gastrium, when  pressure  was  made  with  the  hand :  there  was  greatly 
increased  precordial  dulness  commencing  superiorly  below  the  third  rib, 
and  extending  inwards  to  the  right  synchondrosternal  line,  measuring  12 
centimetres  vertically,  and  14  centimetres  transversely :  the  impulse  of  the 
heart  was  almost  imperceptible,  and  its  sounds  seemed  as  if  muffled  and 
distant. 

"The  wretched  constitution  of  this  patient,  and  probably  old  date  of 
the  beginning  of  the  heart  disease,  did  not  encourage  me  to  subject  him  to 
a  very  energetic  antiphlogistic  treatment.  Moreover,  for  eight  days  he 
had  had  looseness  of  the  bowels,  and  a  state  of  chest  somewhat  doubtful, 
there  being  on  the  left  side  in  particular,  diffused  sibilant  rales  :  this  condi- 
tion still  less  induced  me  to  resort  to  large  bleedings.  On  the  first  day, 
therefore,  I  took  blood  by  six  cupping-glasses,  administered  calomel  inter- 
nally in  small  doses  ;  and  with  a  view  to  induce  rapid  salivation,  I  ordered 
the  front  of  the  chest  to  be  rubbed  three  times  a  day  with  mercurial  oint- 
ment. 

"This  treatment  was  not  in  any  degree  successful.  I  tried  in  vain  to 
assist  it  by  applying  in  succession  two  large  flying  blisters  to  the  rjreeordial 
region.  Not  only  were  the  symptoms  not  arrested,  but  the  effusion  increased 
day  by  day,  and  with  this,  the  impediment  to  respiration  and  circulation 
became  augmented.  Before  thi*ee  days  had  elapsed,  the  pulse  had  become 
feeble,  irregular,  unequal ,  and  very  rapid.  I  persevered  in  the  administration 
of  mercurials,  but  had  great  difficulty  in  even  slightly  affecting  the  gums. 

"  As  the  character  of  the  pulse  was  becoming  more  and  more  indicative 

*  Bulletin  de  l'Academie  de  Medecine,  t.  xxi,  p.  142. 


694  PARACENTESIS    OF    THE    PERICARDIUM. 

of  an  impending  aggravation  of  the  symptoms,  I  soon  found  that  it  was  im- 
perative to  take  action.  On  the  7th  of  August  last,  at  the  morning  visit, 
I  was  told  that  the  previous  day  and  night  had  been  frightful :  the  patient 
had  been  almost  suffocated,  and  had  been  obliged  to  pass  the  night  sitting 
up  in  bed.  The  respirations  were  40,  and  the  pulse  120  in  the  minute : 
the  pulse  was  irregular,  intermittent,  and  unequal.  The  embarrassment  of 
respiration  and  circulation  were  only  too  well  explained  by  the  local  signs : 
there  was  dulness  extending  two  centimetres  beyond  the  right  edge  of  the 
sternum,  and  measuring  transversely  from  14  to  16  centimetres,  and  verti- 
cally 12  centimetres:  below  this  situation,  the  sounds  of  the  heart  were 
inaudible ;  there  was  an  absence  of  impulse :  the  liver  was  pushed  down- 
wards and  to  the  left  of  the  median  line. 

"  What  ought  to  be  done  ?  Ought  the  same  treatment  to  be  continued. 
Its  inutility  was  certain.  Ought  antiphlogistic  measures  to  be  resorted  to? 
The  weak  condition  of  the  patient  explicitly  contraindicated  such  means  ; 
and  moreover,  it  was  necessary  to  relieve  the  patient  at  once,  or  leave  him 
to  die  within  a  few  hours.     I  resolved  to  tap  the  pericardium." 

Dr.  Aran  selected  the  same  mode  of  operating  which  was  adopted  by 
Professor  Jobert  in  the  case  in  my  wards ;  that  is  to  say,  penetrating  with 
a  trocar  through  the  fourth  or  fifth  intercostal  space  direct  into  the  cavity 
of  the  pericardium. 

"However,"  in  continuation,  says  Dr.  Aran,  "I  was  not  without  uneasi- 
ness as  to  the  result  of  using  an  ordinary  trocar ;  and  so,  with  a  view  to 
avoid  a  possible  mishap,  I  employed  a  capillary  trocar,  such  as  I  have  suc- 
cessfully operated  with  in  hydatid  cysts  of  the  liver.  Thus,  I  found  myself 
more  at  my  ease,  being  convinced  that  a  puncture  of  the  heart  by  a  capil- 
lary trocar  could  not  be  followed  by  mortal  hemorrhage  into  the  pericar- 
dium. But  was  there  no  way  of  absolutely  guarding  against  this  accident? 
This  security  I  expected  to  obtain,  by  adopting  the  following  precautions. 

"  The  circumference  of  the  pericardium  was  circumscribed  by  a  series  of 
concentric  lines  of  percussion  proceeding  towards  the  heart  from  different 
parts  of  the  chest,  and  the  shape  of  the  surface  of  the  dull  part  being  thus 
carefully  delineated,  I  endeavored,  by  the  ear,  to  limit  the  zone  within 
which  the  sounds  of  the  heart  were  quite  inaudible,  that  in  which  they  were 
slightly  heard,  and  that  in  which  they  were  distinct.  The  sounds  of  the 
heart  could  not  be  heard  in  the  lower  part  of  the  dull  region,  and  seemed 
as  if  muffled  and  remote  in  the  fourth  intercostal  .-pace,  to  the  inside  of  the 
nipple  ;  they  were  absent  in  a  space  of  sufficient  extent  to  enable  the  opera- 
tor if  necessary  to  inserl  the  trocar  from  before  backwards  without  risk  of 
wounding  the  heart.  For  greater  safety,  I  selected  a  point  in  the  fifth 
intercostal  space,  at  which  I  made  an  incision  in  the  skin  with  the  Lancet, 
and  then,  slowly  introducing  the  trocar  from  without  inwards,  and  some- 
what from  below  upwards,  after  having  once  withdrawn  the  inner  stylet 
without  seeing  any  How,  I  reached  the  pericardium  by  two  stages:  there 
immediately  occurred  a  spurting  gush  or  fluid,  affording  satisfactory  proof 
that  the  sac  had  been  j »« i n  t  rated. 

"The  tapping  of  the  pericardium  was  certainly  accomplished  within  a 

shorter  space  01  time  than  I  have  taken  to  describe  the  operation.  Those 
only  who  can  recollect  the  feelings  with  which  they  performed  this  opera- 
tion for  the  first  time,  can  estimate  my  anxiety  at  the  commencement  of 
the  proceeding,  and  my  lively  satisfaction,  my  extreme  comfort,  when  I  -aw 
the  evacuation  of  the  fluid  progressing.  1  withdrew  by  the  trocar  about 
350  grammes  of  reddish  transparent  serosity.  At  first,  it  came  in  spurt-, 
and  afterwards  it  dribbled  out;  hut  the  patient  aided  the  flow  by  efforts 


PARACENTESIS    OF    THE    PERICARDIUM.  695 

which  he  prolonged  as  much  as  possible,  in  consequence  of  the  decided 
relief  which  he  experienced  from  the  evacuation  of  the  fluid. 

"The  sounds  on  percussion  corresponded  with  the  progressive  diminution 
of  thedulness  arising  from  the  evacuation  of  the  fluid  ;  and  on  auscultation 
they  were  heard,  more  and  more  distinctly,  unaccompanied  by  a  rubbing 
sound.  The  pulse  became  fuller,  more  regular,  and  less  frequent ;  it  fell 
from  120  to  96  in  the  minute. 

"  I  might  have  rested  satisfied  with  having  performed  a  single  palliative 
tapping;  but  I  thought  I  could  do  something  more  for  the  patient.  Rely- 
ing upon  the  success  I  had  obtained  in  pleurisy,  I  slowly  injected  an  iodin- 
ous  solution,  composed  of  50  grammes  of  water,  15  grammes  of  tincture  of 
iodine,  and  1  gramme  of  iodide  of  potassium.  I  did  not  feel  very  com- 
fortable in  respect  of  this  injection.  I  asked  myself:  what  is  going  to 
happen  ?  I  said,  has  it  not  been  alleged  that  the  pericardium  is  endowed 
with  excessive  sensibility?  The  injection,  however,  was  not  even  felt.  After 
having  retained  the  injection  in  the  pericardium  for  some  moments,  I  al- 
lowed some  grammes  of  it  to  escape,  and  then  closed  the  wound  by  means 
of  graduated  compresses,  and  by  placing  a  bandage  round  the  body. 

"  The  results  of  this  tapping  were  very  simple,  but  the  fluid  was  repro- 
duced, and  ere  long  the  patient  lost  a  great  part  of  the  ground  which  he 
had  gained  by  the  operation.  Respiration  became  more  embarrassed,  and 
the  pulse  irregular  and  more  rapid.  The  dulness,  which  had  at  first  seemed 
to  diminish,  increased,  particularly  in  a  lateral  direction.  There  was  mani- 
fest arching  of  the  chest.  The  pulsations  of  the  heart  were  deepseated. 
To  be  brief:  on  the  19th  August,  twelve  days  after  the  first  tapping,  I 
tapped  a  second  time ;  and,  as  before,  between  the  fifth  intercostal  space, 
following,  moreover,  exactly  the  same  proceedings  as  on  the  previous  occa- 
sion. At  this  second  operation,  I  evacuated  1350  grammes  of  a  very 
albuminous,  greenish  liquid,  in  color  resembling  bile.  As  on  the  first  occa- 
sion, this  fluid  came  in  gushing  spurts,  but  it  afterwards  dribbled  out.  The 
patient,  feeling  relief  from  the  flow  of  the  fluid,  assisted  me  by  his  efforts, 
which  it  was  necessary  to  restrain  through  fear  of  allowing  air  to  penetrate 
into  the  pericardium  :  however,  air  did  penetrate  after  the  injection  of  the 
solution  of  iodine,  the  strength  of  which  was  now  increased  to  fifty  parts  of 
tincture  of  iodine  to  the  same  quantity  of  distilled  water,  with  the  addition 
of  four  grammes  of  iodide  of  potassium :  nearly  the  whole  was  allowed  to 
flow  out  again.  I  was  consequently  enabled  to  detect  the  curious  sign  of 
hydropericarditis,  for  the  description  of  which  we  are  indebted  to  Dr.  Briche- 
teau,  viz.,  an  excessive  gurgling,  a  sort  of  churning  sound  [clapotement] 
like  that  produced  by  a  pump  jumbling  air  and  water  together  in  the  same 
cavity.  After  the  operation,  the  precordial  region  was  the  seat  of  well- 
marked  tympanitic  resonance. 

"  The  results  of  the  second  were  not  less  simple  than  the  results  of  the 
first  tapping;  but  the  relief  experienced  was  still  more  marked,  for  some 
hours  after  the  operation,  the  gurgling  and  tympanitic  resonance  had  dis- 
appeared from  the  pericardium.  On  the  very  evening,  however,  of  the  day 
of  the  operation,  the  reproduction  of  the  effusion  began.  Up  to  August 
21st,  the  extent  of  the  dulness  seemed  to  be  increasing ;  on  the  22d,  it  re- 
mained stationary;  and  from  the  23d  it  began  to  diminish,  particularly 
below  and  laterally.  The  sounds,  though  feeble,  soon  began  to  be  per- 
ceptible at  the  apex  of  the  heart ;  and  from  August  28th,  the  dulness  did 
not  extend  inwards  beyond  the  median  line,  nor  outwards  beyond  the 
nipple,  nor  superiorly  beyond  the  third  rib. 

"Notwithstanding  this  apparently  favorable  progress  of  the  disease,  the 
young  man  still  had  other  dangers  to  incur.     The  chest  affection  under 


69G  PARACENTESIS    OF    THE    PERICARDIUM. 

which  he  was  suffering  at  the  date  of  his  admission  to  hospital,  was  not 
remaining  stationary;  and  in  proportion  to  the  degree  in  which  the  heart 
symptoms  seemed  to  moderate,  the  signs  of  pulmonary  tuberculization 
became  more  and  more  evident,  particularly  in  the  left  lung,  in  which,  at 
first,  I  had  noted  symptoms  of  inflammation.  This  was  not  all :  towards 
the  end  of  Sept-ember,  the  ankles  became  oedematous,  and  some  days  later, 
the  swelling  invaded  the  scrotum,  the  lower  extremities,  as  well  as  the 
thoracic  and  abdominal  parietes. 

"  Since  the  end  of  October,  the  oedema  has  been  completely  gone — thanks 
to  his  youth,  and  thanks  also,  probably,  to  the  application  of  numerous 
flying  blisters  to  the  chest,  and  the  use  of  vapor  baths.  There  has  seemed 
also  to  be  a  gradual  amelioration  in  the  thoracic  phenomena  :  with  return 
of  appetite,  there  came  return  of  strength:  respiration  regained  its  freedom, 
and  with  the  exception  of  a  continuance  of  cough  at  night  the  patient  may 
consider  himself  as  completely  cured  of  an  affection  which  had  brought  him 
to  the  very  brink  of  the  tomb.  Need  I  add,  that  the  physical  signs  of  pul- 
monary tuberculization  still  remain,  notwithstanding  the  amendment  which 
has  taken  place  in  the  general  and  local  condition  of  the  patient?" 

I  do  not  feel  at  all  afraid,  gentlemen,  of  having  trespassed  on  your 
patience  by  reporting  at  length  this  case  so  full  of  interest  from  every  point 
of  view  :  it  is  not,  moreover,  the  only  case  of  tapping  the  pericardium  which 
Aran  had  to  record :  a  short  time  before  his  death,  he  told  me  that  he  had 
thrice  performed,  and  thrice  performed  successfully,  this  operation. 

These  cases,  other  cases  which  have  occurred  in  my  own  practice,  and 
cases  which  might  now  probably  be  added,  conclusively  demonstrate  that 
paracentesis  of  the  pericardium  is  not  beset  with  the  perils  which  for  so 
long  time  frightened  experimenters,  but  existed  only  in  their  own  imagina- 
tions. 

Were  it  not  for  the  diagnostic  difficulties  presented  by  dropsy  of  the 
pericardium,  difficulties  very  much  more  serious  than  those  which  some- 
times occur  in  the  diagnosis  of  hydrothorax,  tapping  the  pericardium  would 
be  as  simple  an  operation  as  paracentesis  of  the  chest  or  abdomen.  Indeed 
tapping  the  pleura,  though  in  most  cases  exempt  from  danger,  is  more 
calculated  than  tapping  the  pericardium  to  excite  fears,  and  lead  to  bad 
quences. 

Not  onlv  is  paracentesis  of  the  pericardium  free  from  risks;  but  experi- 
ence appears  likewise  to  have  fully  established  the  safety  of  using  injections 
for  the  radical  cure  of  dropsy  of  the  pericardium.  Thus,  therefore,  are 
realized  the  anticipations  of  Richerand  who  was  the  first  by  whom  the  idea 
was  conceived  of  applying  to  effusions  into  the  pericardium  that  treatment 
which  is  employed  every  day  in  cases  of  hydrothorax,  ascites,  and  eflusions 
into  joints.  Professor  Bouillaud  in  his  Train'  Clinique  des  Maladies  du 
Coeur,  without  venturing  to  give   a  decisive  verdict  on    paracentesis  of  the 

chest  and  the  value  of  iodinized  Injections,  enunciated  the  following  opinion 
in  the  second  edition  published  in  1841 :  "An  exaggerated  notion  has  prob- 
ably been  entertained  of  the  dangers  of  pericarditis,  a  condition  which  must 
he  produced  before  it    is  possible  to   have  adhesion  of  the  opposite  surfaces 

of  the  pericardium,  the  sole  means  of  preventing  a  reaccumulation  of  the 
fluid  evacuated  by  the  tapping:"  and  he  adds  that  "pericarditis  produced 
by  irritant  injections  would  be  a  proceeding  of  the  simplest  possible  de- 
scription." 

Gentlemen,  1  have  now  a  few  words  to  say  on  the  operation  itself. 

Several  points  have  been  proposed  as  the  most  suitable  for  opening  into 
the  pericardium.  As  I  have  already  told  you,  Senac,  Bkielderup,  and 
Laennec  recommended  that  the  sternum  Bhould  be  trepanned  immediately 


PARACENTESIS    OF    THE    PERIC ARDIUM.  697 

above  the  ensiform  cartilage,  and,  with  a  view  to  fix  the  spot  with  more 
precision,  they  advised  the  puncture  to  be  made  below  the  insertion  of  the 
cartilage  of  the  fifth  rib. 

Lai  rev  believed  that  it  was  easier  and  more  convenient  to  make  the 
puncture  between  the  edge  of  the  ensiform  cartilage  and  the  cartilage  of 
the  eighth  rib. on  the  left  side.  By  carrying  the  instrument  from  below 
upwards,  and  a  little  to  the  right,  the  pericardium  will  be  reached,  he  thinks, 
with  greater  safety,  and  in  such  a  way  as  to  give  freer  egress  to  the  fluid. 
I  at  first  looked  on  this  method  as  very  rational :  but  on  recollecting  that 
surgeons  have  properly  called  attention  to  the  risk  of  encountering  a  branch 
of  the  internal  mammary  artery,  which  is  sometimes  of  such  a  calibre  as  to 
reach  to  the  ensiform  cartilage;  and  reflecting  also  on  the  fact  that — in 
accordance  with  a  remark  of  Professor  Velpeau — the  instrument  might  be 
carried  in  such  a  direction  as  to  avoid  the  pericardium  in  subjects  whose 
cedematous  state  or  plump  condition  was  sufficiently  decided  to  prevent  the 
skin  from  coming  into  immediate  contact  with  the  cartilage  and  ensiform 
appendix,  I  renounced  that  method. 

The  place  which  I  select  as  the  most  favorable  for  the  operation  is  that 
which  M.  Jobert  and  I  chose  in  our  own  two  patients, — the  fourth  and  fifth 
intercostal  spaces.  The  precautions  adopted  by  Aran,  and  pointed  out  in 
his  case,  are  useful :  when  an  occasion  occurs,  you  will  do  well  to  put  his 
precepts  into  practice. 

Tapping  may  be  performed  either  directly  by  means  of  the  trocar,  or  by 
incising  with  a  bistoury,  layer  by  layer,  the  thoracic  walls  and  the  peri- 
cardium, or  by  adopting  a  mixed  proceeding ;  that  is  to  say,  by  first  cutting 
through  the  superficial  layers,  and  then  puncturing  the  subjacent  tissues  by 
the  trocar. 

I  admit  that  there  is  something  in  the  simplicity  of  the  proceeding  which 
renders  it  a  more  attractive  operation  to  puncture  with  the  trocar  than  to 
cut  with  the  bistoury.  But  let  me  repeat,  that  the  diagnosis  of  dropsy  of 
the  pericardium  is  not  always  so  easy  as  is  alleged :  in  making  a  direct 
puncture  with  the  trocar,  I  should  be  afraid  of  coming  upon  the  heart. 
This  is  a  risk  which  I  should  dread  even  more  in  a  case  in  which  there 
really  was  effusion  into  the  pericardium,  for  the  heart,  in  place  of  flying 
before  the  instrument,  might,  as  has  been  well  expressed  by  Senac,  come  up 
to  meet  it,  and  thereby  be  run  through.  Even  when  using  Aran's  capillary 
trocar,  I  should  still  be  very  far  from  being  without  anxiety  on  that  score. 

The  only  inconvenience  which  I  can  see  in  using  the  bistoury,  is  that 
some  of  the  fluid  effused  into  the  pericardium  may  fall  into  the  pleura, 
flowing  out  between  the  edges  of  too  large  an  incision,  and  the  canula  in- 
troduced into  the  pericardium.  No  importance  attaches  to  this  inconveni- 
ence :  in  fact,  it  has  been  shown  by  experiments  made  on  wounds  of  the 
chest — a  subject  which  I  discussed  with  you  at  some  length  the  other  day — 
that  blood  effused  into  the  pleural  cavity  is  very  rapidly  absorbed  ;  and 
the  same  rapidity  of  absorption  ought  to  take  place  in  respect  of  a  serous 
effusion. 

There  is,  therefore,  no  danger  in  allowing  a  fluid  which  is  even  less  irri- 
tating than  blood  to  fall  into  the  pleura.  Mark  well  this  fact :  if  the  fluid 
effused  in  a  case  of  pleurisy  is  not  absorbed,  it  is  either  because  the  pleura 
is  still  in  a  state  of  inflammation,  or  because  its  surface  is  coated  with  false 
membrane,  and  consequently  in  a  condition  unfavorable  to  the  accomplish- 
ment of  absorption.  When  there  is  no  morbid  condition  of  the  pleura,  ab- 
sorption goes  on  well,  the  symptoms  are  of  a  less  serious  character,  and 
recovery  is  more  likely  to  occur. 

If  I  were  called  upon  to-day  to  puncture  the  pericardium,  I  should  modify 


698  PARACENTESIS    OF    THE    PERICARDIUM. 

the  operation  in  the  spirit  of  the  remarks  I  have  now  made.  I  should 
make  my  incision  through  the  skin  immediately  external  to  the  sternum, 
about  the  fifth,  sixth,  or  seventh  sterno-costal  cartilage,  selecting,  as  Aran 
recommends,  the  point  where  the  dulness  is  greatest,  and  where  it  is  most 
difficult  to  perceive  the  movements  of  the  heart.  I  should  try  to  penetrate 
between  two  cartilages,  keeping  as  near  as  possible  to  the  sternum.  At  the 
sternum,  the  cartilages  touch  one  another ;  but  by  employing  a  spatula,  or 
any  such  like  suitable  lever,  I  should  be  enabled  somewhat  to  separate  the 
edges  of  the  two  cartilages,  and,  if  it  were  necessary,  I  should  not  hesitate 
to  remove  as  much  cartilage  as  would  allow  the  pulp  of  the  finger  to  reach 
the  pericardium.  The  case  reported  by  Dr.  Vigla  shows  how  necessary 
it  is  to  be  assured  by  digital  examination  that  there  is  a  sufficient  distance 
between  the  heart  and  the  point  at  which  the  pericardium  is  punctured. 

To  facilitate  the  escape  of  the  fluid,  the  most  important  circumstance  to 
attend  to  is  to  allow  the  canula  of  the  trocar  to  remain  some  time  in  the 
pericardium ;  and  it  is  useless  to  practice  the  different  manipulations  which 
have  been  recommended  as  calculated  to  accelerate  the  evacuation.  Suction- 
pumps  afford  no  assistance,  and  give  a  troublesome  complication  to  the 
operative  apparatus.  However,  the  membranous  valve  which  I  employ  in 
paracentesis  of  the  thorax  for  pleuritic  -effusions  may,  without  producing 
any  inconvenience,  be  attached  to  the  free  extremity  of  the  canula,  although 
its  utility  is  an  open  question. 

As  soon  as  the  canula  has  been  introduced  into  the  pericardium,  the 
liquid  begins  gradually  to  flow  out.  Aran  observed  in  his  cases,  that  the 
continuous  jet  which  the  fluid  formed  was  sometimes  projected  to  a  great 
distance  in  spurts  during  deep  inspirations — a  phenomenon  which  he  attrib- 
utes to  the  pressure  of  the  lung  on  the  pericardium.  This  phenomenon 
did  not  present  itself  in  my  two  patients,  nor  was  it  noted  in  the  cases  which 
I  have  reported  to  you. 

When  the  canula  is  removed,  all  that  is  necessary  is  to  close  the  wound 
with  a  diachylon  plaster  kept  in  its  place  by  a  bandage  round  the  body. 
The  wound  requires  no  treatment :  it  hardly  occasions  any  pain,  gives  rise 
to  no  great  amount  of  inflammation,  and  never  leads  to  suppuration  even 
of  very  limited  extent. 

Gentlemen,  paracentesis  of  the  pericardium  is  decidedly  indicated  only 
in  cases  in  which  life  is  threatened  by  the  extent  of  the  effusion.  The 
occasions  on  which  it  ought  to  be  resorted  to  must  always  be  of  rare  occur- 
rence. 

Simple  idiopathic  dropsy  of  the  pericardium  uncomplicated  with  any 
other  dropsy,  or  with  any  serious  lesion  of  the  thoracic  organs,  is  certainly 
seldom  met  with.  Generally,  profuse  effusion  into  the  pericardium  is  only 
one  of  the  manifestations  of  a  state  of  disease  which  is  not  exclusively 
localized  in  that  situation,  but  also  attacks  other  essential  parts  of  the 
economy. 

I  have  told  you  that  A  run  enunciated  an  opinion  to  the  effect  that  effu- 
sion into  the  pericardium  sufficiently  profuse  to  necessitate  paracentesis,  is 
generally  coincident  with  the  tuberculous  diathesis.  I  have  informed  you 
that  this  opinion  was  based  on  facts  observed  by  our  lamented  colleague. 
His  own  two  eases,  and  those  by  the  recital  of  which  1  began  this  lecture, 
completely  support  this  view. 

But  if  we  cannot  hope  in  such  cases,  to  cure  the  patient  by  withdrawing 

the  fluid  from  the  pericardium,  we  are  at  leasl  certain  of  relieving  suffering 
and  prolonging  life  by  removing  a  serious  <•<  mi  plication  involving  imminent 

danger.  Had  paracentesis  of  the  pericardium  no  other  reliable  claim,  this 
would  entitle  it  to  a  place  among  operations  worthy  of  being  retained  and 


ORGANIC    AFFECTIONS    OF    TUE    HEART.  GP9 

sanctioned.  When  we  witness  the  anxiety  produced  by  the  pressure  of 
fluid  on  the  heart,  when  we  witness  the  fearful  and  protracted  agony 
resulting  from  such  a  state,  we  are  only  too  happy  to  have  it  in  our  power 
to  afford  even  temporary  relief,  and  to  be  able  to  prolong  a  life  which  we 
have  rendered  less  painful  to  endure. 


LECTUEE  XXXVIII. 

ORGANIC  AFFECTIONS  OF  THE  HEART. 

General  Considerations. — Insufficiency  of  the  Aortic  Valves  is  the  most  serious 
of  all  the  Lesions  of  the  Cardiac  Orifices. — Dropsy  treated  by  Purgatives. — 
Diarrhoea  sometimes  requires  to  he  arrested:  at  other  times  it  constitutes 
a  natural  crisis  which  ought  not  to  he  interfered  with. — Diagnosis  of 
Affections  of  the  Heart  is  often  difficult. — Embolism  and  its  Consequences. 

Gentlemen:  A  woman,  who,  on  several  occasions,  has  been  a  patient 
in  our  clinical  wards,  will  afford  me  an  opportunity  of  presenting  some 
general  considerations,  pathological  and  therapeutical,  in  relation  to  some 
peculiar  symptoms  which  arise  in  the  course  of  organic  affections  of  the 
heart — considerations  which  you  will  be  able  from  time  to  time  to  apply  at 
the  bedsides  of  our  patients. 

The  woman  to  whom  I  refer  latterly  occupied  bed  34  of  St.  Bernard's 
"Ward :  she  came  into  hospital  on  account  of  complications  dependent  upon 
an  affection  of  the  heart  of  very  easy  diagnosis.  Upon  auscultation,  the 
cardiac  lesion  was  revealed  by  a  double  bellows-murmur,  having  its  maxi- 
mum intensity  in  the  situation  of  the  apex  of  the  heart :  the  blowing 
accompanying  the  first  sound  of  the  heart  was  harsh,  and  that  accompany- 
ing the  second  was  softer.  These  stethoscopic  phenomena  were  characteristic 
signs  of  valvular  insufficiency,  and  of  contraction  of  the  left  auriculo-ven- 
tricular  orifice. 

My  present  object  is  not  so  much  to  call  your  attention  to  organic  lesions 
of  the  heart,  as  to  show  you  the  very  great  difficulty  of  making  a  confident 
prognosis ;  and  to  point  out  to  you  certain  rules  for  the  treatment  of  some 
of  the  complications  which  arise  consequent  upon  the  lesions. 

I  would  remark,  however,  gentlemen,  in  respect  of  valvular  insufficiency, 
that  it  is  generally  coincident  with  contraction  of  the  orifice.  In  fact,  the 
causes  wrhich  most  commonly  prevent  the  valves  from  fitting  closely  to  one 
another  are  changes  of  these  membranous  partitions.  Their  thickening, 
their  induration,  their  fibro-cartilaginous,  osseous,  or  petrous  transformation, 
their  partial  destruction  at  their  free  margin,  their  perforation,  their  more 
or  less  extensive  rupture  at  the  base  or  centre,  the  presence  of  vegetations 
on  their  surface  or  edges,  and  all  kinds  of  structural  change,  which,  coexist- 
ing with  more  or  less  considerable  thickening  and  induration  of  the  valves, 
prevent  them  from  performing  their  functions  in  a  perfect  manner.  This 
thickening  and  hardening,  and  the  presence  of  somewhat  bulky  vegetations 
at  the  edges  or  upon  the  surface  of  the  valves,  irrespective  of  valvular  in- 
sufficiency, necessarily  narrow  the  orifices  at  the  entrance  of  which  the  valves 
are  placed. 


700  ORGANIC  AFFECTIONS  OF  THE  HEART. 

This  valvular  insufficiency  and  contraction  of  the  opening  give  rise  to 
more  or  less  impediment  to  the  circulation  of  the  blood  in  the  heart,  and 
this  again  produces  a  series  of  phenomena,  some  of  which  are  local  and  per- 
tain to  the  heart,  while  others  are  general  and  belong  to  other  organs. 

Some  of  the  local  phenomena  are  subjects  of  complaint  by  the  patients. 
Among  these  are  palpitation,  a  sense  of  embarrassment  and  weight  in  the 
precordial  region  or  towards  the  pit  of  the  stomach,  which  augment  the 
muscular  effort  when  it  is  necessary  to  exert  a  little  more  than  usual,  as,  for 
example,  in  going  up  a  stair.  At  a  more  advanced  stage  of  the  disease  there 
is  greater  or  less  difficulty  of  breathing.  These  symptoms,  however,  are 
often  absent.  Other  local  phenomena,  the  existence  of  which  is  made  out 
by  exploration  of  the  heart  in  different  ways,  afford  us  more  certain  diag- 
nostic signs  of  the  lesion. 

When  the  disease  has  somewhat  advanced,  simple  inspection  of  the  pre- 
cordial region  gives  us  some  information  as  to  the  disturbance  of  the  heart's 
action,  and  application  of  the  hand  enables  us  still  better  to  appreciate  it. 
In  fact,  on  applying  the  hand,  we  can  recognize  that  sort  of  undulatory 
movement,  that  vibratory  thrill,  called  the  purring  fremitus  \Jremig8ement 
eafaire]  which  is  coincident  with  irregularities,  intermittencies,  and  inequali- 
ties of  the  pulsations  of  the  heart.  Auscultation  by  the  ear,  or  by  the  aid 
of  a  stethoscope,  furnish  signs  consisting  of  bellows-murmurs  of  great  diver- 
sity, the  physiological  explanation  of  which  has  been,  and  still  is  explained 
by  different  theories,  which  I  do  not  think  it  necessary  to  discuss  here  in 
detail.  Let  me  say,  however,  that  the  beautiful  experiments  on  horses  per- 
formed by  M.  Chauveau  no  longer  leave  any  room  for  doubt  as  to  the  cause 
of  the  normal  and  abnormal  sounds  of  the  heart :  to  those  present  at  the 
experiments  of  which  I  speak,  it  was  clearly  demonstrated  that  Eouanuet's 
theory  is  that  which  is  alone  admissible. 

Percussion  enables  us  to  recognize  increase  in  the  volume  of  the  heart, 
whether  that  increase  be  dependent  upon  dilatation  of  the  cavities  or  hyper- 
trophy of  their  Avails.  These  alterations  of  the  heart,  almost  invariably 
coincident  with  lesions  of  the  orifices,  are  the  necessary  consequences  of  im- 
pediment to  the  circulation  of  the  blood.  The  mechanism  (if  their  produc- 
tion is  easily  understood.  From  the  moment  that  the  muscular  contractions 
of  the  heart  are  inadequate  to  overcome  the  obstacle  to  the  passage  of  the 
blood  out  of  the  cavity  which  contains  it.  the  walls  of  that  cavity  gradually 
become  distended  by  the  accumulation  of  blood,  and  in  this  way  the  cavity 
it-ell'  i<  dilated.  This  dilatation  is  seldom  simple,  that  is  to  say,  only  the 
result  of  attenuation  of  the  parietes  :  generally — almost  always — the  dilata- 
tion is.  accompanied  by  hypertrophy  of  the  walls  of  the  heart,  originating 
chiefly  in  an  excess  of  muscular  action.  Though  I  do  not  wish  at  present 
to  discuss  a  question  of  general  pathology,  I  would  nevertheless  call  on  you 
to  observe,  that  there  takes  place  in  the  heart  a  change  similar  to  that 
which  occurs  in  other  hollow  organs  in  which  we  see  dilatation  along  with 
greater  development  of  the  muscular  fibres,  from  the  existence  of  an  obsta- 
cle to  the  exit  of  the  content-  requiring  increased  efforts  tor  the  accomplish- 
ment of  the  normal  expulsatory  function.  The  same  takes  place  in  the 
heart,  as  in  the  bladder,  the  bronchial  tubes,  the  stomach,  and  other  por- 
tions of  the  digestive  canal.  This  hypertrophy  of  the  heart,  as  has  been 
justly  remarked  by  clinical  observers,  by   Hunter,   Laennec,  Beau,  and 

others,  is  a   lesion   specially  and    providentially  employed    by   nature,  a-   a 

means  of  overcoming  tl bstacle  to  the  circulation  of  the  blood.  The  re- 
sult is,  the  maintenance  for  a  certain  time  of  the  performance  of  a  function 
essentia]  to  life.     I  have  stated  that  this  lesion  is  to  a  greatextenl  produced 

by   an   excess   of  muscular  action;    hut,  while   I    -ay  .-o,  I    admit    that    we 


ORGANIC    AFFECTIONS    OF    THE    HEART.  701 

musl  also  take  into  account  as  a  cause  of  the  hypertrophy  the  pathological 
change  in  the  muscular  tissue,  brought  about  by  that  morbid  action  conven- 
tionally termed  inflammation  or  irritation. 

Lei  us  now  return  to  the  consideration  of  embarrassment,  more  or  less 
considerable,  to  the  circulation  of  the  blood  in  the  cardiac  cavities.  Gentle- 
men, it'  I  do  not  pause  to  study  with  you  the  precise  diagnosis  of  the  seat 
of  the  lesions  of  the  orifices,  it  is  because — as  has  been  admitted  by  an 
eminent  physician,  whose  competence  to  express  an  opinion  on  such  a  point 
no  one  will  gainsay — the  study  is  essentially  one  more  curious  than  useful.* 
Nevertheless,  the  differential  diagnosis  of  insufficiency  of  the  aortic  valves 
is  of  very  great  importance  in  practice.  The  most  frequent  causes  of  sudden 
death  are  those  which  depend  upon  lesions  of  the  aortic  valves;  and  it  is 
likewise  a  fact  recognized  by  most  practitioners  that  these  are  the  very  lesions 
least  frequently  accompanied  by  that  assemblage  of  morbid  phenomena 
■which  constitute  the  general  symptoms  of  diseases  of  the  heart. 

Let  us  see  what  are  these  general  phenomena. 

Disturbance  of  the  functions  of  the  heart  must  necessarily  produce  decided 
effects  throughout  the  whole  circulatory  apparatus.  Appreciable  modifica- 
tions of  the  arterial  pulse,  of  the  state  of  the  veins  and  capillaries,  show 
that  the  circulation  is  embarrassed.  The  pulse,  irregular,  unequal,  and 
intermittent,  as  are  the  pulsations  of  the  heart,  is  generally  small ;  but 
when  there  is  considerable  hypertrophy  of  the  left  ventricle,  the  pulse  is 
also  hard  and  vibrating,  presenting  sometimes  a  peculiar  fremitus,  which 
is  most  distinct  in  the  carotid,  subclavian,  and  radial  arteries.  In  some 
cases,  the  arterial  pulsations  succeed  one  another  stroke  by  stroke,  and  this 
reduplication  of  the  pulse  is  coincident  -with  a  regurgitant  murmur  heard 
on  auscultating  the  heart.  The  insufficiency  of  the  aortic  valves  is  char- 
acterized by  a  bellows-murmur  at  the  base,  accompanying  the  second  sound 
of  the  heart,  and  by  a  bounding  pulse  with  flexuosity  of  the  radial  artery : 
this  last-named  sign  originally  pointed  out  by  Selle,  and  very  specially 
insisted  upon  by  Corrigan,  is  of  great  diagnostic  value  in  this  affection. 

Marey's  sphygmograph  gives  a  good  representation  of  the  peculiar  char- 
acteristics of  the  pulse  in  aortic  valvular  insufficiency.  You  are  aware  that 
this  ingenious  instrument,  by  means  of  a  pen  attached  to  the  arm  of  a  lever 
resting  by  one  end  on  an  artery,  each  pulsation  of  which  raises  it  up, 
delineates  the  arterial  pulsations  upon  a  strip  of  paper  which  goes  on 
'unrolling.  Well  then !  Corrigan's  special  bounding  of  the  pulse,  which 
strikes  the  finger  smartly  like  a  trigger,  is  expressed  on  the  slip  of  paper 
of  the  sphygmograph  by  an  ascending  vertical  line  terminating  in  a  sharp 
point  or  in  a  sort  of  hook,  after  which  comes  an  oblique  descending  line 
more  or  less  flexuous  in  the  middle.  The  entire  tracing  consists  in  a  series 
of  vertical  and  oblique  lines  joined  by  the  point  or  hook.  The  height  of 
the  vertical  line  is  in  proportion  to  the  force  of  the  arterial  diastole. 

But  in  the  pulse  of  contraction  of  the  aortic  orifice,  the  ascending  line  of 
the  tracing,  corresponding  to  the  arterial  diastole,  is  not  vertical,  but 
oblique  ;  and  the  descending  line  is  oblique  in  an  inverse  direction,  and 
flexuous.  The  ascending  line  never  attains  that  height  which  it  reaches  in 
the  pulse  of  aortic  valvular  insufficiency. 

Iu  insufficiency  of  the  mitral  valve,  the  pulse  is  almost  always  irregular, 

*  Professor  Bouillaud,  in  his  "  Traite  Clinique  des  Maladies  du  Coeur  "  (2d 
edition,  vol.  ii,  p.  362),  says  :  "  Do  distinctive  signs  exist  by  which  we  can  ascertain 
the  precise  seat  of  contraction  in  one  or  other  of  the  cavities  of  the  heart?  The 
solution  of  this  problem,  which  is  essentially  more  curious  than  useful  {qui  est  au 
fond  plus  curieux  qu'uiile),  shall  now  engage  our  attention  for  a  few  minutes." 


702  ORGANIC  AFFECTIONS  OF  THE  HEART. 

and  of  an  irregularity  which  is  absolute,  and  in  no  respect  typical ;  that  is 
to  say,  it  is  not  represented  in  any  uniform  manner  upon  the  sphygmo- 
graphic  tracing.  The  pulse  has  less  volume  :  and  so  feeble  are  some  beats 
that  it  is  almost  impossible  to  appreciate  them  by  the  finger.  On  the  trac- 
ing, the  arterial  diastole  is  figured  by  yertical  lines  of  unecpjal  height,  and 
the  systole  by  oblique  tremulous  lines  of  the  most  irregular  form. 

In  contraction  of  the  mitral  orifice,  the  pulse  is  regular,  and  the  sphygmo- 
graphic  tracing  greatly  approximates  to  the  normal.  In  the  cases  in  which 
there  is  a  presystolic  bellows-murmur,  the  nature  of  the  lesion  may  be  diag- 
nosed by  the  negatiye  characters  of  the  pulse.* 

When  disease  of  the  heart  has  reached  a  pretty  advanced  stage,  the 
existing  impediment  to  the  yenous  circulation  is  indicated  by  swelling  of 
the  veins  near  the  heart — those  for  example  of  the  neck  and  face  ;  and  this 
turgescence  is  particularly  obvious  in  the  external  jugular  veins,  where  it 
is  sometimes  accompanied  by  undulatory  pulsations,  analogous  to  and  syn- 
chronous with  the  aiterial  pulse.  This  is  the  "  venous  pulse ,"  which  Lan- 
cisi  (who  seems  to  have  been  the  first  to  observe)  gave  as  the  sign  of  hyper- 
trophy of  the  right  ventricle.  It  is  caused  by  reflux  into  the  veins  of  a 
certain  portion  of  the  sanguineous  tide  which  the  right  auricle  has  been 
unable  to  send  into  the  ventricle :  it  is  thus  caused,  whether  there  be  con- 
traction of  the  auriculo-ventricular  orifice,  whether  there  be  insufficiency  of 
the  tricuspid  valve  permitting  the  blood  in  the  ventricle  partly  to  regurgi- 
tate into  the  auricle,  or  finally,  whether,  by  reason  of  the  obstacles  which 
the  blood  encounters  in  passing  from  the  right  into  the  left  cavities,  the 
ventricle  is  uuable  to  empty  itself  completely. 

In  addition  to  the  embarrassment  of  the  venous,  there  is  embarrassment 
of  the  capillary  circulation,  which  declares  itself  by  a  livid  tint  of  the  skin, 
swelling  of  the  face,  puffiness  of  the  eyelids,  a  bluish  color  of  the  lips,  and 
more  or  less  injection  of  the  skin  of  the  extremities. 

The  morbid  functional  phenomena  which  occur  are  dependent  upon  dis- 
turbance in  the  capillary  circulation.  The  embarrassed  respiration,  ar  first 
consisting  in  some  breathlessness  after  rather  violent  exercise,  such  a< 
walking  more  rapidly  than  usual,  increases  in  proportion  as  the  affection 
of  the  heart  makes  progress,  and  at  last  reaches  a  high  degree  of  dyspnoea  : 
the  disturbance  of  the  cerebral  function-',  which  supervenes  in  the  last  stage 
of  the  disease — the  sanguineous  congestion  which  occurs  in  the  principal 
viscera,  the  lungs,  liver,  spleen,  and  encephalon,  and  which  sometimes  pro- 
ceeds to  the  extent  of  hemorrhage  I  pneumohemorrhage,  for  example,  a  fre- 
quent complication  of  heart  diseases  ,  or  induces  structural  changes  such 
a-  cirrhosis  of  the  livert — and  finally,  dropsical  affections  such  as  oedema  of 
the  extremities,  ana-area,  effusion  into  the  serous  cavities  :  all  these  phenom- 
ena are  chiefly  consequences  of  mechanical  obstruction  of  the  circulation. 

I  say  chit-fly  the  result  of  mechanical  obstruction,  because  mechanical 
obstruction  is  not  sufficient  of  itself  to  explain  the  production  of  the  morbid 
phenomena  of  which  I  am  now  speaking.  So  true  i-  this,  that  we  BOme- 
times  see  individuals  rapidly  Buccumb  after  having  presented  all  the  general 
and  rational  symptoms  of  cardiac  disease,  and  yet  in  whom  it  was  never 
possible  during  life  to  recognize  well-marked  local  signs  of  such  an  affec- 
tion, and  in  the  post-mortem  examination  of  whose  bodies  there  were 
not  found  any  lesions  of  the  heart  sufficient  to  explain  either  the. symptoms 
observed  or  the  death;  ami  we  likewise  Bee  persons  presenting  all  the  phys- 

M\kky's  work  entitled:  '« Physiologic    Biedicale  de   la   Circulation   du 
Sang."     Paris,  " 

f  See  a  subsequent  lecture  on  Cirrhosis. 


ORGANIC    AFFECTIONS    OF    THE    HEART.  703 

Leal  signs  of  a  disease  of  the  heart  live  for  a  long  time  without  appearing 
to  experience  any  notable  derangement  in  their  health. 

If  we  only  take  into  account  the  anatomical  lesion,  an  organic  affection 
of  the  heart  is  in  reality  not  a  disease.  Should  any  one  be  astonished  at 
this  assertion,  let  me  ask  him  if  he  would  regard  as  a  disease,  slow  progres- 
sive asphyxia  induced  by  passing  a  noose  round  a  man's  neck  and  daily 
tightening  the  cord  to  so  slight  an  extent  that  it  would  take  two  years  to 
cause  death?  Organic  affections  of  the  heart,  however,  are  always,  or 
nearly  always,  more  than  a  simple  mechanical  obstruction  to  the  central 
circulation  :  the  localized  morbid  affection,  which  has  occasioned  the  forma- 
tion of  the  material  obstacles,  is  also  to  a  great  extent  the  cause  of  all  the 
organic  and  functional  disorders  which  arise. 

This,  truly  the  most  medical  point  of  view  from  which  to  consider  dis- 
eases of  the  heart,  is  that  adopted  by  many  clinical  physicians :  it  has 
recently  been  admirably  expressed  by  Dr.  Mauriac  in  his  excellent  thesis, 
from  which,  with  your  permission,  I  shall  read  some  passages.* 

"When,"  says  Dr.  Mauriac,  "we  have  to  estimate  in  a  general  manner 
the  causes  of  death  in  persons  affected  with  diseases  of  the  heart,  it  is  indis- 
pensable, if  one  wishes  fully  to  grasp  the  problem,  and  to  look  at  the  ques- 
tion in  a  manner  at  once  philosophical  and  medical,  to  examine  in  the  first 
place  the  share  which  certain  diatheses  have  in  the  production  of  the  sec- 
ondary phenomena  of  these  diseases,  when,  after  a  period  of  longer  or  shorter 
duration,  they  throw  the  economy  into  a  peculiar  state  of  cachexia,  which 
is  conventionally  designated  cardiac  cacJiexia.  It  is  known  that  this  special 
cachexia  is  the  source  of  profound  modifications  in  the  crasis  of  the  humors ; 
and  that  the  two  principal  phenomena  are  an  asthenic  condition  of  the  cir- 
culation in  all  the  splanchnic  viscera,  whence  result  passive  congestions  of 
these  organs,  and  an  abnormal  exhalation  of  serosity  into  the  cellular  tis- 
sue and  serous  cavities.  These  signs  of  general  disturbance  of  the  system 
show  themselves  sometimes  at  so  early  a  period,  at  a  period  so  close  to  the 
first  manifestation  of  the  local  symptoms  of  heart  disease,  that  it  becomes  a 
question  whether  the  disease,  regarded  as  a  whole,  is  primarily  local  or 
general.  Where  does  it  begin  ?  Is  its  origin  in  the  heart  alone  ?  Is  it 
from  the  heart  that  there  comes  that  morbid  impulse  the  evolution  of  which 
will  soon  involve  the  entire  economy  ?  Or  must  we  seek  for  its  origin  in 
all  parts  of  the  circulatory  system  ?  Or  again,  is  the  entire  circulatory 
apparatus  simultaneously  affected  ;  and  is  it  not  the  heart  which  is  chiefly 
affected,  because  in  its  central  action  is  comprised,  so  to  speak,  all  the  forces 
which  put  in  motion  that  fluid  which  pervades  and  nourishes  all  our  tis- 
sues ?  These  are  great  questions  in  general  pathology  to  which  it  is  not 
easy  to  reply. 

"  It  is  now  an  accepted  scientific  fact,  verified  by  every  day's  experience, 
and  placed  beyond  dispute  by  the  beautiful  researches  of  Dr.  Bouillaud, 
that  there  is  a  primary  diathesic  cause  for  nearly  all  diseases  of  the  heart. 
It  matters  little,  whether  this  general  morbid  state,  which  concentrates  its 
energy  on  the  organs,  of  circulation  is  purely  inflammatory  or  essentially 
rheumatic  or  gouty  ;  but  it  is  important  to  remember  that  every  diathesis 
causes  every  molecule  to  live  a  life  specially  morbid,  and  consequently  ex- 
ercises upon  the  entire  econefmy  a  profoundly  debilitating  influence.  If 
every  diathesis  weakens  the  force  of  the  organism  by  modifying  the  physio- 
logical performance  of  elementary  nutrition,  may  not  the  various  diatheses 
which  originate  diseases  of  the  heart  do  this  much  more  certainly  by  attack- 

*  Mauriac:  Essai  sur  Les  Maladies  du  Cceur.  De  la  Mort  Subite  dans  l'lnsuffi- 
sance  des  Valvules  Sigmoides  de  l'Aorte.   [These  de  Paris,  I860.] 


704  ORGANIC    AFFECTIONS    OF    THE    HEART. 

ing  the  apparatus  which  conveys  to  all  parts  of  the  body  the  fluid  whence 
assimilation  derives  the  materials  by  which  the  tissues  are  nourished? 
Herein  lies,  does  it  not,  the  primary  cause  of  that  general  morbid  deteriora- 
tion of  which  we  have  to  take  account  ? 

"  This  is  not  all :  the  pathological  processes  peculiar  to  each  diathesis, 
and  from  which  it  derives  its  characteristic  physiognomy,  disorganize  the 
cardiac  tissue,  and  so  begins  a  series  of  secondary  phenomena,  which  have 
been  too  exclusively  ascribed  to  the  existence  of  impediments  to  the  circu- 
lation of  the  blood  in  the  cavities  of  the  heart.  Some  pathologists  have 
even  gone  further  than  this  in  localizing  the  causes  of  the  morbid  phe- 
nomena ;  they  have  ascribed  these  impediments  to  the  circulation  solely  to 
the  material  obstacles  situated  at  the  orifices.  The  lesions  of  the  orifices — 
contractions  or  inadequacies — only  express  one  of  the  phases  of  the  patho- 
logical changes  of  which  the  heart  is  the  theatre :  the  danger  which  they 
occasion  is  only  relative." 

Dr.  Mauriac  supports  these  propositions  by  cases,  such  as  I  have  just  been 
pointing  out  to  you,  of  persons  who,  though  they  have  the  physical  signs  of 
aj^parently  serious  disease  of  the  heart,  live  for  a  very  long  time,  and  more- 
over without  presenting  the  symptoms  of  general  disturbance  of  the  economy 
apparently  imminent  from  the  certainty  that  there  existed  an  obstacle  to 
the  passage  of  the  blood  through  the  heart.     He  then  thus  continues  : 

"  The  doctrine  regarding  diseases  of  the  heart  which  is  exclusively  based 
upon  considerations  referring  to  material  obstacles  to  the  passage  of  the 
blood  does  not  solve  every  difficulty  nor  remove  every  doubt.  The  attrac- 
tiveness of  the  doctrine  arises  from  its  simplifying  the  phenomena  by  making 
them  subordinate  to  a  mechanical  cause  which  the  mind  can  appreciate 
much  better  than  a  vital  or  diathesic  cause.  But  the  operations  of  nature 
are  essentially  complex :  a  pathological  phenomenon  which  at  first  sight 
seems  to  be  simplicity  itself,  implies  a  change,  permanent  or  temporary,  in 
so  many  elements,  or  an  exaltation  of  so  many  organic  functions,  that  there 
is  a  great  risk  of  only  seeiug  one  side  of  the  truth,  and  leaving  the  others 
in  the  shade,  if  we  found  a  theory  solely  on  one  class  of  phenomena." 

In  reality,  a  practical  fact  is  dominant  in  the  pathology  of  the  heart : 
the  diseases  of  this  organ  are  those  which  most  deceive  the  physician  at  the 
bedside  of  the  patient :  their  diagnosis  is  simple,  but  it  is  quite  otherwise  in 
respect  of  their  prognosis.  The  course  of  the  disease,  and  its  possible  com- 
plications, are  subordinate  to  very  many  circumstances,  some  of  which — 
such  as  the  intercurrent  affections — are  recognizable,  but  the  majority  of 
which  elude  recognition. 

Speaking  in  a  general  way,  it  may  be  said,  that  a  predisposition  to  pul- 
monary affections,  that  an  exaggerated  susceptibility  of  the  nervous  system, 
place  those  suffering  from  diseases  of  the  heart  in  an  untoward  position  in 
consequence  of  the  manner  in  which  pulmonary  and  nervous  affections  react 
on  the  central  organ  of  the  circulation.  The  former  tend  to  occasion  stasis 
of  the  blood  in  the  right  side  of  the  heart,  and  consecutively  in  the  entire 
venous  and  capillary  system,  thereby  leading  to  passive  congestions  and 
serous  effusions:  the  second  are  direct  causes  of  functional  disorders  which 
greatly  complicate  the  organic  disease.     But  leaving  generalities,  I  ask: 

who   can   explain    why  a  particular   individual,  with    the   exception   of  the 

morbid  conditions  of  which  I  have;  been  speaking,  may  go  on  tor  a  Long 
time  without  experiencing  much  derangement  of  health  notwithstanding  an 
extensive  cardiac  Lesion,  while  another  person  sinks  rapidly  under  anor- 
ganic  disease   of  the    heart,  the    local  symptoms   of  which    were    much  less 

serious,  their  seat  in  other  respects  being  the  same?  I  make  this  latter  dis- 
tinction, because,  as  I  have  already  said,  the  insufficiency  of  the  sigmoid 


ORGANIC    AFFECTIONS    OF    THE    HEART.  705 

valves  of  tlic  aorta  is  of  all  cardiac  organic  affections  the  most  serious,  as 
well  as  one  of  the  most  frequent  causes  of  sudden  death/although  it  is  the 
least  frequently  attended  by  general  symptoms  during  life. 

Gentlemen,  let  us  now  resume  consideration  of  the  cases  at  present  under 
our  observation:  let  us  return  to  the  patient  occupying  bed  34  in  St.  Ber- 
nard's Ward. 

This  woman  was  admitted  four  or  five  months  ago,  suffering  from  exten- 
sive  ana-area.  Besides  infiltration  of  the  cellular  tissue  of  the  lower  ex- 
tremities, and  purfiness  of  the  face,  she  had  pulmonary  oedema,  which,  on 
auscultation,  was  found  to  be  characterized  by  sibilant  and  subcrepitant 
rales,  heard  principally  at  the  base  of  the  lung.  So  greatly  was  respiration 
embarrassed,  that  death  from  asphyxia  seemed  likely  to  occur  within  forty- 
eight  hours.  The  affection  of  the  heart,  however,  judging  from  the  analysis 
of  the  symptoms  which  I  was  enabled  to  make  (though  with  difficulty  in 
consequence  of  the  greatly  embarrassed  state  of  the  respiration  and  circu- 
lation) was  not  more  serious  than  it  is  to-day.  It  was  not  the  first  occa- 
sion on  which  the  patient  had  had  symptoms  similar  to  those  which  I  was 
then  called  upon  to  relieve.  Under  the  circumstances,  all  that  I  could  do 
was  to  attack  the  general  dropsy,  under  the  impression  that  by  promoting 
the  evacuation  of  the  infiltrated  fluid,  by  freeing  the  blood  from  its  excess 
of  serum,  I  should  re-establish  the  equilibrium  of  the  circulation,  and  facili- 
tate the  working  of  the  pulmonary  apparatus. 

Drastic  purgatives — purgatives  which  quickly  produce  copious  serous 
evacuations,  and  have  for  that  reason  been  termed  hydragogues — best  fulfil 
this  urgent  indication.  I  therefore  gave  the  compound  tincture  of  jalap 
with  forty  grammes  of  hollauds.  Under  the  influence  of  the  first  brisk 
purging,  the  anasarca  was  sensibly  diminished  on  the  following  day.  At 
my  second  visit,  I  repeated  the  same  prescription,  and  obtained  from  it  a 
still  more  decided  effect.  The  hollands  was  administered  some  days  later 
in  the  same  manner:  before  two  weeks  had  elapsed,  the  dropsy  had  com- 
pletely disappeared,  and  there  was  no  longer  any  difficulty  in  breathing. 
I  was  then  enabled  to  verify  much  more  easily  than  I  could  at  the  date  of 
the  patient's  admission,  the  physical  and  local  signs  of  her  cardiac  affection. 

Under  the  influence  of  a  class  of  remedies  which  the  old  physicians  called 
panckymagogues,  that  is,  remedies  which  purge  offending  humors  from  the 
blood,  within  from  forty-eight  to  seventy-two  hours,  I  got  rid  of  the  exten- 
sive anasarca  which  had  occasioned  such  formidable  symptoms.  I  averted 
imminent  death,  which  was  the  sole  result  which  the  nature  of  the  case 
allowed  me  to  aspire  to  accomplish  ;  for  unfortunately,  I  could  do  nothing 
to  cure  the  organic  lesion,  the  basis  of  the  disease. 

Having  realized  this  terrible  fact,  I  went  on  giving  the  diuretic  wine  of 
the  Hotel-Dieu,  and,  after  a  time,  bitters. 

Of  all  the  hydragogue  remedies  which  I  have  ever  employed,  the  most 
powerful  is  that  known  as  the  "vin  diiiretique  del' Hotel-Dieu,"  the  formula 
for  preparing  which  I  devised,  and  which  is  as  follows : 


Take  of — 


"White  wine,         .....         750  grammes. 

Squill  bulbs, 5  " 

Juniper  berries,  .....  50  " 

Foxglove  leaves,  .         .         .         .  10  " 

Macerate  them  together  for  four  days. 


Then  add  of — 


Acetate  of  potash.       ....  15 

Filter. 


vol.  i. — 45 


706  ORGANIC    AFFECTIONS    OF    THE    HEART. 

This  wine,  which  I  have  employed  for  many  years,  and  which  has  been 
accepted  by  my  Colleagues  according  to  my  formula  which  I  have  now 
given  you,  is  generally  borne  well  by  patients:  to  it,  both  in  my  hospital 
and  private  practice,  I  owe  apparent  recoveries  from  affections  complicating 
diseases  of  the  heart — complications  for  the  relief  of  which  there  seemed 
nothing  to  be  done. 

Freed  from  danger  for  the  time  being,  the  patient  soon  found  herself 
sufficiently  well  to  ask  for  her  dismissal  from  the  Hotel-Dieu :  the  only 
discomfort  which  remained  was  some  shortness  of  breath,  an  inevitable  con- 
sequence of  her  disease  of  the  heart.  In  about  six  weeks,  she  came  back  in 
a  condition  exactly  similar  to  that  in  which  she  was  when  first  received  into 
the  hospital. 

This  relapse  alarmed  me  all  the  more  that  I  too  well  knew  that  such 
complications  are  liable  to  return,  and  must  ultimately  be  beyond  the  re- 
sources of  art :  a  time  will  come,  when — if  I  may  so  express  myself — the 
cup  being  already  full  to  the  brim,  a  single  drop  will  cause  it  to  overflow ; 
in  short,  I  knew  that  this  woman  was  doomed  within  a  short  period  to  sink 
under  her  disease,  and  that  she  would  probably  be  carried  off  by  the  symp- 
toms which  affected  the  general  economy.  The  success  of  my  treatment 
had,  however,  been  so  conspicuous  on  the  first  occasion  as  to  constrain  me 
to  resort  to  it  a  second  time.  I  again  employed  the  same  means  ;  and  on 
the  third  day,  the  anasarca  had  again  disappeared,  and  the  breathlessuess 
had  again  ceased.  The  patient  asked  for  food,  and  complained  that  she 
had  too  little  to  eat ;  but  from  the  occurrence  of  a  new  complication  I  was 
prevented  from  satisfying  her  appetite. 

The  diarrhoea  produced  by  the  tincture  of  jalap  and  diuretic  wine  con- 
tinued. That,  however,  did  not  give  me  any  anxiety,  as  I  thought  that 
the  flux  which  I  had  produced  with  a  view  to  remove  the  dropsy  would 
also  prevent  its  return.  The  event  was  not  in  accordance  with  these  antici- 
pations, for  although  the  diarrhoea  continued,  the  anasarca  steadily  in- 
creased, till  it  was  as  great  as  when  the  patient  came  into  hospital.  It  was 
no  longer  possible  to  recur  to  the  treatment  which  had  been  so  marvellously 
successful  on  two  previous  occasions,  for  the  administration  of  drastic-  and 
diuretics  would  have  necessarily  increased  the  irritation  of  the  digestive 
canal,  and  augmented  the  disorders  of  the  nutritive  function  upon  which 
evidently  depended  the  third  appearance  of  the  dropsical  symptoms. 
Clearly,  the  first  indication  was  to  modify  the  pathological  state  of  the  in- 
testinal canal :  that  indication  having  been  fulfilled,  there  would  be  ground 
to  hope  that  the  dropsy  might  be  advantageously  dealt  with  by  acting  on 
the  kidneys  or  skin,  the  secretion  from  which  organs  might  come  in  the 
place  of  that  from  the  intestinal  canal. 

Subnitrate  of  bismuth  and  prepared  chalk  were  firs!  given  separately, 
ami  then  in  conjunction,  but  without  any  beneficial  result.  Nitrate  of 
silver  given  by  itself  to  the  extent  of  10  centigrammes  in  the  course  of  the 
day,  in  10  pills,  and  the  nitrate  of  silver  in  combination  with  opium,  suc- 
ceeded no  hotter.  The  diarrhoea,  in  place  of  becoming  less,  became  more 
profuse.  I  then  employed  hydrargyrum  cum  en  In  (mercury  killed  in 
chalk)  a  preparation  taken  from  the  English  Pharmacopoeia,  where  it  is 
called  "gray  powder:"  while,  like  calomel,  this  preparation  is  a  purgative, 
it  is  also,  like  it,  when  administered  in  a  particular  manner,  an  excellent 
alterative,  a  modifier  of  the  state  of  the  intestinal  canal,  very  useful  in 
certain  kinds  of  diarrhoea.  The  patient  took  ten  centigrammes  (about  two 
grain-i  of  gray  powder  on  the  firsl  day;  and  from  thai  day  the  intestinal 
flux  moderated.  Next  day,  I  added  three  drops  of  laudanum  to  mj  pre- 
scription, ordering  them  to  he  taken   immediately  after  the  gray  powder. 


ORGANIC    AFFECTIONS    OF    THE    HEART.  707 

Under  the  influence  of  this  medication,  the  number  of  stools  in  the  twenty- 
four  hours  decreased  from  seven  or  eighl  to  two. 

This  beneficial  result  was  obtained,  but  the  dropsy  continued:  as  it  was 
no  longer  possible  to  excite  the  intestinal,  I  calculated  on  the  renal  secre- 
tion. As,  however,  the  substances  which  act  on  the  kidneys  are  apt  to 
irritate  the  intestines,  I  was  afraid  that  if  I  administered  them  internally, 
I  might  overturn  the  therapeutic  platform  which  had  cost  me  so  nruch 
trouble  to  erect.  I  consequently  resolved  to  apply  diuretics  externally,  a 
practice  of  which  I  have  had  experience  during  the  last  twenty  years,  and 
which,  during  that  period,  has  often  rendered  me  signal  services. 

I  cause  a  strong  decoction  to  be  made  of  squill  bulbs  and  digitalis  leaves: 
or,  I  take  from  100  to  150  grammes  of  squills  and  the  same  quantity  of 
the  tincture  of  digitalis  and  mix  them  with  two-thirds  of  water.  Flannels 
soaked  in  this  mixture  are  applied  to  the  abdomen  and  thighs  of  the  patient, 
and  the  flannels  are  covered  up  by  a  large  wrapper  of  oiled  silk.  By  per- 
sisting in  the  use  of  this  measure,  a  very  abundant  supply  of  urine  is  often 
obtained.  This  is  what  you  saw  in  our  patient :  in  her,  too,  the  diuresis 
led  to  resolution  of  the  dropsy.  Having  a  third  time  got  quit  of  her  symp- 
toms, she  felt  herself  sufficiently  well  to  leave  the  hospital. 

You  see  therefore  that  in  this  woman,  the  diarrhoea  which  I  brought  on 
for  the  purpose  of  getting  rid  of  serious  symptoms  involving  danger  to  life, 
became  in  turn  a  cause  of  exactly  similar  symptoms,  and  that  I  had  con- 
sequently to  contend  against  it.  In  another  woman,  whom  you  have  like- 
wise seen  in  our  clinical  wards,  suppression  of  the  usual  intestinal  flux  was 
the  cause  of  death. 

This  patient,  like  the  first,  came  into  our  wards  with  an  affection  of  the 
heart  characterized  by  palpitation  of  the  heart,  with  irregular  frequency 
and  inequality  in  the  arterial  pulse.  On  auscultation,  I  heard,  at  the  apex 
of  the  heart,  a  sawing  murmur  accompanying  the  first  sound,  continuing 
during  the  short  interval  between  the  two  sounds,  and  prolonged  till  the 
second  sound.  I  diagnosed  contraction  with  inadequacy  of  the  mitral 
valve,  and  hypertrophy  of  the  heart.  The  precordial  dulness  on  percus- 
sion extended  beyond  its  normal  limits. 

The  patient  told  me  that  for  more  than  two  years  she  had  never  been 
without  diarrhoea ;  but  she  added,  that  she  never  was  so  well  as  when  she 
had  abundant  diarrhoeal  evacuations.  Not  paying  much  attention  to  this 
specialty,  and  not  placing  implicit  confidence  in  the  woman's  statements, 
I  endeavored  to  moderate  the  intestinal  flux.  My  attempt  was  successful; 
but  I  bitterly  regretted  having  made  it,  for  great  disturbance  of  the  circu- 
lation soon  supervened,  and  three  days  after  the  cure  of  her  diarrhoea,  this 
poor  woman  died. 

I  am  convinced  that  the  profuse  secretion  from  the  intestinal  surface  was 
a  discharge  which  protected  the  patient  from  the  congestions  and  dropsies 
which  usually  accompany  cardiac  affections.  As  soon  as  I  perceived  the 
untoward  symptoms  occasioned  by  my  inopportune  medical  intervention, 
I  tried  to  restore  the  critical  evacuation  which  I  had  imprudently  checked  : 
my  attempts  were  unavailing.  The  case  of  the  other  patient  of  whom  I 
have  just  been  speaking  would  tend  to  show,  that  artificial  critical  evacua- 
tions are  very  far  from  being  satisfactory  substitutes  for  the  evacuations 
which  arise  spontaneously. 

I  have  gone  into  these  details  to  show  you,  how  difficult  it  is  to  lay  down 
general  rules  of  treatment :  to  show  that  that  which  suits  some  cases  is  un- 
successful in  others — that  therapeutic  measures  of  benefit  in  given  circum- 
stances may  fail  subsequently  even  in  the  same  subject — and  that  we  must 
often  seek  to  attain  the  same  object  by  different  means. 

Gentlemen,  I  have  already  told  you  that  affections  of  the  heart  expose 


708  OROANIC    AFFECTIONS    OF    THE    HEART. 

phy.-icians  to  the  risk  of  making  many  mistakes — in  this  sense,  that  there 
is  nothing  so  difficult  as  to  form  a  prognosis  of  even  approximate  certainty 
as  to  their  ulterior  progress.  I  now  add,  that  although  it  is  generally  easy, 
from  the  perfection  which  in  our  day  has  been  attained  in  auscultation  and 
percussion,  to  ascertain  the  existence  of  heart  diseases,  their  diagnosis  still 
sometimes  presents  great  difficulties.  This  may  arise  from  the  structural 
changes  not  manifesting  themselves  during  the  life  of  the  patients  by  the 
physical  phenomena  which  generally  characterize  them,  as  is  proved  by 
cases  reported  by  Stokes  of  Dublin.  And  sometimes,  as  has  been  remarked 
by  Dr.  Beau,  the  examination  of  the  dead  body  confutes  our  too  precise 
diagnosis  of  a  cardiac  affection. 

Of  this  I  only  wish  to  lay  before  you  two  examples.  Let  me  speak  in  the 
first  place  of  a  man  in  whose  case  I  showed  the  morbid  anatomical  parts  in 
this  theatre.  The  patient"  was  suffering  from  hypertrophy  of  the  heart  of 
old  standing,  and  I  thought  that  there  also  existed  insufficiency  of  the 
mitral  valve  with  contraction  of  the  auriculo-ventricular  opening.  He  had 
also  had  slight  haemoptysis.  Some  of  the  sputa  were  tinged  with  blood : 
others  were  black  and  viscid,  while  others  again  were  frothy  and  bright  red. 
Finally,  great  general  anasarca  and  ascites  were  added  to  the  already  seri- 
ous complications.  The  patient  died  three  days  after  his  arrival  in  our 
wards. 

On  opening  the  body,  I  found  that  there  was  a  notable  increase  in  the 
volume  of  the  heart.  This  hypertrophy  involved  the  left  ventricle,  which 
was  also  dilated.  I  detected  nothing  abnormal  in  respect  of  the  orifices, 
except  slight  thickening  of  the  mitral  valve,  both  segments  of  which,  how- 
ever, seemed  to  play  perfectly  well,  there  being  neither  valvular  insufficiency, 
nor  any  appreciable  contraction  of  the  auriculo-ventricular  opening.  One 
of  the  sigmoid  valves  of  the  aorta  was  ossified  at  its  base,  but  it  nevertheless 
adequately  performed  its  office.  There  was,  therefore,  neither  valvular 
insufficiency  at,  nor  contraction  of,  the  aortic  orifice.  The  aorta  was  some- 
what dilated,  and  its  walls  presented  incrustations  similar  to  those  upon  the 
sigmoid  valve. 

The  reasons  which  influenced  mejn  forming  my  diagnosis — insufficiency 
of  the  mitral  valves  and  contraction  of  the  auriculo-ventricular  opening — 
seemed  to  me  to  be  the  natural  inferences  from  the  signs  and  symptoms 
now  stated. 

When,  as  in  our  patient,  there  is  only  hypertrophy  of  the  heart  with 
dilatation,  and  no  serious  lesion  of  the  mitral  or  tricuspid  valves,  the  circu- 
lation generally  remains  regular. 

So  it  is  also,  when  the  sigmoid  valves  of  the  aorta  are  insufficient,  a  con- 
dition which  is  indicated  by  the  bellows-murmur  accompanying  the  second 
sound  of  the  heart,  heard  at  the  base  of  the  heart,  prolonged  through  the 
arch  of  the  aorta;  by  a  remarkable  vibratory  character  in  the  radial  pulse; 
also,  by  greater  force  and  fulness  in  the  beat  of  the  large  arteries,  such  as 
the  carotid,  humeral,  and  femoral. 

The  absence  in  our  patient  of  the  physical  signs  which  characterize  insuf- 
ficiency in  the  aortic  valves,  although,  in  spite  of  the  absence  of  bellows- 
murmurs,  I  detected  all  the  phenomena  which  indicate  lesions  of  the  auriculo- 
ventricular  orifices,  viz.,  very  greal  irregularity  in  the  pulsations,  also  g(  neial 

ana-area,  and  a  pulse,  which  besides  being  intermittent,  was  bo  exceedingly 
feeble  as  to  make  it  impossible  to  count  the  number  of  the  beats.  By  all 
these  siirns,  I  was  led  to  my  diagnosis. 

Tic  autopsy  proved  my  diagnosis  to  have  been  wrong;  ami  showed  that 
the  symptoms  observed  during  life,  thai  the  excessive  disturbance  of  the 
circulation    entirely  depended   on  what    Dr.  Beau   has  called  "aaystok 


ORGANIC    AFFECTIONS    OF    THE    HEART.  709 

want  of  contractile  power.  I  had  certainly  attributed  to  this  asystolie  the 
absence  of  the  bellows-murmur  characteristic  of  lesion  of  the  auriculo- 
ventricular  orifice ;  but  I  believed  that  it  did  not  proceed  from  impaired 
muscular  contractility  of  the  heart,  but  from  resistance  to  this  contractility 
by  an  obstacle  situated  at  the  orifices.  I  based  my  opinion,  I  repeat,  upon 
the  presence  of  phenomena  which  I  have  described  to  you,  and  which  are 
seldom  associated  with  mere  increase  in  the  volume  of  the  heart. 

There  can  be  no  doubt  that  I  committed  an  error  in  my  diagnosis;  but  I 
question  whether  it  was  an  error  which  it  would  have  been  easy  to  have 
avoided.  I  confess  that  were  a  similar  case  to  occur  to  me,  I  should  be 
equally  embarrassed,  and  should  probably  fall  into  the  same  error.  In 
reality,  the  matter  is  not  of  much  importance  in  a  practical  point  of  view: 
and  here  let  me  repeat  a  remark  which  I  have  already  made,  that  the  exact 
seat  of  a  cardiac  lesion  is  a  study  more  interesting  than  useful. 

Apart  from  the  reasons  which  I  have  mentioned,  the  occurrence  of  pul- 
monary apoplexy  in  our  patient  was  an  additional  reason  for  believing  that 
there  was  a  lesion  at  the  auriculo-ventricular  opening,  because  it  is  in  cases 
in  which  such  lesions  exist  that  pulmonary  hemorrhage  most  commonly 
supervenes. 

The  attack  of  pulmonary  apoplexy  was  slight.  At  the  autopsy,  we  only 
found  a  very  small  clot,  about  the  size  of  a  jrigeon's  egg,  situated  at  the 
posterior  part  of  the  left  lung.  This  accounted  for  its  presence  not  having 
been  revealed  during  life  by  auscultation,  and  explained  why  we  had  only 
heard  some  mucous  subcrepitant  rales  unaccompanied  by  bellows-murmur 
or  dulness. 

The  patient  had  had  albuminuria ;  and  his  kidneys  presented  all  the 
characters  of  congestion.  In  this  there  was  nothing  extraordinary;  for,  as 
as  you  are  aware,  there  is  nothing  more  common  than  albuminuria  in  the 
last  stage  of  disease  of  the  heart.  I  say  albuminuria  and  not  Bright"  s  dis- 
ease, which  is  a  very  different  affection.  Albuminuria  is  an  expressive 
symptom  met  with  in  a  great  many  diseases,  such,  for  example,  as  typhoid 
fever,  small-pox,  scarlatina,  and  diphtheria — a  symptom  which  may  be 
transitory,  and  relate  either  to  a  temporary  state  of  the  kidneys  or  of  the 
blood.  Bright's  disease,  again,  in  which  albuminuria  is  the  predominant, 
or,  if  I  may  so  speak,  the  specific  symptom,  is  characterized  by  a  structural 
change,  irremediable  and  more  or  less  profound,  in  the  kidney.  The  pres- 
ence of  albumen  in  the  urine  of  individuals  affected  with  diseases  of  the 
heart  probably  depends  upon  passive  hypersemic  congestion,  on  engorge- 
ment, on  hypostasis,  which  may  take  place  quite  as  readily  in  the  kidneys 
as  in  any  other  viscus,  their  vascular  tension  allowing  transudation  of  the 
most  liquid  part  of  the  blood,  or,  in  other  words,  of  the  serum.  There 
takes  place  in  the  urinary  apparatus  something  analogous  to  that  which 
takes  place  in  other  organs,  in  the  cellular  tissue,  in  the  serous  cavities  in 
particular,  where  under  the  influence  of  the  impediment  to  the  venous  cir- 
culation, we  see  passive  congestions  occurring,  which  give  rise  to  dropsies. 

The  second  example  which  I  wish  to  bring  before  you  is  the  case  of  a 
woman  who  was  received  into  the  hospital  with  all  the  local  and  general 
symptoms  of  an  affection  of  the  heart.  There  existed  an  abnormal  amount 
of  dulness  in  the  precordial  region  ;  and  a  bellows-murmur,  having  its  max- 
imum intensity  at  the  apex  of  the  heart,  was  heard,  instead  of  the  click  of 
the  valves.  The  pulsations  of  the  heart  were  unequal  in  force,  and  the 
pulse  was  so  quick  that  it  could  not  be  counted.  There  existed  greatly 
embarrassed  breathing  and  oedema  of  the  extremities.  The  geueral  symp- 
toms yielded  to  the  treatment  which  I  adopted  ;  but  the  serious  character 
of  the  local  phenomena  continued,  excepting  that  there  was  a  diminution 


710  ORGANIC    AFFECTIONS    OF    THE    HEART. 

in  the  rapidity  of  the  pulse.  The  diagnosis  which  I  had  ordered  to  be 
inserted  in  the  descriptive  paper  on  the  bed  [la  feuille  d' observation]  was — 
"  valvular  insufficiency,  contraction  of  the  auriculo-ventricular  opening,  and 
hypertrophy  of  the  heart."  This  was  also  the  diagnosis  of  those  who  were 
in  the  habit  of  following  nie  in  my  hospital  visit,  and  who  had  on  many 
occasions,  at  intervals  of  some  days,  attentively  examined  the  patient,  as  I 
had  also  done.  I  had  no  idea  that  I  was  mistaken  ;  when,  upon  one  occa- 
sion (after  having  for  some  time  discontinued  to  auscultate  the  heart),  I  was 
surprised  not  to  find  the  bellows-murmur,  previously  so  manifest.  For  eight 
days  there  was  no  return  of  this  murmur,  and  the  sound  of  the  valvular 
click  was  only  a  little  duller  than  in  the  normal  state.  There  was,  more- 
over, no  return  of  the  general  symptoms. 

I  certainly  could  not  pretend  to  have  cured  the  cardiac  affection :  I  was 
well  aware  that  when  lesions  of  this  kind  attain  a  certain  point,  they  do 
not  improve :  their  remaining  stationary  is  the  most  favorable  result  which 
can  occur.  To  a  certain  extent,  therefore,  I  was  mistaken  :  the  bellows- 
murmur  accompanying  both  sounds  of  the  heart  very  evidently  indicated 
a  morbid  condition  at  the  auriculo-ventricular  orifice,  an  obstacle  to  the 
free  play  of  the  valves,  which  only  imperfectly  closed  the  opening,  while, 
at  the  same  time,  there  was  a  diminution  in  the  calibre  of  the  opening. 
There  existed  a  permanent  cardiac  lesion,  which  was  apparently  a  certain 
amount  of  thickening  of  the  valves.  There  had  been  a  temporary  lesion, 
probably  constituted  by  the  vegetations,  the  presence  of  which  upon  the 
surface  of  the  valves  has  been  pointed  out  by  Laennec,  Professor  Bouillaud, 
and  others. 

Gentlemen,  there  can  be  no  doubt  that  it  is  impossible  absolutely  to 
diagnose  such  lesions,  but  we  may  have  good  grounds  for  suspecting  their 
existence.  It  is  my  opinion,  therefore,  that  in  our  patient  fibrinous  con- 
cretions existed,  which  under  the  influence  of  a  condition,  probably  inflam- 
matory, were  deposited  upon  the  already  diseased  valves,  concretions  such 
as  are  deposited — to  use  Dr.  Bouillaud's  happy  comparison — upon  the 
rods  with  which  blood  is  whipped  to  separate  its  fibrin.  These  concretions 
interfered  with  the  play  of  the  membranous  valves  to  which  they  adhered, 
and  also  narrowed  the  calibre  of  the  auriculo-ventricular  orifice,  causing 
the  bellows-murmur  which  we  heard.  The  disappearance  and  non-repro- 
duction of  the  bellows-murmur  must  be  ascribed  to  the  opening  being  ren- 
dered free  by  removal  of  the  partial  obstruction,  its  gradual  solution,  and 
no  new  fibrinous  deposit  having  taken  place.  I  am  unable  otherwise  to 
explain  the  production  and  cessation  of  the  physical  phenomena  observed  : 
but  I  admit  that  very  serious  objections  may  be  urged  against  the  validity 
of  this  explanation. 

This  is  no  doubt  an  exceptional  case  ;  but  it  is  not  unique  in  the  annals 
of  science.  Such  of  you  as  have  attended  my  clinic  for  some  time  musl 
have  seen  patients  presenting  all  the  local  and  general  symptoms  of  a  very 
advanced  cardiac  disease — great  anxiety,  extreme  depression,  purple  face, 
rapid  and  irregular  pulsi — recover  from  these  symptoms,  which  admitted 
of  no  other  explanation  than  a  temporary  obstacle  to  the  circulation  caused 
by  polypiform  concretions. 

trrespective  of  symptoms  resulting  from  the  disturbance  of  the  circula- 
tion through  the   cardiac   cavities,  there  arc    others    of  a  still  more  serious 

character  which  are  generally  consequences  of  fibrinous  concretions  in  the 
heart  or  vessels :  I  refer  to  the  symptoms  caused  by  embolia. 

The  term  embolium,  as  you  are  aware,  signifies  a  foreign  body,  which, 
formed  in  the  heart,  the  arterial  system,  or  the  venous   system,  i-  launched 

into  the  torrent  of  the  circulation,  and  obliterates  more  or  less  completely 


ORGANIC    AFFECTIONS    OF    THE    HEART.  711 

the  vessel  in  which  it  becomes  impacted.  The  migration  of  clots  in  the 
vascular  system  is  a  feet  to  which  attention  was  first  called  by  Legroux, 
or  at  all  events,  lie  was  the  first  to  describe  their  migration  in  the  arterial 
system.     More  recently,  and  particularly  since  the  researches  of  Professor 

Virchow,  the  subject  has  been  studied  anew,  and  in  a  more  complete  man- 
ner. 

Embolia,  according  to  the  importance  of  the  vessels  which  they  obstruct, 
may  occasion  more  or  less  serious  symptoms.  Suppose,  for  example,  that  a 
fragment  detached  from  the  polypiform  concretions  of  which  I  have  just 
been  speaking,  be  impelled  through  the  aorta  into  the  main  artery  of  a 
limb,  that  it  be  there  arrested  in  its  progress,  forming  a  plug  by  which 
an  obstacle  is  presented  to  the  passage  of  the  blood,  gangrene  of  the  limb 
will  be  the  consequence.  The  gangrene  will  be  analogous  to  that  very  in- 
appropriately called  senile  gangrene,  which  is  also  the  result  of  arterial  oblit- 
eration. Suppose  again,  that  the  embolium  stops  the  circulation  in  one  of 
the  principal  arteries  of  the  brain,  you  can  readily  understand  that  the 
consequences  will  be  much  more  serious,  and  may  even  prove  rapidly  fatal. 

Some  years  ago,  a  young  married  lady  whom  I  was  at  the  time  seeing  in 
consultation  with  my  friend  Dr.  Voillemier  felt  uncomfortable  sensations 
in  the  region  of  the  heart,  and  was  afterwards  suddenly  seized  with  painful 
tingling  in  the  fingers.  The  fingers  had  a  bluish  color,  and  very  soon  pre- 
sented all  the  appearances  of  a  dry  gangrenous  affection :  fortunately,  the 
gangrene  was  limited  to  one  of  the  last  phalanges,  which  the  patient  lost. 
Eighteen  months  later,  this  lady  was  suddenly  struck  with  complete 
paralysis  of  one  side  of  the  body,  and  subsequently  sunk  with  all  the  symp- 
toms of  softening  of  the  brain.  The  age  of  the  patient  made  it  improbable 
that  she  had  had  an  attack  of  simple  apoplexy ;  the  suddenness  of  the 
paralytic  seizure,  and  the  nature  of  the  symptoms  which  had  eighteen 
months  previously  shown  themselves  in  the  hand,  led  me  to  the  conclusion 
that  on  both  occasions  something  similar  had  occurred.  On  the  first  occa- 
sion, an  embolium  having  obliterated  an  artery  of  the  hand,  caused  partial 
paralysis  of  the  finger  ;  and  on  the  second  occasion,  an  embolium  penetrated 
the  arteries  of  the  brain  and  produced  softening — a  sort  of  cerebral  gan- 
grene, of  which  hemiplegia  was  the  characteristic  manifestation. 

Nearly  at  the  same  time,  a  friend,  quite  a  young  man,  was  carried  off  by 
an  attack  of  paralysis,  which  supervened  under  circumstances  similar  to 
those  now  described :  the  hemiplegia  with  which  he  was  suddenly  seized 
came  on  abruptly  in  the  course  of  an  attack  of  rheumatism  of  the  heart. 

Two  years  previously,  one  of  my  colleagues  was  sent  for  to  Bourges,  to 
see  a  patient  who  had  rheumatic  endopericarditis :  and  in  whom  had  sud- 
denly supervened  gangrene  of  the  great  toe  accompanied  by  coldness  and 
purpling  of  the  integuments.  After  death,  which  was  not  long  in  occurring, 
the  popliteal  artery  was  found  completely  obliterated  by  a  clot. 

Similar  facts  have  been  recorded  in  different  medical  repertories.  Dr. 
Worms  has  reported  a  case  of  acute  endocarditis,  followed  by  gangrene  of 
the  left  leg  caused  by  an  embolium  which  had  obliterated  the  trunk  of  the 
tibio-fibular  artery.  The  patient  was  a  soldier,  29  years  of  age.  The  gan- 
grene was  complete,  and  involved  the  loss  of  the  limb  in  which  it  occurred. 
The  two  lower  thirds  of  the  leg  separated  almost  without  any  interference  ; 
and  six  months  after  that  occurrence  M.  Follin  was  obliged  to  give  shape 
to  the  stump  by  an  operation. 

Judging  from  what  takes  place  in  limbs  attacked  by  gangrene,  we  may 

*  Virchow  :  Uber  die  Verstopfung  der  Lungenartcrie.  [Froriep's  Neue  Notizen, 
1846.] 


712  ORGANIC    AFFECTIONS    OF    THE    HEART. 

conclude  that  the  apoplectic  attacks  of  which  I  have  been  speaking  may 
originate  in  a  similar  mechanism.  As  the  anastomosing  arteries  of  the 
brain  are  so  numerous  and  so  large  that  the  common  carotid,  and  even  both 
carotids,  may  be  tied  without  occasioning  either  death  or  cerebral  lesion,  it 
is  possible  that  in  cases  of  embolism  the  apoplectic  phenomena  are  the  result, 
not  merely  of  vascular  obliteration,  but  of  a  more  direct  action  of  the  clot 
upon  the  cerebral  substance. 

Be  that  as  it  may,  the  disturbance  of  the  cerebral  functions  is  subordi- 
nate to  its  cause.  Let  me  explain  :  if  an  embolium  is  only  large  enough  to 
obstruct  partially  the  vessel  in  which  it  is  impacted,  if  it  be  of  so  slight  a 
consistence  as  to  admit  of  being  disintegrated  and  dissolved,  the  obstacle 
which  it  presented  to  the  current  of  the  blood  disappearing,  the  brain  will 
resume  its  functions ;  but  if,  on  the  contrary,  the  embolium  is  large  enough 
completely  to  plug  the  vessel,  of  a  sufficiently  resisting  consistence  not  to 
break  up  and  dissolve,  there  will  ensue  a  real  gangrene  of  the  brain,  and 
the  cerebral  softening  may  lead  to  death. 

You  must  remember  a  woman  of  47  years  of  age  whom  we  had  in  bed  4 
of  St.  Bernard's  Ward.  She  came  into  the  hospital  to  be  treated  for  disease 
of  the  heart ;  and  my  diagnosis  was — contraction  of  the  auriculo-ventricular 
orifice  with  inadequacy  of  the  valves.  I  also  found  that  there  existed 
ascites  and  anasarca.  The  state  of  liver,  which  extended  beyond  the  false 
ribs  and  seemed  to  be  increased  in  volume,  led  me  to  believe  that  there  was 
incipient  cirrhosis. 

After  some  time,  the  condition  of  this  woman  had  improved  :  the  anasarca 
had  disappeared,  and  the  ascites  had  decreased  ;  when,  in  the  beginning  of 
December,  suddenly  she  felt  very  acute  pain  in  the  right  side  of  the  head, 
and  was  struck  with  hemiplegia  of  the  left  side  of  the  body.  She  retained 
consciousness  up  to  death,  which  occurred  ere  long.  My  diagnosis  was : 
softening  of  the  brain,  caused  probably  by  obliteration  of  an  artery. 

The  autopsy  was  made  on  the  following  day  at  my  request,  and  with  the 
greatest  possible  care  by  Dr.  Ludovic  Hirschfeld,  a  very  distinguished 
anatomist,  now  professor  of  anatomy  in  the  medical  university  of  Varsovia. 
The  middle  cerebral  artery,  which  presented  no  trace  of  ossification,  was 
completely  obliterated  by  a  clot  of  blood,  black,  homogeneous,  and  three 
centimetres  in  length:  the  branches  going  to  the  right  corpus  striatum, 
which  was  in  process  of  softening,  were  also  obliterated  in  the  same  way. 
All  the  other  arteries  were  free  from  obstruction. 

I  found  also  serious  lesions  at  both  auriculo-ventricular  orifices,  the  valves 
of  which  were  indurated,  adherent,  and  insufficient.  There  also  existed 
dilatation  with  hypertrophy  of  the  heart. 

The  cirrhosis  of  the  liver  which  I  had  diagnosed  certainly  existed  :  but 
the  disease  was  in  a  much  more  advanced  state  than  I  had  supposed. 
The  increased  volume  of  the  liver  was  only  apparent,  the  organ  being 
pushed  down  by  the  right  lung,  which  was  in  a  very  emphysematous  state. 

Bear  also  in  mind  the  case  of  die  recently  delivered  woman  who  occu- 
pied bed  20  in  the  same  ward.  The  attendants  attached  to  the  ward 
informed  us   that   on   the   evening   before   her  admission  to  the  hospital  she 

had  been  struck  by  paralysis  without  immediate  loss  of  consciousness:  she 

bad  been  able  to  say  :  "  Take  me  to  the  hospital  "—hut  on  the  day  on  which 
.1  saw  her,  she  could  nut   reply  to  any  of  my  <|Uestions.      I  found  that   there 

was  complete  hemiplegia  of  the  motor  power  of  the  right  side,  hut  do  dimi- 
nution of  natural  sentienl  power. 

The  pulse,  was  frequenl  and  irregular:  auscultation  of  the  heart  enabled 
one  to  near  a  bellows-murmur,  having  its  maximum  intensity  at  the  apex, 
.beyond  the  nipple.     This  murmur  was  harsh,  and  the  mitral  orifice  was  its 


ORGANIC    AFFECTIONS    OF    THE    HEART.  713 

probable  seat.  Connecting  those  two  facts — the  lesion  of  the  left  side  of 
the  heart  and  the  cerebral  apoplexy — recalling  to  mind  the  beaut  iul 
researches  of  Virchow  upon  the  migration  of  clots,  and  reasoning  from  the 
facility  with  which  sanguineous  coagula  form  in  recently  delivered  women, 
and  upon  the  rapidity  with  which  the  symptoms  were  developed  in  the 
case  now  under  consideration,  I  had  no  hesitation  in  concluding  that  1  had 
to  do  with  an  embolium  situated  in  the  middle  cerebral  artery  of  the  left 
side,  which  had  induced  softening  of  the  corresponding  parts  of  the  nervous 
centres.  The  patient,  without  having  had  any  inflammatory  reaction, 
without  regaining  consciousness,  and  without  showing  any  change  in  the 
state  of  the  paralyzed  side,  died  eight  days  after  her  admission  to  the 
hospital. 

The  autopsy  fully  confirmed  my  diagnosis.  A  portion  of  the  brain  in 
front  of  the  left  corpus  striatum  was  softened  :  on  the  same  side,  the  calibre 
of  the  middle  cerebral  artery,  in  the  situation  in  which  it  expands  into  a 
dense  vascular  network,  was  obliterated,  only,  however,  to  the  extent  of 
two  millimetres,  by  a  small  fibrinous  clot,  which  was  yellow,  resistant,  and 
did  not  adhere  to  the  parietes  of  the  vessel :  all  around  this  little  fibrinous 
clot  there  was  coagulated  blood,  which  on  the  one  side  became  lost  in  the 
anastomosing  plexus  of  the  middle  cerebi-al  artery,  and  which  on  the  other 
side  terminated  abruptly  at  the  origin  of  the  artery  of  Sylvius.  The  little 
central  clot  which  plugged  the  artery  was  like  a  millet-seed.  There  was 
no  lesion  of  the  walls  of  the  middle  cerebral  artery. 

At  the  bifurcation  of  the  left  common  carotid  artery,  there  was  a  small 
fibrinous  clot  which  also  was  of  the  size  of  a  millet-seed,  which  sent  three 
filiform  prolongations,  cruoric  and  fibrinous,  one  into  the  common  carotid, 
another  into  the  internal  carotid,  and  the  third  into  the  middle  thyroid. 

The  mitral  valve  w7as  the  seat  of  consjuicuous  lesions.  On  the  auricular 
surface  of  the  valve,  some  adherent  to  the  pericardium,  and  others  so  free 
as  to  be  almost  unattached,  were  warty-looking  clots  of  different  sizes. 
Gentlemen,  it  would  be  very  difficult  to  avoid  seeing  that  there  was  a  rela- 
tion of  cause  and  effect  between  the  mitral  lesion  and  the  fibrinous  clots 
found  in  certain  cerebral  arteries  and  the  accompanying  softening  of  the 
brain.  Observe  that  the  other  arteries  of  the  brain,  examined  with  care, 
presented  no  intravascular  coagulation,  and  that,  except  in  the  situation 
of  the  softening,  the  entire  brain  was  normal  in  color  and  consistence. 
Finally,  the  similarity  of  form  and  the  identity  of  structure  of  the  fibrinous 
concretions  of  the  mitral  valve  with  those  of  the  artery  of  Sylvius  consti- 
tuted an  additional  reason  in  favor  of  embolism. 

With  reference  to  the  softening  of  the  brain,  I  wish  to  remark  to  you, 
that  most  frequently  the  lesion  of  consistence  and  nutrition  is  seated  in  that 
portion  of  the  left  hemisphere  supplied  by  the  middle  cerebral  artery,  or 
artery  of  Sylvius.  I  am  not  going  to  attempt  to  explain  this  fact  to  you, 
for  were  I  to  do  so,  I  should  only  be  entering  upon  an  anatomical  discus- 
sion of  doubtful  value. 

I  would  merely,  in  relation  to  our  patient,  remind  you  that  my  colleague, 
Dr.  Broca,  in  his  interesting  memoir  on  aphemia,  or  the  loss  of  articulate 
speech,  has  localized  the  function  of  speech  in  the  posterior  part  of  the  third 
frontal  convolution  of  the  left  side.*  Let  me  also  remind  you  that  cerebral 
softening  is  most  frequent  on  the  left  side,  and  in  that  portion  of  the  brain 
which  is  supplied  with  blood  by  the  artery  of  Sylvius.  We  are  led  by  a 
consideration  of  these  facts  to  see  that  there  may  be  a  relationship  between 
an  embolium,  the  seat  of  cerebral  softening  on  the  left  side,  and  aphemia, 


Broca:  Bulletins  de  la  Societe  Anatomique.     1861. 


714  ORGANIC    AFFECTIONS    OF    THE    HEART. 

or  aphasia,  as  I  have  proposed  to  call  the  affection.     This  is  a  point  to 
which  I  propose  to  return  in  future  lectures.* 

To  revert  to  the  subject  more  immediately  before  us:  it  is  now  a  well- 
established  fact  that  migratory  clots  of  a  certain  volume  may,  when  lodged 
in  the  brain,  or  in  other  parts  of  the  body,  lead  to  softening  orto  gangrene : 
these  results  do  not  always  take  place  when  the  clots  are  so  small  as  to  be 
only  stopped  in  their  passage  through  the  capillaries.  The  consequent 
phenomena  mav  then  be  of  another  kind.  Capillary  embolia  seldom  cause 
partial,  very  circumscribed  gangrene,  but  often  give  rise  to  numerous  ecchy- 
motic  spots,  small  parenchymatous  abscesses,  and  secondary  deposits  of 
fibrin,  to  which  the  name  of  visceral  stuffing  or  iwfarctus  has  been  given.  The 
capillary  embolia  are  the  result  of  the  breaking  up  of  the  clots,  and  dis- 
integration of  the  fibrin  deposited  on  the  cardiac  valves  ;  or,  of  the  sponta- 
neous opening  of  atheromatous,  fibrinous,  or  purulent  cysts  of  the  arteries. 

There  are  some  cases  in  which  the  starting-point  of  embolia  is  uJeeroui 
endocarditis,  which  at  other  times  gives  rise  to  symptoms  of  general  poison- 
ing, leading  to  a  typhoid  state.  This  is  a  point  which  I  propose  afterwards 
to  develop  in  lectures  specially  devoted  to  the  subject.t  Here  I  will  only 
remark  that  Professor  Bouiliaud,  in  his  Traite  des  Maladies  du  Coeur, 
has  reported  a  case  of  gangrenous  endocarditis  with  ulceration  and  perfora- 
tion of  the  aortic  valves ;  but  both  Professor  Bouiliaud,  and  Dr.  Gigon  (of 
Angouleme)  who  quotes  the  case,  have  only  called  attention  to  the  morbid 
phenomena  of  endocarditis,  and  to  the  contraction  of  the  orifice  with  inade- 
quacy of  the  aortic  valves.  Subsequently,  Rokitansky,  Virchow,  Bamber- 
ger, and  Friedreich  in  Germany,  as  well  as  Charcot  and  Vulpiau  in  France,! 
showed  that  ulcerous  endocarditis  may  be  the  starting-point  of  capillary 
embolism ;  and  that  it  may  also,  by  introducing  morbid  elements  into  the 
current  of  the  circulation,  give  rise  to  symptoms  of  a  general  putrid  poison- 
ing of  the  system  so  closely  simulating,  as  to  be  liable  to  be  mistaken  for, 
the  symptoms  peculiar  to  typhoid  fever  and  severe  jaundice. 

Ulcerous  endocarditis  is  more  frequent  in  the  left  than  in  the  right  side 
of  the  heart:  such  at  least  is  the  conclusion  arrived  at  from  the  cases  eol- 
lected  by  Bouiliaud, Virchow,  Bamberger,  and  Friedreich:  Charcot  and 
Yulpian,  however,  have  published  a  case  in  which  the  valves  of  the  right 
side  of  the  heart  were  affected.  To  explain  the  symptoms  of  poisoning 
which  occurred  in  that  case,  it  is  necessary  to  admit  that  the  product-  of 
the  ulcerative  action  in  part  had  passed  through  the  capillary  vessels  of  the 
lung:  such  is  the  hypothesis  enunciated  by  Drs.  Charcot  and  Vulpiau. 
But  though  we  grant  that  the  blood  may  lie  poisoned  by  the  products  of 
ulceration,  it  is  not  necessary  to  assume  that  they  travel  over  the  whole 
vascular  Bystem  :  it  i~  sufficient  that  the  blood  in  the  right  side  of  the  heart 
come  in  contact  with  these  products,  to  be  changed    to  such  an  extent  a-  to 

cause  general  poisoning. 

Just  as  the  coincidence  of  an  organic  lesion  of  the  heart  with  apoplexy 
leads  us  to  infer  that  there  is  an  embolium  in  the  brain,  so  does  the  eoexist- 
ence  of  cardiac  symptoms  with  a  typhoid  condition,  not  depending  on  doth- 
inenteria,  justify  the  supposition  that  there  i-  ulcerous  endocarditis. 


*  Sep  the  lecture  on  Aphasia,  p.  218  of  the  First  Volume  ol  the  New  Sydenham 
(Society's  translation. 

f  Bee  the  lecture  i.ii  Ulcerous  Endocarditis. 

Pu- 


ON    VENESECTION    IN    CEREBRAL    HEMORRHAGE,    ETC.         715 

I  propose  to  study  with  you  the  subject  of  venous  embolism — very  common 
in  cachexic  conditions  and  in  the  puerperal  state — when  I  come  to  lecture 
on  phlegmasia  alba  <l<>/<ii*. 


LECTUKE   XXXIX. 

ON  VENESECTION  IN  CEREBRAL  HEMORRHAGE  AND  APOPLEXY. 

Apoplexy  is  not  to  be  confounded  with  Hemorrhage. —  Cerebral  Hemorrhage 
rarely  sets  in  with  Aptoplectiform  Phenomena,  properly  so  called. — Apo- 
plexy may  be  the  expression  of  various  grave  lesions  of  the  Encephalon. — 
Value  of  Facial  Hemiplegia  in  Hemorrhage. — Inutility  of  Venesection, 
of  Bloodletting  in  general,  of  Purgatives  and  Emetics  in  Hemorrhages 
and  Apoplexy. — Differential  Diagnosis  between  Softening  and  Hemor- 
rhage.—  Value  of  certain  signs  with  regard  to  Prognosis. 


Gentlemen:  The  patient  lying  in  hed  No.  7,  St.  Agnes  Ward,  affords 
me  the  opportunity  of  raising  a  question  of  the  highest  clinical  impor- 
tance, namely,  the  contraindication  of  bloodletting  in  cerebral  hemor- 
rhage, and  more  generally  in  apoplexy.  I  will  at  the  same  time  draw 
your  attention  to  the  semeiotic  value  of  facial  paralysis  when  it  occurs  in 
connection  with  a  lesion  of  the  opposite  hemisphere  of  the  brain,  and  not 
as  a  consequence  of  disease  exclusively  limited  to  one  of  the  facial  nerves. 
Lastly,  I  will  say  a  few  words  respecting  the  differential  diagnosis  between 
softening  of,  and  hemorrhage  into,  the  brain. 

The  patient  wThom  I  mentioned  just  now,  was  admitted  into  the  hos- 
pital for  a  chronic  pulmonary  catarrh,  which  had  not  caused  any  notable 
disturbance  of  his  general  health.  He  was  under  treatment  for  that  com- 
plaint, when  he  was  suddenly  seized  with  symptoms  which  caused  me  some 
anxiety,  although  he  did  not  himself  complain  of  them. 

Without  any  premonitory  headache  or  giddiness,  he  found  a  few  days 
ago  that  his  tongue  was  embarrassed,  and  that  his- speech  was  thick.  His 
intellect  was  not  in  the  least  affected,  his  sight  was  perfect,  his  activity  and 
his  muscular  strength  were  not  diminished  in  the  slightest  degree ;  for  his 
legs,  at  least,  carried  him,  and  moved  as  usual,  and  his  gait  was  not  vacil- 
lating. Having  had  occasion  to  write,  however,  he  noticed,  as  soon  as  he 
took  up  his  pen,  that  he  had  some  difficulty  in  using  it,  and  that  his  letters 
were  not  formed  so  well  as  usual.  These  symptoms  excited  so  little 
anxiety  in  him  that  he  complained  to  nobody,  and  that  at  my  visit,  on 
the  following  morning,  he  did  not  think  of  mentioning  them.  On  coming 
near  him,  I  was  struck,  however,  with  the  alteration  in  his  features ;  for 
there  was  evident  deviation  of  his  mouth.  I  questioned  him,  and  then 
heard  of  the  above-mentioned  symptoms,  which  he  had  noticed  on  the  pre- 
vious day.  You  heard  him  state  and  repeat  that  no  intellectual  disturb- 
ance, no  affection  of  the  senses,  preceded  of  accompanied  this  thickness  of 
speech,  of  which  he  was  perfectly  conscious,  and  the  awkwardness  with 
which  he  used  the  fingers  of  his  right  hand. 

You  could  study  the  character  of  the  deformity  of  his  face — how,  on  the 
left  side,  the  labial  commissure  was  markedly  pulled  upwards  and  out- 
wards, whilst  it  was  lower  on  the  right,  the  corresponding  cheek  being  at 


716  ON    VENESECTION    IN    CEREBRAL    HEMORRHAGE 

the  same  time  flattened  and  almost  motionless.  At  first,  you  might  have 
thought  that  there  was  also  deviation  of  the  tongue,  for  when  the  patient 
was  asked  to  protrude  it,  the  organ  seemed  to  incline  to  the  right  of  the 
middle  line;  but  this  deviation  was  only  apparent,  and  was  due  to  a  change 
in  the  normal  relations  of  the  tongue  to  the  aperture  of  the  mouth  from 
the  pulling  outwards  and  to  the  left  of  the  labial  commissure.  The 
paralysis  did  not  involve  the  face  alone,  for  beside  the  awkwardness  in 
writing  noticed  on  the  preceding  day,  there  was  weakness  of  the  whole 
upper  extremity  on  the  right  side,  and  he  added,  also,  that  he  had  had, 
that  very  morning,  tingling  sensations  in  the  tips  of  the  fingers  of  his  right 
hand,  which  had  lasted  a  minute  or  two.  The  sensibility  of  the  skin  was 
perfect  and  normal. 

Xow,  what  is  the  matter  with  this  man  ?  I  have  no  doubt  that  he  is 
suffering  from  the  effects  of  a  small  hemorrhage  into  the  left  hemisphere  of 
the  brain.  Yet  I  acknowledge  that,  at  first  sight,  the  diagnosis  offered 
some  difficulty,  for  the  case  might  have  been  thought  one  of  facial  paral- 
ysis only.  It  was  the  face  that  was  chiefly  affected,  and  the  power  of 
motion  of  the  lower  limb  was  perfect  according  to  the  patient,  who  averred 
that  he  noticed  no  difference  between  his  right  and  left  legs,  and  that  on 
both  sides  he  possessed  as  much  strength  as  before.  There  was,  indeed, 
undoubted  paralysis  of  the  right  arm,  but  very  slightly  marked,  involving 
limited  movements  only,  and  even  then,  it  was  on  having  occasion  to  write 
that  the  patient  noticed  the  deficiency  in  the  suppleness  of  his  fingers.  Xot 
so  with  the  paralysis  of  the  face ;  this  was  evident  to  all  bystanders,  more 
so  than  to  the  patient  himself,  who  was  so  unconscious  of  it  that  he  did 
not  complain  of  it.  In  this  paralysis  of  the  face,  however,  we  already 
possessed  an  element  of  great  value  for  making  the  diagnosis  of  Cerebral 
Hemorrhage,  which  I  wrote  on  the  card,  because  this  paralysis  of  the  facial 
muscles  was  not  so  complete  as  it  usually  is  when  it  depends  exclusively 
on  disease  of  the  seventh  cranial  nerve. 

In  facial  paralysis,  caused  by  a  lesion  of  one  hemisphere  of  the  brain, 
whether  attended  or  not  by  paralysis  of  the  limbs  on  the  same  side,  the 
patient  cannot  perform  with  ease  certain  movements  on  the  affected  side) 
such  as  the  act  of  blowing  or  getting  back  into  the  cavity  of  the  mouth 
food  which  has  lodged  between  the  cheek  and  teeth,  but  he  is  not  <mn- 
pletelv  incapable  of  performing  such  movements,  and  the  difficulty  he 
experiences  is  never  so  great  as  that  felt  by  individuals  suffering  from  pure 
facial  paralysis.  In  the  former  case,  also,  the  orbicularis  palpebrarum  is 
never  paralyzed  to  the  same  extent  as  in  the  latter  ;  hence,  if  a  heraiplegic 
patient  be  asked  to  shut  his  eye,  he  does  it  completely  enough  to  hide  the 
globe  of  the  eye,  whilst  the  eyeball  remains  uncovered  in  cases  of  paralysis 
of  the  seventh  pair. 

I  do  not  attempt  to  find  a  reason  for  this  difference;  1  merely  uote  it  as 
a  fact  taught  me,  long  ago,  by  experience,  and  the  importance  of  which,  in 
making  a  differential  diagnosis,  you  will  immediately  recognize.  Tim-,  in 
this  patient,  the  incompleteness  of  his  facial  palsy,  in  the  absence  even  of 
other  characteristic  phenomena  of  a  mure  extensive  hemiplegia,  sufficed  to 
lead  me  to  believe  that  the  paralysis  was  due  t<>  some  lesion  of  the  left 
hemisphere  of  the  brain,  and  nol  to  disease  of  the  portio  dura. 

But  this,  gentlemen,  is  not  the  most  essential  point  to  which  1  wished  to 
direct  your  attention.  The  patienl  had,  I  Bay,  cerebral  hemorrhage  to  a 
small  amount.  Observe  that  I  do  not  use  the  word  apoplexy,  and  pur- 
posely bo,  because  there  is  a  greal  difference  between  cerebral  hemorrhage 
and  apoplexy,  although  some  confound  them  -till,  in  Bpite  of  the  majority 
of  our  classical  authors  who  try  to  do  away  with  thi-  deplorable  confusion. 


AND    APOPLEXY.  717 

Now,  what  is  meant  by  apoplexy t  According  to  its  etymology,  it  means 
an  affection  in  which,  as  the  ancients  described  it,  an  individual  falls,  and 
is  struck  down  suddenly,  like  an  ox  felled  by  the  butcher.  "Apoplexia 
dieitur  adesse  quandb  repente*  <n-ti<>  quinque  sensuum  externorum,  turn  inter- 
norum,  omnesque  motua  voluntarii  aoolentur,  superstite  pitlsn  plerurnque  forti, 
et  respiratume  difficili,  magna,  stertente,  una  cum  imagine  profundi  per- 
petuiqut  somni."  And  if  to  this  short  sketch  of  apoplectiform  phenomena, 
given  by  Boerhaave,  you  add  the  definition  of  Paulus  Egineta,  that  this 
abolition  of  consciousness  and  of  the  sensibility  of  the  whole  body  is  caused 
by  an  affection  of  the  sensoriinn  commune  {communi  nervorum  prineipio 
affecto),  you  will  know  what  is  meant  by  apoplexy. 

You  understand  now  why  this  term  and  that  of  hemorrhage  should  not 
be  considered  as  synonymous.  On  the  one  hand,  apoplexy  is  a  generic  term 
which  must  be  specified,  because  apoplectiform  phenomena  are  often  con- 
nected with  pathological  conditions  very  different  from  hemorrhage.  Thus, 
they  may  be  the  result  of  cerebral  softening,  of  a  rapid  and  more  or  less 
considerable  accumulation  of  serosity  in  the  ventricles  and  in  the  cerebral 
meninges,  as  in  wdiat  is  called  serous  apoplexy ;  or  they  may  be  due  to  con- 
gestion carried  to  the  highest  point,  without  actual  extravasation  of  blood, 
as  in  what  is  termed  ictus  sanguinis  (but  in  the  next  lecture  I  will  show 
you  how  rare  such  cases  are)  ;  or  again,  apoplexy  may  be  produced,  as  the 
ancients  had  already  noted  it,  by  what  we  now  term  embolism.  Lastly,  it 
sometimes  occurs  independently  of  all  appreciable  lesion,  on  dissection,  in 
the  so-called  nervous  apoplexy.  On  the  other  hand,  cerebral  hemorrhage 
is  not  necessarily  accompanied  by  symptoms  of  apoplexy  ;  these  show 
themselves  only  when  the  hemorrhage  is  pretty  considerable.  Small 
hemorrhagic  clots  can  be  formed,  not  only  without  the  patient  presenting 
the  series  of  phenomena  constituting  apoplexy,  but  without  his  having  any 
impairment  of  intellect,  any  affection  of  the  senses  ;  in  fact,  without  any 
symptom  indicating  that  the  brain  has  been  deeply  modified  in  its  func- 
tions. The  only  symptoms  which  then  characterize  the  case  are  those  of 
paralysis,  more  or  less  complete,  and  more  or  less  limited  in  extent  on  the 
opposite  side  of  the  body. 

During  the  period  that  I  have  been  in  the  habit  of  delivering  clinical 
lectures  at  the  Hotel-Dieu  of  Paris,  I  have  only  seen  one  female  and  two 
male  patients  in  whom  cerebral  hemorrhage  seems  to  have  set  in  at  once 
with  apoplectiform  phenomena.  You  doubtless  remember  that  rag-collec- 
tor who  was  found  in  the  streets,  and  brought  to  the  hospital  in  the  most 
profound  stupor,  and  laid  in  bed  No.  5,  St.  Agnes  Ward.  He  died  on  the 
second  day  after  his  admission,  and  when  his  brain  was  placed  on  the  am- 
phitheatre table,  I  announced  to  you  that  we  should  find  an  effusion  into 
the  ventricles.  It  turned  out  that  the  blood  had  been  first  poured  out  in 
one  of  the  corpora  striata,  from  there  had  passed  into  the  lateral  ventricle 
of  the  same  side,  and  after  filling  it,  had  broken  down  the  septum  lucidum, 
and  got  into  the  other  lateral  ventricle. 

During  the  summer  of  1861  you  saw  in  the  St.  Bernard  Ward  also,  a 
woman,  aged  63,  who  had  had,  the  preceding  year,  a  so-called  paralytic 
stroke.  She  had  faltered  in  her  speech  all  of  a  sudden,  and  had  been 
seized  with  weakness  of  one  half  of  the  body.  There  was,  on  that  occasion, 
no  loss  of  consciousness,  no  giddiness  even.  This  time,  she  was  found  in 
her  bed  in  a  state  of  profound  coma.  She  died  without  having  been 
roused,  and,  as  in  the  last  case,  there  was  found,. in  addition  to  the  remains 
of  the  small  hemorrhage  of  the  previous  year,  an  enormous  clot,  beginning 
in  one  optic  thalamus,  and  distending  both  lateral  ventricles. 

Again,  you  may  still  recollect  that  young  man  lying  in  No  15  bed,  St. 


718  OX    VENESECTION    IN    CEREBRAL    HEMORRHAGE 

Ague?  Ward,  who,  whilst  presenting  all  the  symptoms  of  encephalitis,  was 
suddenly  seized  with  epileptiform  convulsions,  and  died  a  few  minutes  after- 
wards in  a  state  of  carus.  In  this  ease  there  was  hemorrhage  into  the  pons 
Varolii,  which  had  made  its  way  into  the  fourth  ventricle,  and  ruptured 
the  valve  of  Vieussens.  I  repeat,  gentlemen,  apoplexy  proper  is  very  rare 
in  cerebral  hemorrhage.  You  have  seen  at  Xo.  34,  in  the  St.  Bernard 
Ward,  a  very  intelligent  woman,  49  years  old,  who  relates  with  perfect 
clearness  her  sad  history.  She  was  enjoying  excellent  health,  when  she 
noticed,  one  morning  about  eight  o'clock,  an  impediment  in  her  speech,  and 
some  numbness  of  her  les:  and  arm.  Feeling  anxious  at  this,  she  walks 
down  stairs  from  the  third  floor,  and  goes  to  a  neighboring  chemist's  shop. 
She  there  takes  a  few  drops  of  ether,  and  returns  home  with  less  facility, 
feeling  the  numbness  rapidly  increasing.  On  reaching  the  bottom  of  her 
stairs,  she  is  unable  to  proceed  further,  tries  to  prevent  herself  from  falling 
by  resting  against  the  wall,  but  drops  down,  nevertheless,  without  losing 
consciousness,  or  even  feeling  in  the  least  giddy.  Her  neighbors  came  to 
her  help,  and  brought  her  to  the  Hotel-Dieu.  She  was  paralyzed  on  the 
right  side. 

You  have  not  forgotten,  either,  the  woman  lying  at  Xo.  10,  St.  Bernard 
Ward.  She  had  just  prepared  and  served  the  family  dinner,  at  four  o'clock 
in  the  afternoon.  She  was  eating  with  a  very  good  appetite  in  company 
of  her  husband  and  children,  without  any  headache  or  other  premonitory 
symptom  that  attracted  her  attention.  All  of  a  sudden  she  finds  that  she 
cannot  cut  her  bread  ;  she  says  so  to  her  husband,  but  with  a  thick  voice. 
She  tries  to  get  up,  and  falls  down  with  her  chair,  without  losing  conscious- 
ness or  having  felt  giddy.  As  she  is  raised  up  she  is  found  to  be  hemi- 
plegic,  and  on  her  admission  into  the  hospital  she  relates  herself  the  above 
details,  with  perfect  clearness,  and  even  with  a  certain  degree  of  cheerful- 
ness. 

I  insist  on  these  two  cases,  because  of  the  fall  of  both  patients,  the  one  on 
trying  to  get  up  from  her  chair,  the  other  on  reaching  the  foot  of  the  stairs. 
This  fall,  I  beg  you  to  observe,  differs  essentially  from  that  of  a  person 
struck  down  by  apoplexy,  but  is  analogous  to  the  fall  of  a  soldier  whose 
leg  i~  broken  by  a  ball;  inability  to  move  the  leg,  aud  its  extreme  weak- 
ness, being  the  essential  cause  in  both  cases.  The  intellect  is  nor  affected, 
as  it  is  in  the  apoplectic  attack  of  epilepsy  or  of  eclampsia.  In  the  latter 
case,  the  individual  drops  like  an  ox  knocked  down  by  the  butcher,  and 
the  phenomena  which  ensue  are  really  those  of  apoplexy,  such  as  described 
by  our  predecessors,  phenomena  which  are  observed  in  cases  of  cerebral 
hemorrhage  only  when  there  is  effusion  of  blood  into  the  ventricles,  or  the 
pons  Varolii,  or  to  an  enormous  amount  in  the  centrum  ovale  of  Vieussens, 
or  again,  into  the  arachnoid  sac. 

I  made  use,  just  now,  gentlemen,  of  a  very  restricted  form  of  expression, 
when  speaking  of  the  rag-collector  who  had  been  picked  up  in  the  streets  in 
a  state  of  apoplexy.  1  told  you  thai  the  cerebral  hemorrhage  seemed  to  have 
set  in  witli  apoplectic  symptoms,  as  if  I  had  some  reason  for  doubting  the 

accuracy  of  the  fad.  I  doubt  it,  indeed,  for  if  it  he  undeniable  thai  the 
man  was  picked  up  and  brought  to  the  H6tel-Dieu  in  a  state  of  apoplexy, 
and  that  the  old  woman  I  just  mentioned  was  found  one  morning  in  her 
bed  in  a  Btate  of  coma,  who  can  positively  affirm  thai  these  symptoms  of 

apoplexy  sel   in  all  of  a  sudden  ? 

In  the  spring  of  1863  I  was  asked  by  my  friend  Dr.  Marchal  (de  Calvi) 
to  see  a  man,  aged  '''•'>,  who  had  had  a  tit  thai  same  morning.  Whilst  at 
breakfast,  he  bad  suddenly  found  some  difficulty  in  holding  his  fork,  and 
had  tilt  slightly  giddy.     On  attempting  to  speak,  he  noticed  himself  that 


AND    APOPLEXY.  719 

his  speech  was  thick,  and  his  children  made  the  same  observation.     He 

staggered  as  he  rose,  felt  weaker  on  one  side  than  on  the  other,  but,  with 
the  help  of  his  son,  managed  to  walk  as  far  as  his  bedroom.  He  was  then 
undressed  and  put  to  bed,  he,  all  the  time,  understanding  perfectly  all  that 
was  being  done,  without  any  impairment  of  intellect,  nor  were  his  move- 
ments abolished.  The  hemiplegia  made  rapid  progress,  however,  and  be- 
came complete  within  half  an  hour.  The  intellect  got  gradually  more  and 
more  clouded,  and  when  Dr.  Marchal  arrived,  half  an  hour  or  three-quar- 
ters of  an  hour  after  the  setting  in  of  the  first  symptoms,  the  patient  was 
already  in  an  apoplectic  condition.  Things  went  on  from  bad  to  worse,  and 
when  I  came  myself  at  five  o'clock  in  the  evening,  the  apoplectic  stupor 
was  at  its  height.  In  spite  of  the  most  energetic  treatment,  the  patient  died 
in  the  night. 

About  the  same  date,  I  was  fetched  to  see  a  patient  of  Dr.  Revilloux,  a 
man  about  62  years  old,  who  noticed,  whilst  at  dinner,  that  one  of  his  hands 
felt  heavy  ;  he  was  not  giddy,  and  only  faltered  in  his  speech.  He  tried  to 
rise  from  his  chair,  but  one  of  his  legs  being  paralyzed,  he  fell  down,  with- 
out losing  consciousness,  however.  His  children  lifted  him  up,  and  with 
their  assistance  he  walked  as  far  as  the  next  room,  and  there  teat  on  a  chair. 
I  arrived  three-quarters  of  an  hour  after  the  manifestation  of  the  first  symp- 
toms. The  patient  retained,  or  seemed  at  least  to  retain,  all  his  intellect. 
He  answered  me  to  the  point,  although  his  tongue  was  very  much  affected ; 
and  his  left  arm  and  leg  were  almost  completely  paralyzed  of  motion.  Pro- 
found coma  set  in  a  few  hours  later,  and  death  occurred  the  following 
morning. 

Very  recently  again,  I  admitted  into  the  St.  Bernard  Ward  a  woman, 
aged  56,  who  had  formerly  been  subject  to  the  periodic  headaches  of  gout, 
and  who,  eight  months  previously,  had  been  seized  one  morning  with  the 
first  symptoms  of  cerebral  hemorrhage.  She  had  gone  out  marketing,  in  as 
good  health  as  ever  ;  on  returning  home  she  noticed  that  she  dragged  her 
right  leg,  and  that  her  right  arm  felt  heavy.  She  even  changed  to  her 
left  hand  a  folded  newspaper  which  she  was  carrying  home,  for  fear  of 
dropping  it  into  the  mud.  She  walked  upstairs  to  her  room,  undressed, 
and  got  into  bed.  To  questions  of  her  husband,  she  replied  in  a  faltering 
voice.  The  symptoms  growing  hourly  worse,  she  became  completely  hemi- 
plegic,  and  partially  unconscious  towards  evening.  About  twelve  hours 
after  the  setting  in  of  the  illness,  and  for  three  days,  she  remained  in  a 
state  of  profound  stupor.  This  case  is  interesting  from  other  points  of  view 
also,  and  I  shall  return  to  it  later ;  for,  contrary  to  what  usually  obtains, 
the  patient  regained  the  power  of  moving  her  arm  much  more  quickly  and 
more  completely  than  her  leg,  and  I  shall  tell  you  wdiat  is  the  value  of  this 
sign. 

But  to  return  to  my  proposition.  In  the  case  of  the  rag-collector  and 
that  of  the  old  woman  I  spoke  of  before,  who  knows  how  the  attack  set  in  ? 
who  knows  whether  for  half  an  hour,  an  hour,  and  even  more,  the  symp- 
toms had  not  run  the  same  slow  and  progressive  course  as  in  the  three 
cases  I  have  just  related  to  you  ?  Nay,  I  add  that  this  is  infinitely  proba- 
ble, if  not  absolutely  certain.  The  reason  why  I  speak  so  positively  is, 
because  for  more  than  fifteen  years  my  attention  has  been  directed  to  this 
point  in  the  history  of  cerebral  hemorrhage,  and  I  never  had  the  chance, 
never  once,  of  seeing  a  patient  struck  down  suddenly  by  apoplexy,  in  the 
classical  and  etymological  sense  of  the  word.  I  have  not  seen  a  single 
case  in  my  hospital  or  my  private  practice,  or  in  the  practice  of  my  pro- 
fessional brethren  who  have  done  me  the  honor  of  asking  me  to  meet  them 
iff  consultation.     I  have,  indeed,  seen  a  great  number  of  individuals  suffer- 


720  OX    VENESECTION    IN    CEREBRAL    HEMORRHAGE 

ing  from  cerebral  hemorrhage,  in  the  most  profound  apoplectic  stupor ; 
but  in  every  case,  without  exception,  when  the  attack  had  occurred  in  pres- 
ence of  witnesses,  it  had  come  on  gradually,  and  had  in  general  been  slight 
at  the  outset,  coma  supervening  ten  minutes,  half  an  hour,  an  hour,  or 
several  hours  afterwards  ;  but  in  no  single  instance,  I  repeat,  have  I  seen 
a  man  with  cerebral  hemorrhage  struck  down  as  by  a  blow,  and  drop- 
ping instantly  in  a  state  of  unconsciousness. 

Under  certain  circumstances  only  is  this  the  case,  and  I  hasten  to  make 
the  statement,  lest  my  views  should  be  deemed  exaggerated  or  singular. 
The  patient  in  No.  15  bed,  St.  Agnes  Ward,  who  died  of  hemorrhage  into 
the  pons  Varolii  and  tearing  of  the  valve  of  Vieussens,  became  suddenly 
comatose,  and  remained  so  until  his  death,  which  occurred  shortly  after. 
But  what  did  his  night  attendant  tell  us '?  The  patient,  you  remember, 
had  acute  encephalitis,  that  would  have  carried  him  off  a  few  days  later 
had  not  this  unforeseen  attack  occurred.  All  of  a  sudden  he  is  seized  with 
epileptiform  convulsions,  and  he  dies  a  few  minutes  afterwards,  without 
having  been  roused  from  the  most  profound  apoplectic  stupor.  Note  well, 
gentlemen,  that  to  the  ordinary  phenomena  of  hemorrhage  there  Avas  super- 
added, in  this  case,  an  attack  of  convulsions,  which  alone,  and  apart  from 
all  complications,  suffice  for  producing  apoplectic  stupor.  I  admit,  then, 
that  whenever  cerebral  hemorrhage  begins  with  an  epileptiform  attack, 
apoplectic  stupor  will  set  in  suddenly,  as  it  does  after  every  attack  of  epi- 
lepsy. I  will  add  further,  with  regard  to  this  case,  that  the  hemorrhage 
was  seated  in  the  pons  Varolii,  that  is,  in  a  point  where  all  the  nerve- 
fibres  converge.  When  hemorrhage  occurs  in  a  part  so  essential  to  life,  I 
understand  the  suddenness  of  apoplectiform  phenomena.  But  again,  I 
repeat,  apoplectic  stupor  is  a  very  exceptional  symptom  of  invasion  in  cases 
of  cerebral  hemorrhage,  unless  there  be  lesion  of  a  central  part,  or  an 
attack  of  convulsions. 

I  make  no  exception  even  in  favor  of  blood  effusion  into  the  lateral  ven- 
tricles. Before  this  happens  the  blood  has  accumulated  in  a  portion  of  the 
brain,  near  the  surface  of  the  ventricles,  and  has  already  given  rise  to 
symptoms  which  may  have  been  mistaken,  but  which  indicate,  to  the 
experienced  practitioner,  the  existence  of  hemorrhage,  or  of  a  morbid  pro- 
cess which  has  caused  capillary  hemorrhage.  Suppose,  for  example,  that 
such  a  morbid  process  takes  place  in  a  corpus  striatum,  and  that  in  conse- 
quence of  it  a  number  of  small  clots  have  formed,  varying  from  the  size  of 
a  small  pin's  head  to  that  of  a  small  lentil,  so  far  there  will  only  be  a  sensa- 
tion of  weight  in  tin-  head,  and  of  numbness  in  the  side  opposite  t<>  the 
lesion  ;  but  if,  all  of  a  sudden,  on  the  blood  finding  its  way  into  a  ventri- 
cle, the  person  falls  down,  struck  with  apoplexy,  the  symptoms  noticed 
before  the  occurrence  will  be  considered  a-  premonitory  only,  whilst  they 
were  iii  reality  symptoms  of  a  simple  or  multiple  hemorrhage,  dating  :i  few- 
days  back,  En  such  a  case  the  hemorrhage  is  supposed  t"  occur  only  when 
the  patient  becomes  apoplectic ;  whereas  the  blood  is  effused  into  the  cere- 
bral Bubstance  at  the  time  the  first  symptoms  manifested  themselves,  the 
subsequent  formidable  accidents  being  caused  by  the  Budden  irruption  of 
the  blood  into  the  ventricles. 

You  raw  what  happened    in    the  case  of  the   patient  who   forms   the  BUD- 

jed  of  this  Lecture.  lb-  had  do  warning  when  the  hemorrhage  began,  ami 
even  after  in  occurrence  there  was  nothing  Berious  enough  to  excite  his 
anxiety.  lie  had  only  some  impediment  in  his  speech,  some  difficulty  in 
writing,  which  alone  attracted  his  attention,  and  a  deviation  of  the  mouth, 
of  which  he  was  not  conscious  before  I  observed  it.  [f  the  suddenness  with 
which  the  symptoms  Bhowed  themselves,  and  their  truly  hemiplegic  char- 


AND    APOPLEXY.  721 

acter,  although  the  hemiplegia  was  limited  to  the  face  and  the  right  arm, 
led  us  to  infer  that  hemorrhage  had  taken  place  in  the  left  cerebral  hemi- 
sphere, the  slight  degree  of  impairment  of  motor  power  led  us  also  to 
believe  that  the  clot  was  very  small,  probably  of  the  size  of  a  lentil  or  a 
cherrystone.  Now,  such  hemorrhages  are  not,  by  themselves,  followed  by 
fatal  results,  although  they  sometimes,  it  is  true,  indicate  an  unpleasant 
Organic  predisposition  to  the  recurrence  of  similar  accidents.  By  this 
organic  predisposition  I  do  not  mean  softening  of  the  cerebral  substance, 
which  according  to  Rochoux,  necessarily  precedes  hemorrhage,  and  which 
he  accordingly  considers  as  paving  the  way  to  it,  and  terms  "hsemorrha- 
gipare,"  nor  those  changes  in  the  cerebral  vessels  to  which  Abercrombie 
attributed  the  greatest  share  in  the  production  of  hemorrhage.  Agreeing 
in  this  with  the  majority  of  medical  men,  I  believe  that  the  softening  of 
the  brain  which  accompanies  hemorrhage  is  an  effect,  and  not  a  cause.  Its 
importance,  however,  is  not  the  less  great,  for  much  more  frequently  than 
the  hemorrhage  itself,  the  sequential  acute  softening,  the  encephalitis,  is  the 
cause  of  grave  cerebral  accidents,  and  ultimately  of  the  patient's  death. 
As  to  the  changes  in  the  coats  of  the  cerebral  arteries,  such  as  yellow 
lamina?  of  cartilaginous  consistency,  mostly  impregnated  with  calcareous 
salts,  they  cannot  be  an  essential  condition  for  the  production  of  cerebral 
hemorrhages,  since  they  are  not  met  with  in  the  greater  number  of  cases, 
although  present  in  some,  as  I  have  shown  you  instances. 

To  return  to  our  patient  in  the  St.  Agnes  Ward,  the  symptoms  in  his 
case  were  so  mild,  that  we  were  authorized  to  suppose  the  cerebral  lesion  to 
be  unimportant,  and  to  hope  that  the  case  would  turn  out  favorably.  In- 
deed, the  man  leaves  the  hospital  to-day,  feeling  well  enough  to  resume  his 
usual  occupation. 

Perhaps  you  have  been  surprised  to  see  me  do  nothing  in  this  case;  and 
have  you  asked  yourselves  why,  when  so  many  others  would  have  hastened 
to  employ  active  treatment  and  had  recourse  to  bleeding,  either  local  or 
general,  or  both,  purgatives  and  revulsives,  I  simply  did  nothing?  Those 
who  have  seen  my  practice  for  some  length  of  time  have  been  less  surprised 
because  they  know  that  I  never  use  violent  remedies,  that  I  not  only  abstain 
from  all  energetic  treatment  when  the  symptoms  of  cerebral  hemorrhage 
are  as  slight  as  they  were  in  this  case,  but  that  I  even  refrain  from  doing  so 
in  very  grave  cases,  in  fact,  in  all  cases  of  apoplexy. 

My  reasons  are  these :  If  I  do  not  have  recourse  to  bloodletting,  purga- 
tives, or  revulsives  in  cerebral  hemorrhage,  whether  considerable  or  not,  it 
is  because  experience  has  taught  me  that  the  patients  do  better  without 
them.  For  when  I  reflect  on  what  happens  then,  I  do  not  see  how  those 
methods  of  treatment  can  be  of  any  use,  since  the  hemorrhage  is  an  accom- 
plished fact  when  we  are  called  upon  to  note  its  symptoms.  What  influ- 
ence, I  ask,  can  be  exerted  on  a  foreign  body  in  the  shape  of  extravasated 
blood,  by  letting  out  blood  from  a  vein  of  the  arm,  or  of  the  foot,  or  from 
the  jugular,  or  by  dividing  an  artery,  by  cupping,  or  leeches  ?  Of  what 
use  are  purgatives  or  revulsives?  It  is  said  that  bloodletting,  and  that  pur- 
gatives, a  kind  of  serous  bleeding,  empty  the  vessels,  and  thus  facilitate  ab- 
sorption of  the  extravasated  blood  ;  that  they  antagonize  the  cerebral  con- 
gestion, which,  according  to  the  practitioners  who  recommend  them,  pre- 
cedes, accompanies,  or  follows,  at  the  least,  the  extravasation  of  blood,  and 
by  thus  preventing  an  exaggerated  flow  of  liquid,  they  diminish  the  risks 
of  the  effusion  becoming  more  considerable  or  occurring  a  second  time. 

With  regard  to  the  first  point,  we  may  well  doubt  whether  any  difference 
obtains  between  cerebral  hemorrhages  and  other  hemorrhages,  and,  to  take 
a  very  simple  example,  whether  any  difference  exists  between  what  takes 
vol.  i. — 46 


722  ON    VENESECTION    IN    CEREBRAL    HEMORRHAGE 

place  in  cases  of  extravasation  of  blood  into  the  cerebral  substance  and  ex- 
travasation under  the  skin.  In  the  latter  case,  has  general  or  local  blood- 
letting ever  been  seen  to  facilitate  the  absorption  of  the  effused  blood  ?  Do 
not  most  surgeons  reject  leeches,  on  the  contrary,  as  being  injurious,  instead 
of  useful  ?  An  individual  receives  a  blow,  or  falls  on  his  head,  for  example, 
and  the  violent  contusion  produces  a  more  or  less  considerable  effusion  of 
blood  into  the  subcutaneous  cellular  tissue.  Any  medical  man  who  may 
be  sent  for,  will  never  think  of  prescribing  anything  more  than  cold  lotions 
on  the  affected  part,  or  using  slight  compression ;  and  he  does  so,  because 
he  knows  full  well  that  futher  interference  would,  to  say  the  least,  be  super- 
fluous. Xow,  can  we  act  more  powerfully  on  ecchymose-s  of  the  brain  than 
on  those  of  the  surface  of  the  body ?  Reasoning,  therefore,  agreeing  with 
experience,  pronounces  useless  the  treatment  against  which  I  raise  my  voice. 

As  to  the  second  point,  namely,  that  bloodletting  is  imperatively  required 
with  a  view  of  arresting  the  molimen  hemorrhagicum  which  caused  the 
first  symptoms,  and  might  cause  them  a  second  time,  it  is  indeed  very 
doubtful.  The  part  played  by  congestion  seems  to  me  to  have  been  very 
much  exaggerated,  and  although  a  great  many  practitioners  believe  gen- 
eral or  local  bloodletting  to  be  so  clearly  indicated  that  there  need  be  no 
hesitation  in  having  recourse  to  it,  I  do  not  think  that  the  necessity,  nay 
more,  the  usefulness  of  the  measure,  has  been  clearly  proved. 

Do  we  know  well  the  organic  conditions  under  the  influence  of  which 
cerebral  hemorrhage  is  produced?  That  congestion  sometimes  accom- 
panies it,  is  a  fact  generally  accepted  ;  but  is  not  this  an  effect  rather  than 
the  cause  of  the  extravasation  of  blood '?  What  influence  then  can  blood- 
letting exert  on  this  secpiential  hyperemia,  when  it  has  none  on  the  foreign 
body  formed  by  the  effused  blood,  which  is  the  starting-point  of  the  deter- 
mination of  blood  ?  Furthermore,  far  from  being  useful,  bloodletting  has 
seemed  hurtful  to  me,  and  I  believe  that  it  favors  instead  of  preventing 
congestion.  In  the  next  lecture  I  purpose  studying  apoplectiform  cerebral 
congestion,  and  I  shall  then  tell  you  how  I  understand  what  occurs  in 
apoplexy,  and  I  shall  speak  of  what  I  term  cerebral  surprise.  I  hope  to 
be  able  to  show  you  that  apoplectic  phenomena  are  in  some  measure  more 
allied  to  syncope  than  to  congestion,  and  that  bleeding  is  therefore  contra- 
indicated,  not  demanded.  This  is  what  experience  has  taught  me.  and  has 
taught  others  who  follow  in  their  practice  the  same  rules  as  I  do. 

What  treatment  then  do  I  adopt  in  eases  of  cerebral  hemorrhage,  and 
more  generally  in  apoplexy?  Instead  of  bleeding  my  patients,  of  putting 
them  on  low  diet,  and  keeping  them  in  bed,  I  do  not  draw  blood  from 
them,  I  recommend  to  them  to  get  up  if  possible,  at  least  to  remain  in 
the  sitting  posture,  and  I  feed  them.  I  am  convinced  that  I  thus  obtain 
much  more  favorable  results  than  when  I  interfered  more  actively,  and 
that  patients  bo  treated  do  a  great  deal  better  than  those  whom  I  bled  in 
former  days,  kept  on  low  diet,  and  confined  to  their  beds. 

I  reject  bloodletting  from  the  treatment  of  cerebral  hemorrhage,  al- 
though I  think,  that  very  plausible  reasons  are  urged  by  those  who  act 
differently  from  me.  1  did  myself  for  a  long  time  what  most  practition- 
ers -till  continue  to  do  now,  and  I  used  to  think  my  plan  very  rational.  I 
may  add  that,  in  spite  of  ourselves,  we  feel  the  influence  of  fashion,  how- 
ever sad  the  confession  maybe,  i  began  practicing  medicine  at  a  time 
when  the  doctrines  of  Broussais  were  in  all  their  glory;  and  although  I 

had  been  a  pupil   of  liretoiineau,  who  had  dealt    the  heaviesl    blows  to  the 

doctrines  of  the  illustrious  physician  of  the  Vale  de  Grace,  I  fell  not  the 

less  the  powerful  influence   of  those  doctrines,  and    I   was    induced    to    piv- 

scribe  leeches  in  cases  where  I  never  think  of  doing  so  now,  merely  because 


AND    APOPLEXY.  723 

everybody  « 1  i <  1  it,  and  because  no  amount  of  self-confidence  can  make  one 
believe  he  is  right  when  he  is  in  opposition  to  everybody  else.  I  bled, 
therefore,  in  cerebral  hemorrhage,  because  bleeding  was  used  before  and 
arotiud  me.  Now  that  I  have  reached  an  advanced  age  and  that  I 
occupy  a  position  which  allows  me  freely  to  follow  my  inspirations,  1  .-(ill 
understand  how  a  young  practitioner  has  neither  courage  nor  self-con- 
fidence enough  to  reject  a  mode  of  treatment  which  has  been  in  some 
measure  sanctioned  by  the  experience  of  several  generations  of  medical 
men. 

But  there  is  another  circumstance  which  renders  non-interference  still 
more  difficult — I  mean,  the  febrile  action,  which  rarely  fails  in  hemorrhages 
of  u  certain  amount.  This  febrile  action,  on  which  classical  authors  lay 
too  little  stress,  usually  commences  from  twrenty  to  twenty-four  hours  after 
the  outset  of  the  attack,  and  reaches  its  maximum  on  the  second  or  third 
day.  The  pulse  becomes  hard  and  frequent,  the  skin  hot  and  often  bathed 
in  perspiration,  the  face  flushed,  respiration  labored.  I  confess  that  I  have 
been  induced  to  bleed  under  those  circumstances  when  I  had  refused  to  do 
so  in  the  beginning  ;  but  I  must  confess  also  that  the  bleeding  has  never 
seemed  of  any  use  to  me;  that  it  has  often  been  manifestly  injurious,  and 
that  if  I  had  the  courage  to  resist  the  seemingly  pressing  indication,  the 
fever  ceased,  and  the  patient  regained  his  strength  with  a  much  greater 
rapidity  than  if  bloodletting  had  been  had  recourse  to.  In  such  cases,  I 
still  better  understand  how  difficult  it  is  for  a  young  practitioner  not  to 
yield  to  the  apparent  urgency  and  to  the  entreaties  of  the  friends  who  ask 
"for  bleeding,  as  well  as  the  advice  of  brother  practitioners  who  regard  it 
as  necessary.  And  as  in  a  certain  number  of  cases,  this  fever  lighted  up 
on  the  second  and  third  day,  and  the  cause  of  which  I  cannot  well  explain, 
only  ushers  in  formidable  brain  symptoms  which  become  rapidly  fatal,  I 
understand  that  antiphlogistics  may  be  thought  of,  although  they  prove 
useless,  alas  !  when  the  disease  runs  the  course  I  just  mentioned.  To  save 
your  responsibility  in  such  cases,  avoiding  at  the  same  time  what  your  con- 
science forbids,  open  a  vein,  but  in  such  a  way  as  only  to  draw  an  insig- 
nificant quantity  of  blood  and  explain  to  the  friends  that  it  would  be  dan- 
gerous to  go  further.  In  many  cases  there  will  be  real  danger  in  doing  so, 
for  some  persons  have  been  seized  with  fearful  symptoms  even  after  a 
moderate  bleeding.  A  short  time  ago,  a  gentleman,  a  former  pupil  of  mine, 
was  sent  for  to  a  magistrate  who  had  just  been  struck  down  with  cerebral 
hemorrhage.  There  were  well-marked  hemiplegia,  distortion  of  the  face, 
and  impairment  of  speech  ;  the  intellect  was  perfect.  Although  he  was  of 
opinion  that  bleeding  was  not  required,  he  was  compelled  to  yield  to  the 
consulting  physician,  who  had  over  him  the  superiority  of  age  and  of  a 
high  scientific  position.  The  patient  was  therefore  bled ;  but  he  had 
scarcely  lost  100  grammes  of  blood  (about  three  ounces)  when  he  fell  into 
a  state  of  complete  resolution,  from  wdvich  he  never  rallied,  until  his  death, 
which  occurred  a  few  days  afterwards.  But  a  moment  before  the  bleeding 
he  was  in  the  full  enjoyment  of  all  his  faculties,  and  conversed  freely  and 
ably  with  his  friends  around. 

I  am  not  the  only  one,  gentlemen,  who  regards  bleeding,  and  the  other 
means  usually  recommended  in  cerebral  hemorrhage  and  apoplexy,  as 
useless  and  inconvenient.  Very  recently  one  of  my  colleagues,  Professor 
Monneret,  declared  that  he  had  for  a  long  time  given  up  the  active  treat- 
ment which,  like  myself,  he  formerly  had  recourse  to.  Far  from  lowering 
his  patients,  he  feeds  them,  and  gives  them  wine.  Since  I  have  conformed 
to  the  rule  of  keeping  up  the  strength  of  my  patients  by  giving  them  food 
in  moderation,  I  find  that  the  bad  symptoms  under  which  they  labor  dis- 


724  ON    VENESECTION    IN    CEREBRAL    HEMORRHAGE 

appear  more  rapidly  than  when  I  interfered  actively,  and  the  case  you 
have  lately  had  occasion  to  observe  is  another  proof  in  favor  of  my  asser- 
tion. 

In  the  case  of  the  patient  in  the  St.  Agnes  Ward,  there  supervened,  in 
the  course  of  his  illness,  certain  phenomena  to  which  I  wish  to  draw  your 
attention.  You  often  heard  him  complain  of  attacks  of  giddiness,  which 
were  more  or  less  prolonged  ;  and,  doubtless,  many  among  you  looked  upon 
them  as  symptoms  of  a  determination  of  blood  to  the  head,  and  concluded 
that  if  I  had  bled  the  patient  I  would  have  avoided  those  threatenings  of 
returning  hemorrhage.  On  carefully  questioning  the  man,  however,  I 
found  that  the  giddiness  came  on  more  frequently  when  he  had  been  fast- 
ing, and  ceased  immediately  on  his  taking  food.  It  was  not  cerebral 
congestion,  therefore,  at  least,  congestion  as  it  is  generally  understood, 
which  caused  the  symptoms  I  alluded  to.  These  were  due  to  a  deficiency 
in  the  normal  constituents  of  the  blood,  unfitting  it  for  stimulating  the 
brain,  and  not  to  an  excess  of  blood  in  the  vessels.  Bleeding  would  have 
aggravated  this  vertiginous  disturbance,  whereas  nourishment  speedily  got 
rid  of  it. 

Since  we  are  on  the  subject  of  cerebral  hemoiThage,  allow  me,  gentle- 
men, to  take  the  opportunity  of  speaking  to  you  of  softening  of  the  brain, 
and  of  answering,  to  the  best  of  my  ability,  the  questions  you  often  ask  me 
in  the  course  of  my  visits  round  the  wards,  embarrassing  questions  though 
they  be,  because  you  expect  me  to  solve  one  of  the  most  difficult  problems 
in  pathology,  namely,  the  differential  diagnosis  between  cerebral  hemor- 
rhage and  softening.  Lying  at  Xo.  18,  in  our  male  ward,  is  a  patient 
whose  history  is  interesting  from  this  very  point  of  view.  He  was  admitted 
into  the  hospital  a  few  days  ago,  suffering  from  complete  hemiplegia  of 
the  right  side.  His  history  is  very  short,  and  is  as  follows:  He  was  seized 
in  the  midst  of  the  most  perfect  health,  with  the  exception  that  for  the  last 
eight  or  ten  days  he  had  suffered  from  occasional  giddiness  and  headache, 
and  had  felt  confused  at  times.  He  had  also  noticed  a  sensation  of  Dumb- 
ness in  his  right  hand  and  foot.  He  was  not,  however,  prevented  from 
walking  or  moving  about,  and  attending  to  his  usual  occupation,  when 
suddenly,  a  few  days  ago,  he  was  struck  with  palsy  of  the  right  side.  He 
then  came  to  the  Hutel-Dieu,  where  I  found  complete  paralysis  of  motion, 
with  relaxation  of  the  right  arm  and  leg,  involving  the  corresponding  half 
of  the  face,  besides  nearly  absolute  anaesthesia  of  the  integuments  of  the 
affected  parts,  marked  dulness  of  aspect,  and  slowness  of  speech.  The 
patient  was  free  from  fever. 

I  thoughl  that  cerebral  hemorrhage  had  occurred  in  this  case,  although 
I  felt  some  hesitation  at  first,  because  of  the  complete  loss  of  the  power  of 
motion,  and  the  thorough  resolution  of  the  limbs  on  the  right  side,  that 
were  scarcely  proportionate  to  the  small  degree  of  intellectual  disturbance. 
Indeed,  it  does  not  usually  happen,  in  my  opinion  at  least,  that  in  cerebral 
hemorrhage  there  should  be  such  complete  paralysis  of  motion  as  there  wa- 
in this  instance,  without  there  being  loss  of  consciousness  also.-  Complete 
loss  of  motor  power,  without  accompanying  coma  at  the  time  of  Beisure, 
belongs,  I  believe,  more  especially  to  softening.  On  many  occasions,  and 
for  many  years,  I  have  specially  called  your  attention  to  these  elements  of 
a  differential  diagnosis  between  hemorrhage  and  Boftening,  diagnostic  char- 
acters laid  down  by  Recamier,  and  for  which  1  claim  tfo  credit  to  myself. 
According  to  my  illustrious  teacher,  the  value  of  actual  symptoms  is  infi- 
nitely greater  than  thai  of  the  phenomena  which  in  some  cases  precede  the 
attack,  although  he  does  not  deny  thai  they  are  of  some  value.  Recamier, 
indeed,  affirmed,  and  in  many  cases  I  have  been  enabled  to  verity  the  truth 


AND    APOPLEXY.  725 

of'liis  proposition,  that  whenever  hemiplegia,  complete  and  absolute,  occurs 
suddenly  (and  I  insist  on  this  point — the  suddenness  of  attack"),  without 
loss  of  consciousness,  softening  of  the  brain  may  be  diagnosed.  Whenever, 
on  the  contrary,  the  complete  loss  of  motor  power  is  attended  by  loss  of 
consciousness,  whenever,  especially,  the  individual  has  become  suddenly 
Comatose,  hemorrhage  may  be  diagnosed,  and  hemorrhage  to  a  considerable 
amount.  But  when  the  intellect  is  affected  to  some  extent,  but  not  entirely — 
when  there  is  obtusencss,  but  not  complete  loss  of  sensibility — whilst  there 
is  absolute  loss  of  motor  power,  as  in  the  case  of  our  patient  in  St.  Agues 
Ward,  we  must  always,  according  to  Recarnier,  diagnose  hemorrhage  in 
connection  with  softening,  or  what  has  been  termed  capillary  hemorrhage. 
This  latter  form  usually  takes  place  in  a  softened  portion  of  the  brain,  and 
is  characterized,  on  dissection,  by  the  presence  either  of  a  large  number  of 
small  clots,  perfectly  isolated  from  one  another,  or  coalesced  so  as  to  form 
larger  hemorrhagic  centre's.  In  those  cases,  but  in  them  alone,  was  the 
eminent  physician  of  the  Hotel-Dieu  disposed  to  admit  the  antecedent  soft- 
ening which  is  by  Rochoux  regarded  as  the  organic  condition,  the  morbid 
process  which  must  of  necessity,  and  in  all  instances,  precede  cerebral 
hemorrhage.  I  am  too  much  a  pupil  of  Recamier,  I  confess,  not  to  adopt 
his  conclusions,  which  my  personal  experience  seems  to  me,  besides,  to  have 
corroborated,  in  the  case  I  have  just  alluded  to.  I  am  therefore  inclined 
to  diagnose  hemorrhage  connected  with  softening  of  the  brain.  The 
grounds  on  which  I  rest  my  belief  are,  that  the  patient  never  suffered  from 
the  grave  disturbance  of  the  intellect,  the  loss  of  consciousness,  the  coma, 
or  the  somnolence  at  least,  which  usually  accompany  hemorrhage  of  great 
magnitude;  that  he  only  felt  a  little  confused,  bewildered,  and  stupid, 
which  symptoms  coincided  with  a  diminution  in  the  cutaneous  sensibility 
of  the  side,  which  was  completely  paralyzed  of  motion. 

When  speaking  to  you  of  the  female  patient  lying  in  bed  No.  11,  St.  Ber- 
nard Ward,  I  said  that  I  wished  to  call  your  attention  to  an  unusual 
svmptom  which  she  presents,  a  symptom  to  which,  I  believe,  sufficient  im- 
portance is  not  given,  as  influencing  prognosis.  She  told  you,  and  we 
verified  her  statement,  that  she  could  move  her  arm  better  than  her  leg, 
and  she  added  that  for  a  few  months  after  her  seizure  she  had  walked  much 
better  than  she  does  now.  You  know  that  the  reverse  usually  obtains,  and 
that  in  the  great  majority  of  instances  the  lower  limb  regains  the  power  of 
motion  much  quicker  than  the  arm.  Why  it  is  so  I  do  not  know,  and  I  am 
not  aware  that  anybody  has  ever  given  a  satisfactory  explanation  of  it. 
This  is  remarkable,  however,  that  when  the  arm  regains  power  quicker  and 
better  than  the  leg,  the  patient  is  worse  off  than  when  the  reverse  obtains. 

Three  years  ago,  I  was  sent  for  to  see  a  general  officer,  a  near  relative  of 
mine.  He  had  been  seized  that  morning,  a  little  before  breakfast,  with 
paralvsis  of  the  right  side.  For  three  or  four  days  after  this  his  symptoms 
looked  unfavorable,  but  fever  soon  ceased,  and  a  fortnight  after  the  attack 
-he  could  write,  shave  himself,  and  walk  pretty  well.  The  extreme  preci- 
sion of  the  movements  required  for  writing  and  shaving  showed  clearly 
enough  that  his  arm  was  considerably  better  than  his  leg,  for  he  walked 
very  lame.  After  the  lapse  of  a  few  months  his  leg  became  stiff  and  pain- 
ful, and  he  walked  with  more  difficulty.  A  stick  was  no  longer  enough 
for  him,  and  he  required  the  help  of  a  friend's  arm  ;  later,  even  with  this 
help,  he  was  unable  to  walk.  At  that  time  the  arm  itself  began  to  lose 
power,  and  the  intellect  failed  in  proportion.  Subsequently,  the  poor  man 
could  not  leave  his  arm-chair,  and  suffered  excruciating  pain  in  the  para- 
lyzed side,  especially  in  the  leg.  He  at  last  died  in  a  state  of  perfect  im- 
becility. 


726  ON    APOPLECTIFORM    CEREBRAL    CONGESTION, 

The  same  fate  awaits  the  woman  in  the  St.  Bernard  "Ward.  She,  too, 
uses  her  arm  much  better  than  her  leg ;  but  already,  for  the  last  tAvo  or 
three  months,  her  leg,  at  night  especially,  has  become  acutely  painful.  For 
two  months  after  her  seizure  she  walked  pretty  well,  whereas,  now,  she 
cannot  take  a  single  step  unless  strongly  supported,  and  before  another  two 
or  three  months  shall  have  elapsed,  she  will  probably  not  be  able  to 
leave  her  arm-chair  and  she  will  die  within  the  year  consumed  by  pain, 
and  a  thorough  imbecile. 

Now,  gentlemen,  if  you  ask  me  why  our  prognosis  should  be  unfavorable 
when  the  arm  regains  power  more  completely  and  more  rapidly  than  the 
leg,  I  must  confess  my  ignorance,  and  content  myself  Avith  noting  a  fact 
which  has  often  enough  occurred  in  my  practice  to  have  attracted  my  at- 
tention. I  cannot  say  whether  a  morbid  process  goes  on  round  the  clot, 
causing  chronic  softening  or  irregular  cicatrices ;  but  whateATer  the  cause 
may  be  the  fact  remains,  and  seems  to  me  to  possess  some  value. 

I  will  not  leave  this  subject  Avithout  calling  your  attention  to  another 
sign,  which,  like  the  preceding,  is  of  great  prognostic  value.  You  doubt- 
less remember  two  women,  the  one,  still  young,  lying  in  ]So.  34  bed,  St.  Ber- 
nard Ward,  the  other,  aged  64,  lying  in  bed  28.  They  were  both  paralyzed 
on  the  left  side  after  an  attack  of  cerebral  hemorrhage.  There  had  been 
no  impairment  of  intellect,  and  they  both  could  walk  before  a  month  had 
elapsed  from  the  date  of  seizure.  I  drew  your  attention  at  the  time  to  the 
fact  that  the  fingers  of  both  these  women  Avere  flexed  into  the  palm  of  the 
hand  through  permanent  contraction  of  the  flexors,  and  I  told  you  then,  as 
it  has  since  unfortunately  happened,  that  they  would  neA'er  be  able  to  use 
their  hands  :  that  the  extensors  would  never  regain  the  poAver  they  had  lost, 
that  the  hand  would  always  look  like  claws,  and  the  power  of  motion  in 
the  upper  limb  would  be  almost  completely  abolished. 

This  is  another  fact  taught  by  clinical  experience  AA'hich  you  should  not 
ignore,  because  you  must  not  hold  out  the  promise  of  cure,  or  even  of  im- 
provement in  such  cases,  as  the  symptoms,  far  from  getting  better,  Avill 
grow  AA'orse  Avith  every  succeeding  year. 


LECTURE  XL. 

ON    APOPLECTIFORM   CEREBRAL  CONGESTION,  AND  ITS   RELA- 
TIONS  TO    EPILEPSY  AND  ECLAMPSIA. 

§  1.  Tin'  cristinor  of  Cerebral  Congestion  i*  not  contested;  but  if  hap  been 
singularly  abused,  in  order  to  explain  Cerebral  Phenomena  in  thu  produc- 
tion of  which  Congestion  plays  no  part  whatever. — Sudden  and  tra 
fit*  of  Apojt/r.ry  urc  among  these,  and  the  so-called  Apoplectiform  <  '•  r<  bral 
<  bngestions  are  off*  m  r  conn*  >-f>  d  with  Epilepsy  than  is  gt  ru  rally  bt  lu  ved. 
— A  few  considerations  on  the  sudden  and  irresistible  impulses  o)  Epi- 
leptics in  general,  and  on  the  inferences  to  bi  drawn  from  them  win 
medico-legal  point  of  riew. 

( rEBTLEMEN  :  Apoplectiform  <  en  bral  ( ongestion  La  a  term  usually  applied 
to  a  group  of  transienl  phenomena  occurring  suddenly,  and  resembling  those 
of  apoplexy  properly  so  called.  These  latter  are  well  defined  in  the  aphor- 
ism oi Boerhaave,  which  I  have  already  quoted  in  t h«-  preceding  Lecture; 


AND    ITS    RELATIONS    TO    EPILEPSY    AND    ECLAMPSIA.        727 

namely, — "  Apoplexia  dicitur  adesse,  quandb  repentk  actio  quinque  senmum 
externum  m,  tiim  int&rnorum,  omnesque  motics  vohmtarii  abolentur,  superstite 

pul&it  plerumque  forti,  et  rexpi  rati  one  dijficili,  magna,  stertente,  una  cum 
imagine  profundi  perpetuique  somni." 

When  these  apoplectic  phenomena  are  transitory,  the  case  is  said  to  be 
one  of  apoplectiform,  cerebral  congestion;  when  they  are  persistent,  cerebral 
hemorrhage  is,  in  the  majority  of  cases,  supposed  to  have  taken  place  to  a 
large  amount.  It  is  a  current  opinion,  as  you  are  well  aware,  that  apoplec- 
tiform cerebral  congestion  is  a  common  complaint,  and  this  opinion  is  so 
generally  accepted,  so  firmly  established,  that  it  seems  strange  for  any  one 
to  appear  to  doubt  it.  During  the  first  years  of  my  practice  I  saw,  or 
thought  I  saw,  a  pretty  large  number  of  cases  of  apoplectiform  congestion, 
but  for  a  longtime  I  have  not  seen  any;  yet  other  medical  men  see  as  many 
as  before.  Let  us,  therefore,  inquire  on  whose  side  the  error  lies.  A  man, 
for  instance,  with  or  without  premonitory  symptoms,  falls  down  suddenly 
in  an  apoplectic  condition.  When  picked  up  he  looks  stupefied,  and  for  a 
quarter  of  an  hour,  an  hour,  or  perhaps  more,  he  complains  of  heaviness  of 
the  head  and  mental  confusion,  and  staggers  in  walking.  On  the  next  day 
all  these  symptoms  have  disappeared.  In  such  a  case  the  patient  is  said 
to  have  had  apoplectiform  cerebral  congestion.  I  used  to  say  so  like  the 
rest,  but  I  do  not  now. 

Another  man,  whilst  walking,  is  suddenly  seized  with  giddiness.  He 
loses  his  sight  and  the  faculty  of  speech,  merely  muttering  a  few  unintelli- 
gible words.  He  staggers,  and  sometimes  falls  down ;  but  rises  immediately. 
The  whole  set  of  symptoms  have  occurred  within  a  few  seconds,  and  are 
followed  by  a  slight  heaviness  of  the  head  only,  and  sometimes  by  transient 
mental  confusion ;  but  after  three  or  four  minutes  he  is  as  well  as  before. 
Such  a  case  is  said  to  be  one  of  slight  cerebral  congestion.  I  also  used  to 
say  so,  but  no  longer  say  so  now. 

Why,  then,  have  I  altered  my  views,  gentlemen  ?  Not,  certainly,  from 
a  love  of  paradox;  but  because  facts  have  forced  on  me  a  new  conviction. 
In  the  year  1845  a  friend  of  mine  was  found  in  his  bed  in  a  state  of  insen- 
sibility. His  face  was  turgid  and  livid,  his  intellect  in  abeyance,  and  all 
power  of  motion  and  sensation  completely  lost ;  there  was  stertor  also.  He 
was  a  vigorous  man,  aged  42.  How  long  he  had  been  in  this  condition 
his  wife  could  not  tell ;  for  she  had  been  awakened  by  a  strange  snoring 
noise,  and  she  had  sent  for  me.  I  had  already,  at  that  time,  given  up  bleed- 
ing in  the  treatment  of  apoplexy.  I  had  the  patient  placed  in  a  half-sitting 
posture,  and  threw  cold  water  in  his  face.  I  also  applied  two  ligatures 
round  the  upper  part  of  his  thighs,  in  order  to  retain  temporarily  a  large 
quantity  of  venous  blood  in  the  vessels  of  the  lower  limbs  (although  I  in 
reality  expected  little  from  the  measure),  and  I  waited.  An  hour  scarcely 
elapsed  before  the  patient  regained  the  power  of  motion  and  feeling,  and 
answered  questions  pretty  well  to  the  point.  On  the  following  day,  great 
lassitude  was  the  only  symptom  remaining. 

Some  time  afterwards  I  was  fetched  in  haste  to  see  a  neighbor,  aged  70, 
who  had  been  seized  with  apoplexy  on  the  Boulevards.  He  had  been  in- 
sensible for  a  quarter  of  an  hour,  but  was  recovering  his  senses  as  I  arrived. 
He  did  not  yet  recognize  me,  however,  and  looked  vacantly  round,  moving 
his  arms  and  legs  about,  without  being  conscious  of  it.  His  lips  and  nose 
were  swollen,  his  eyes  injected.  By  degrees,  and  within  a  few  hours,  he 
recovered  entirely,  without  my  having  had  recourse  to  any  active  measures. 
His  valet  then  informed  me  that  his  master  had,  in  the  last  two  or  three 
years,  had  several  attacks  of  the  same  kind,  and  that  the  symptoms  had 
passed  off  in  the  same  way,  once  after  bleeding,  and  on  the  other  occasions 


728       ON  APOPLECTIFORM  CEREBRAL  CONGESTION, 

after  a  mustard  foot-bath.  In  the  same  year  I  was  consulted  by  a  solicitor 
from  the  country,  aged  35,  who  in  the  course  of  the  previous  six  months 
had  suffered  from  three  apoplectic  fits.  He  had  been  bled  and  purged  on 
each  occasion,  to  his  great  satisfaction,  and  leeches  were  applied  once  a 
month  round  his  anus.  The  last  attack  had  occurred  as  he  was  going  up 
a  staircase  to  his  apartments,  on  his  return  from  some  important  pleadings. 
His  head  had  struck  against  the  stairs,  and  there  were  still  on  his  forehead 
the  marks  of  a  pretty  deep  cut.  The  apoplectiform  phenomena  had  lasted 
an  hour  at  the  most ;  and  when  I  saw  him,  his  intellect,  sensibility,  and 
power  of  motion  were  perfectly  normal. 

I  can  with  difficulty  believe  that  apoplexy  occurs  in  persons  aged  35, 
particularly  when  the  attacks  return  every  two  months.  It  immediately 
occurred  to  me  that  the  case  was  one  of  epilepsy,  and  I  suggested  it  to  the 
medical  man  who  had  sent  the  patient  to  me.  His  answer  was  that  nothing 
authorized  mjr  suspicions,  and  that  convulsions  had  never  been  noticed.  I 
still  maintained  my  opinion,  however;  and  shortly  afterwards  the  poor  man 
had,  in  court,  a  regular  epileptic  fit,  which  unfortunately  left  no  doubt  in 
anybody's  mind,  and  he  was  compelled  to  give  up  his  profession. 

But  my  attention  had  now  been  roused;  I  asked  myself  whether  so  many 
persons  whom  I  had  seen  with  apoplectiform  cerebral  congestion  were  not 
epileptics,  and  I  kept  on  the  watch.  My  first  patient  soon  had  other  attacks, 
and  he  now  has  sometimes  as  many  as  four  or  five  epileptic  fits  in  a  day, 
and  very  often  the  vertigo  of  petit-mal.  He  has  lost  his  sight,  and  his 
mind  is  considerably  impaired.  As  to  the  old  man  whose  history  I  Have 
related  to  you,  he  is  still  living,  and  has  almost  every  year  one  or  two 
similar  attacks.  Since  the  day  he  fell  down  on  the  Boulevards,  he  never 
goes  out  unless  accompanied  by  a  servant,  who  has  informed  me  that  his 
master  makes  grimaces  when  on  the  ground,  and  has  startiugs  in  one  of  his 
arms,  which  last  scarcely  a  minute,  but  are  amply  sufficient  to  characterize 
epilepsy. 

Since  that  time,  whenever  I  have  been  consulted  for  a  case  of  apoplec- 
tiform cerebral  congestion,  I  have  inquired  with  the  greatest  care  whether, 
from  time  to  time,  there  were,  during  the  day,  sudden  and  transient  attacks 
of  vertigo,  having  the  characters  I  have  indicated  above,  and  whether 
those  congestive  seizures  occurred  more  frequently  at  night  than  in  the  day- 
time, and  whether  also  there  had  been  nemows  twitches  in  the  beginning  of 
the  attack.  In  every  case  almost,  when  the  seizures  had  occurred  in  the 
presence  of  witnesses,  convulsions  could  be  made  out.  When  they  had 
taken  place  in  the  night,  and  during  sleep,  I  was  told  that  the  urine  had 
been  sometimes  passed  involuntarily,  and  that  for  a  few  days  the  tongue 
bad  been  sore.  The  face,  forehead,  and  ueefe  had  often  been  covered  with 
small  ecchymoses,  looking  like  flea-bites.  I  was  told  particularly  that  the 
attacks  recurred  at  pretty  short  intervals,  and  left  no  lasting  traces.  In  a 
word,  epilepsy  became  plain  when  it  was  soughl  for. 

Not  a  month  elapses  without  my  seeing,  in  my  consulting-room,  patients 

suffering  from  epilepsy,  who  are  said  to  have  had  apoplexy.  Not  a  week, 
perhaps,  goes  by  without  my  being  consulted    by  adults  and  old    people,  or 

fur  children,  affected  with  epileptic  vertigo,  wno  are  said  to  be  suffering 
from  Blight  cerebral  congestions.  Although  epilepsy,  in  all  it-  form-,  i- 
better  known  now  than  iivc-and-t wenty  or  thirty  years  ago,  yet  many  prac- 
titioners will  not  believe  in  so  terrible  a  disease;  and  even  if  they  recognize 
it,  they  will  not  tell  the  patient's  friends  the  real  nature  of  the  case,  and 
prefer  to  Leave  the  painful  task  to  the  consulting  physician. 

Very  frequently,  epileptic  vertigo  gives  rise  to  symptom-  usually  attrib- 
uted to  cerebral  congc.-tion  ;  symptoms  to  which  attention  has  long  been 


AND    ITS    RELATIONS    TO    EPILEPSY    AND    ECLAMPSIA.        729 

drawn  by  those  who  specially  devote  themselves  to  the  treatment  of  the 

insane. 

Alter  an  attack  of  vertigo,  the  patient  is  frequently  delirious  for  a  few 
minutes,  and  perhaps  longer.  The  records  of  courts  of  justice  and  of  police- 
offices  arc  fill]  of  cases  of  suicide  and  of  murder,  too  often  attributed  by 
medical  men  to  what  they  call  cerebral  congestion,  but  which  should  be 
ascribed  to  epilepsy.  It  may  be  said,  almost  without  fear  of  making  a 
mistake,  that  if  a  man  suddenly  commits  murder,  without  any  previous 
intellectual  disturbance — without  having  up  to  that  time  shown  any  symp- 
toms of  insanity,  and  if  not  under  the  influence  of  passion,  or  of  alcohol, 
or  any  other  poisonous  substance  which  acts  with  energy  on  the  nervous 
system — it  may  be  said,  I  repeat,  that  the  man  is  afflicted  with  epilepsy, 
and  that  he  has  had  a  fit,  or,  more  usuaHy,  an  attack  of  vertigo.  The 
reason  why  these  strange  acts  are  attributed  by  most  medical  men  and 
by  magistrates  to  passing  cerebral  congestion,  is  that  the  epileptic  seizure 
is  sometimes  mistaken,  and  that  the  vertigo  is  almost  always  so. 

I  never  pretended,  gentlemen,  that  because  a  culprit  is  epileptic  he  should 
be  exonerated  from  all  criminality.  Let  a  barrister  use  this  argument ;  let 
him  pretend  that  his  client  was  not  a  free  agent  at  the  moment  when  the 
criminal  act  was  committed  ;  I  grant  it,  but  I  will  never,  for  my  part,  dare 
support  such  a  doctrine  before  a  court  of  justice.  I  am  perfectly  convinced 
that  many  epileptics  are  great  criminals  in  the  moral  sense  of  the  word,  and 
that  the  acts  of  which  they  are  guilty  have  been  premeditated,  and  com- 
mitted by  them  as  free  agents.  But  in  such  cases,  the  preparations  for,  and 
the  perpetration  of  the  crime,  are  in  nothing  different  from  what  usually 
happens.  The  epileptic,  if  not  insane  in  the  interval  between  his  fits,  is 
like  any  other  man,  and  as  such  is  amenable  to  the  laws.  On  this  point 
no  difference  of  opinion  exists.  But  if  this  same  individual  has  committed 
a  murder,  without  any  possible  motive,  without  profit  to  himself  or  any 
other  person,  without  premeditation  or  passion,  openly,  and  consequently 
in  a  manner  quite  different  from  that  in  which  crimes  are  usually  commit- 
ted, I  have  the  right  of  affirming  before  a  magistrate  that  the  criminal 
impulse  has  been  the  result,  almost  to  a  certainty,  of  the  epileptic  shock.  I 
w'ould  say  almost,  if  I  had  not  seen  the  fit ;  but  if  I  myself,  or  others,  had 
seen  a  fit  or  an  attack  of  vertigo  immediately  precede  the  criminal  act,  I 
would  then  affirm  most  positively  that  the  culprit  had  been  driven  to  the 
crime  by  an  irresistible  impulse,  and  he  would  be  absolved  by  virtue  of 
Art.  G4  of  the  Penal  Code. 

It  would  be  a  mistake  to  believe  that  epileptics  have  sudden  and  irre- 
sistible impulses  in  the  interval,  and  independently  of  the  fits.  When 
insanity  has  been  brought  on  by  epilepsy,  as  is,  unfortunately,  very  com- 
mon ;  when  acute  mania  follows,  for  a  few  days,  on  a  convulsive  fit,  no 
doubt  can  exist;  and  persons  so  afflicted  are  rarely  brought  before  a  court 
of  justice  if  they  commit  a  crime  or  misdemeanor.  Where  dementia  is  evi- 
dent, the  law  does  not  punish.  The  magistrate  orders  the  man  to  be  con- 
fined, because  he  owes  protection  to  society  that  is  menaced,  and  to  the  poor 
madman  himself,  who  is  legally  incapable. 

But  the  epileptic  shock  can  strike  at  the  will.  The  perfect  intelligence  of 
the  epileptic  immediately  before  and  shortly  after  the  attack,  his  absolute 
moral  liberty  in  the  interval  between  his  fits,  can  alone  make  him  appear 
guilty.     Those,  then,  are  the  conditions  which  should  be  studied. 

In  general,  the  question  of  guilty  or  not  guilty  is  not  raised  when  the 
crime  or  misdemeanor  has  been  committed  immediately  after  a  fit,  when 
those  who  witnessed  the  crime  also  witnessed  the  convulsions,  any  more 
than  it  is  in  the  case  of  a  maniac  confined  in  a  lunatic  asylum,  or  of  an 


730  ON    APOPLECTIFORM    CEREBRAL    CONGESTION, 

hospital  patient  under  the  influence  of  delirium,  who  may  commit  any  acts 
of  violence.  It  may  happen,  however,  that  the  fit  does  not  occur  in  pres- 
ence of  any  witnesses,  or  that  the  acts  which  are  committed  soon  after  are 
not  seen  by  those  who  witnessed  the  fit,  and  then  doubts  may  arise. 

The  following  case  was  related  to  me  by  Dr.  Jozat :  A  young  man, 
whilst  on  his  way  to  the  Palais  Royal,  in  company  of  some  friends,  with 
whom  he  was  going  to  dine,  suddenly  falls  down  on  the  "  Place  Louvois," 
but  soon  gets  up  again,  and  rushes  on  the  passers-by,  striking  them  with 
violence.  He  is  taken  to  the  police-station,  and  for  some  time  keeps  insult- 
ing the  soldiers  who  hold  him,  and  spitting  in  their  faces.  Now,  had  there 
been  no  witnesses  of  the  epileptic  attack  which  had  preceded  this  extraor- 
dinary scene,  and  had  not  the  physician  who  related  the  fact  to  me,  inter- 
fered, the  young  man  would  ha^e  been  tried  for  rebellion  against  the  police 
authorities.  It  will  be  easily  conceived  how  difficult  it  is  to  arrive  at  the 
truth,  when  the  epileptic  and  the  victim  of  his  violence  have  been  quite 
alone.  And  on  this  point  allow  me  to  bring  before  you  a  certain  number 
of  cases  that  fell  under  my  own  observation,  and  for  the  truth  of  which  I 
can  vouch.  I  was  very  recently  consulted  by  a  newly-married  couple. 
The  lady  told  me  that,  shortly  after  her  marriage,  she  had  been  awakened 
one  night  by  strange  movements  of  her  husband,  who  had  suddenly  struck 
her  with  awful  violence.  Had  she  not  managed  to  ring  the  bell,  she  added, 
and  a  maid-servant  rushed  in  and  delivered  her,  she  might  have  been 
seriously  hurt.  Another  scene,  of  the  same  kind,  had  again  taken  place 
a  few  days  before  I  was  consulted ;  but  on  this  occasion  she  awoke  in  time, 
lighted  a  candle,  and  saw  the  convulsions  with  which  her  husband  was 
seized.  Flight  saved  her  from  the  violence  which  immediately  followed. 
These  details  were  told  me  in  the  presence  of  the  poor  man,  who  was  per- 
fectly conscious  of  having  felt  something  that  he  could  not  account  for, 
and  who  now  informed  me  that  he  had  often,  before  his  marriage,  had 
attacks  of  vertigo,  the  character  of  which  had  not  been  recognized  by  the 
medical  men  whom  he  had  consulted. 

I  have  still  in  one  of  my  wards  at  the  Hotel-Dieu  a  young  girl,  of  a  quiet 
and  gentle  disposition,  who  sometimes  has,  within  the  twenty-four  hours,  as 
many  as  a  hundred  attacks  of  petit-mal.  On  the  night  of  her  admission 
she  was  put  in  a  separate  room,  with  a  very  intelligent  nurse.  About  the 
middle  of  the  night,  she  got  out  of  bed  after  an  attack,  and  began  to  beat 
the  nurse,  who  woke  in  a  fright.  Scarcely  half  a  minute  elapsed  before  the 
patient  recovered  her  senses,  and  got  into  bed  again,  ignorant  of  what  -ho 
had  done.  You  have  all  heard,  without  doubt,  of  that  highly  intelligent 
lady,  and  perfectly  respectable  in  every  respect,  who,  in  a  drawing-room, 
at  a  theatre,  in  church,  or  when  walking  out,  suddenly  makes  use  of  most 
insulting  or  obscene  expressions,  of  which  she  is  said  to  be  unconscious. 

I  have  myself  known  a  very  intelligent  magistrate,  of  whom  I  shall  speak 
again  by  and  by,  who  was  subjecl  to  frequent  attacks  of  epileptic  vertigo. 
Hi-  sister  had  been  confined  at  Charenton,  where  I  knew  her.  He  was 
president  of  a  provincial  tribunal.  One  day  he  gets  up  all  of  a  Blldden, 
mutters  a  few  unintelligible  words,  anil  goes  to  the  delihorating-room.  He 
is  followed    by  the    usher,  who   sees    him    make  water   in  a  cornel-.      A   few 

minute-  afterwards  he  returns  to  his  seat,  and  again  listens  with  intelligence 
ami  at teli tin 1 1  to  the  pleadings,  momentarily  interrupted,  lie  had  qo  recol- 
lection of  the  incredibly  incongruous  act  which  he  had  committed. 

1  could  cite  an  endless  number  of  similar  instances,  borrowed  from  my 
own  practice  and  that   of  others;    hut   I  wish  to  answer  one  of  the  gravi  -t 

objections  made  by  medical  men,  and  still  more  by  magistrates,  t"  the 
theory  of  sudden  and  irresistible  impulses  in  Borne  epileptic-.     The  disturb- 


AND    ITS    RELATIONS    TO    EPILEPSY    AND    ECLAMPSIA.        731 

ance  of  the  reason  which  follows  a  convulsive  fit,  and  especially  an  attack 
of  vertigo,  is  not  always  reeomiized  so  easily  as  it  might  be  supposed.  A 
medical  man,  for  instance,  is  sent  for  to  see  an  epileptic  immediately  after 
an  attack.  The  patient  answers  questions  pretty  well  to  the  point,  follows 
out  the  doctor's  prescriptions,  takes  a  foot-bath,  allows  himself  to  be  bled 
or  leeched,  and  describes  his  feelings  pretty  accurately  ;  but  a  few  hours 
later  he  has  not  only  forgotten  what  occurred  during  the  attack,  as  the 
rule  is,  but  he  has  even  forgotten  all  the  above  circumstances,  in  which  he 
had  apparently  concurred  with  so  much  presence  of  mind.  It  must,  there- 
fore, be  concluded  that  his  intellect  had  been  deeply  perturbed.  Who, 
now,  can  calculate  the  degree  of  liberty  possessed  by  a  man  in  this  state  of 
transition  between  the  actual  attack  and  the  complete  recovery  of  the 
mental  faculties?  Is  there  a  medical  man  bold  enough  to  pronounce  on 
this  point,  and  to  affirm  that  a  crime  committed  after  the  attack  must 
entail  responsibility  ? 

Not  only,  gentlemen,  may  the  patient's  reason  remain  in  a  perturbed 
condition  for  some  time  after  the  attack,  although  a  superficial  observer 
may  not  perceive  it,  but  it  sometimes  happens  that,  during  the  attack,  the 
epileptic  seems  to  retain  enough  reason  to  appear  free.  Allow  me  to  cite  a 
few  instances  in  illustration. 

The  young  girl  now  in  my  ward,  to  whom  I  alluded  just  now,  goes, 
during  her  attacks  of  vertigo,  through  certain  acts  that  require,  in  some 
measure,  liberty  and  intelligence.  If,  at  the  outset  of  the  attack,  any  one 
snatches  from  her  an  object  she  is  holding,  she  rushes  on  him  to  regain 
possession  of  it,  pursues  him  without  staggering,  without  stumbling  or 
knocking  against  anything  in  her  way,  and  is  even  violent  if  she  be  re- 
sisted ;  then,  all  of  a  sudden,  before  half  a  minute  has  elapsed,  she  exclaims, 
"  It  is  over,"  stops,  and  falls  into  a  state  of  prostration.  If  questioned  at 
once,  she  has  no  recollection  whatever  of  what  has  just  occurred.  When 
I  treat  more  particularly  of  e]:>ilepsy,  I  shall  detail  to  you  the  case  of  a 
young  man,  a  great  musical  amateur  and  very  skilful  violinist,  who  is 
afflicted  with  epilepsy.  He  is  so  passionately  fond  of  music  that  he  plays 
second  violin  at  some  theatres  without  any  remuneration.  He  has  often 
been  seized  with  vertigo  whilst  playing  a  piece ;  but  during  the  attack, 
which  does  not  last  more  than  ten  or  fifteen  seconds,  he  continues  to  play 
in  perfect  time.  He  then  comes  round,  knows  full  well  that  he  has  had  a 
fit  of  absence,  and  continues  to  play  without  difficulty. 

The  lady  whom  I  mentioned  just  now  as  being  liable  to  singular  and 
irresistible  impulses,  prompting  her  to  use,  without  her  being  conscious  of 
it,  most  strange  expressions,  makes  in  a  loud  voice  witty  and  pointed 
remarks,  contrary  to  the  rules  of  society.  But,  although  she  acts  under 
the  influence  of  an  irresistible  impulse,  her  remarks  are  so  perfectly  appo- 
site, however,  that  persons,  not  familiar  with  the  phenomena  of  epilepsy, 
must  incline  to  believe  that  they  are  made  intentionally.  If,  instead  of 
insulting  or  obscene  expressions,  or  epigrams,  you  substitute  murder,  say 
whether  there  would  be  crime,  and  whether,  in  such  a  case,  the  article  64 
of  the  Penal  Code  would  not  find  its  application  ? 

The  magistrate  concerning  whom  I  told  you  such  a  singular  anecdote, 
remained  for  some  time  in  a  disturbed  mental  condition  after  an  attack: 
but  this  state  was  noticed  by  his  wife  alone,  who  was  an  excellent  judge  of 
it,  and  watched  him  with  great  solicitude.  He  belonged  to  a  literary 
society,  which  held  its  meetings  at  the  Hotel  de  Ville  of  Paris.  At  one  of 
these,  during  a  discussion  on  an  important  historical  point,  he  is  seized  with 
vertigo.  He  runs  quickly  down  to  the  Place  de  l'Hotel  de  Ville,  and  walks 
about  for  a  few  minutes  on  the  quays,  avoiding  with  success  both  carriages 


732  ON    APOPLECTIFORM    CEREBRAL    CONGESTION, 

and  the  passers-by.  On  recovering  himself,  he  perceives  that  he  has  come 
out  without  his  great  coat  and  his  hat,  returns  to  the  meeting,  and  resumes, 
with  a  perfectly  lucid  mind,  the  historical  discussion  in  which  he  had 
already  taken  a  very  active  part.  He  retained  no  recollection  whatever 
of  what  occurred  between  the  beginning  of  the  attack  and  the  moment  he 
recovered  himself. 

Xow  had  this  patient  quarrelled  with  and  killed  a  man  in  the  streets, 
would  a  magistrate  have  believed  that  an  individual  who,  five  minutes 
before  and  five  minutes  after,  was  remarkably  intelligent,  and  who,  during 
this  pretended  nervous  seizure,  seemed  to  have  his  free  will,  could  commit 
murder  under  the  influence  of  an  irresistible  impulse  ? 

Every  physician  who  has  studied  epileptic  vertigo  practically  must  have 
seen  cases  of  individuals  speaking  and  answering  questions  during  the 
attack  ;  speaking,  it  is  true,  in  a  strange,  jerked  voice,  but  still  answering 
questions  to  the  point.  The  paroxysm  once  over,  they  have  no  recollection 
of  what  has  just  passed. 

I  had  a  motive,  gentlemen,  for  going  into  all  these  details,  and  you  will 
soon  see  that  they  are  the  key  to  the  solution  of  the  question.  I  showed 
you  by  numerous  instances  in  point  that  sudden  and  irresistible  impulses 
are  of  usual  occurrence  after  an  attack  of  petit-mal,  and  pretty  frequent 
after  a  regular  convulsive  fit.  I  stated  that  the  patients  should  not  be  held 
responsible  for  their  acts,  whether  these  be  followed  or  not  by  grave  and 
painful  consequences,  the  gravity  of  the  act  itself  having  nothing  to  do  with 
the  question.  The  individual  is  not  a  free  agent  for  the  time,  and  is,  there- 
fore, free  from  guilt.  This  is  the  first  point.  The  next  is,  that  the  epileptic 
acts  unconsciously  and  without  retaining  any  recollection  of  what  he  has 
done. 

The  very  reverse  obtains  in  the  case  of  an  insane  individual,  who  is 
prompted  to  his  acts,  it  is  true,  by  hallucinations  or  by  motives  connected 
with  his  delirium,  but  who  still  acts  with  a  very  determined  will,  after  long 
and  matured  premeditation.  He  always  knows  what  he  has  done,  and  is, 
therefore,  conscious  of  his  act;  for  if  he  commits  the  crime  suddenly,  and 
sometimes  from  an  irresistible  impulse,  he  does  so,  in  most  cases,  under  the 
influence  of  hallucinations  which  justify  the  act  in  his  eyes.  Whenever 
delirium  supervenes  in  the  course  of  an  acute  disease,  whenever  it  consti- 
tutes what  is,  by  common  consent,  termed  insanity,  or  follows  chronic  pois- 
oning by  alcoholic  drinks,  or  is  the  consequence  of  repeated  attacks  of 
epilepsy  which  lead  to  dementia,  the  acts  prompted  by  it  are  voluntary, 
methodical,  and  the  patients  always  remember  them. 

I  admit  that  the  acts  of  an  individual  poisoned  by  alcohol,  belladonna, 
or  hashish,  may  be  unpremeditated  and  committed  under  the  influence  of 
an  irresistible  impulse,  and  that  all  recollection  of  them  may  be  completely 
Lost,  aa  in  the  case  of  an  epileptic.  I  admit  that  an  idiot,  whose  intelligence 
and  moral  sense  do  not  rise  to  the  level  of  those  of  the  lower  animals,  may 

kill  a  man  as  he  breaks  a  piece  of  wood,  without  being  Conscious  of  hi.-  act, 
or  keeping  any  recollection  of  it.  But  I  never  meant  to  include  these  par- 
ticular cases  in  the  general  proposition  1  Laid  down,  since  [supposed  a  com- 
plete integrity  of  the  reason  immediately  before  and  soon  after  the  perpe- 
tration of  the  criminal  act. 

That  proposition  I  maintain,  therefore,  and  I  do  not  sec  t lint  the  argu- 
ments opposed  to  it  in  the  discussion  al  the  Academy  of  Medicine  have  a.> 
yet  refuted  it. 

I  dare  not  here,  I  confess,  raise  the  question  of  irresistible  impulses  in 
hysterica]  and  in  pregnanl  women.  <>n  that  point  I  deny  and  1  affirm 
nothing,  but  remain  very  incredulous. 


AND    ITS    RELATIONS    TO    EPILEPSY    AND    ECLAMPSIA.        733 


§  2.  Apart  from  Epilepsy,  a  great  many  cases  of  so-called  Cerebral  Conges- 
tion, in  what  is  "popularly  known  as  the  Coup  de  Sang  (ictus  sanguinis), 
belong  to  the  class  of  Internal  Convulsions,  of  Vertigo  occurring  in  con- 
nection with  disease  of  the  Internal,  Ear,  and  with  Dyspepsia. —  What 
happens  in  the  Brain  in  these  attacks  is  much  more  nearly  allied  to  Syn- 
cope than  to  Congestion. — The  Apoplectic  Stupor  of  Cerebral  Hemorrhage, 
of  Epilepsy  and  Eclampsia,  is  due  to  what  I  have  called  "  Cerebral  Sur- 
prise."— Epilepsy  and  Eclampsia  present  remarkable  analogies. —  The 
condition  of  the  Cerebrospinal  Axis,  of  which  they  are  both  an  expression 
(a  condition  unknown  in  its  essence),  suffices  for  producing  Stupor. —  The 
Cerebral  Congestion,  which  in  attacks  of  Epilepsy  and  Eclampsia  may  be 
pushed  as  far  as  Hemorrhage,  is  a  Secondary  Phenomenon. 

• 

But  let  us  return  to  cerebral  congestion.  One  reason  why  epilepsy  is 
often  unrecognized,  is  the  repugnance  felt  by  families  to  confide  the  sad 
complaint  even  to  the  physician.  A  mother  may  have  witnessed  a  regular 
convulsive  fit,  and  yet  is  unwilling  to  believe  in  epilepsy.  When  questioned 
by  the  physician,  she  will  mention  the  loss  of  consciousness,  the  coma,  but 
will  often  omit  the  convulsions.  She  will  ask  for  remedies  against  the  acci- 
dents which  follow  the  attack,  but  will  not  allow  the  truth  to  be  suspected. 
I  have  often  been  consulted  by  persons  who  were  perfectly  well  aware  that 
they  were  afflicted  with  epilepsy,  but  who  only  spoke  of  congestion.  Wives 
conceal  the  nature  of  their  husbands'  complaint ;  husbands,  of  their  wives' 
affliction ;  and  in  most  cases  parents  hide  the  symptoms  presented  by  their 
children. 

The  physician  is  therefore  constantly  deceived  in  cases  of  epilepsy ;  de- 
ceived by  the  patient,  who  knows  nothing  of  his  attack,  except  that  he  lost 
his  senses,  and  remained  several  hours  in  a  state  of  semi-stupidity ;  and  he 
is  deceived  by  the  parents,  who  are  with  difficulty  persuaded  to  confess  that 
a  member  of  their  family  is  an  epileptic.  He  is  misled  also  by  what  he  was 
taught  when  a  student,  namely,  that  apoplectiform  cerebral  congestion  is  a 
common  complaint.  There  need  be  no  surprise,  then,  that  congestion  is  so 
generally  accepted.  Medical  men  themselves  are  often  the  authors  or  ac- 
complices of  these  mistakes.  One  of  my  best  friends  was  an  epileptic.  As 
the  disease  was  hereditary  in  his  family,  his  wife  dreaded  lest  her  only  son 
should  come  in  for  the  sad  legacy,  and  the  name  alone  of  epilepsy  inspired 
her  with  intense  terror.  When  I  first  found  out  the  painful  truth,  I  confess 
I  had  not  the  courage  to  tell  her  of  it.  I  spoke  of  cerebral  congestion,  and 
I  succeeded  in  persuading  herself,  as  well  as  her  son  and  her  intimate  friends, 
that  epilepsy  had  nothing  to  do  with  the  terrible  complaint  he  was  suffering 
from. 

A  few  years  ago,  under  similar  circumstances,  I  wilfully  committed  the 
same  error.  A  young  lady,  belonging  to  a  family  I  knew  intimately,  had 
married  a  gentleman  of  good  standing.  A  year  after  her  marriage,  she 
told  me  that  she  had  fainted  in  the  night,  had  passed  her  urine  involun- 
tarily, and  had  bitten  her  tongue.  The  next  morning  she  had  felt  general 
lassitude,  and  had  a  violent  headache  on  waking.  Fortunately  she  did  not 
sleep  in  the  same  bedroom  with  her  husband.  I  confess  that  I  had  not  the 
courage  to  tell  her  or  her  friends  the  awful  truth.  For  several  years  the 
fits  recurred  during  the  night  only,  and  in  the  daytime  she  had  frequent 
attacks  of  vertigo.  Whilst  staying  at  the  seaside,  she  was  one  day  on  the 
beach,  bathing  one  of  her  children  in  less  than  two  feet  of  water,  when  she 
was  seized  with  a  fit,  and  was  drowned  in  less  than  two  minutes.    The  news- 


731  ON    APOPLECTIFORM    CEREBRAL    CONGESTION, 

papers  spoke  of  it  as  of  death  caused  by  cerebral  congestion,  and  I  did  noth- 
ing to  correct  the  mistake. 

There  is,  I  admit,  one  form  of  convulsive  epilepsy  which  may  simulate 
cerebral  congestion.  In  some  cases,  but  very  rarely,  at  the  beginning  of  a 
fit,  in  the  tonic  stage,  when  the  muscles  of  the  chest  are  perfectly  rigid,  it 
happens  that  instead  of  lasting  only  from- fifteen  to  thirty  seconds,  this 
tonic  condition  extends  over  two  or  three  minutes,  and  the  patients  die  of 
asphyxia,  in  the  same  way  as  patients  afflicted  with  tetanus  die  in  a  par- 
oxysm, or  animals  poisoned  by  strychnine,  as  so  well  shown  by  Segalas. 
In  such  cases  there  occur  no  clonic  convulsions,  with  which  persons  not  be- 
longing to  the  profession  are  most  familiar.  All  the  time  the  tonic  condi- 
tion lasts,  the  face  is  swollen,  the  bloodvessels  of  the  neck  look  distended, 
almost  knotty,  and  there  is  in  reality  intense  congestion,  but  of  a  passive 
character,  analogous  to  what  takes  place  during  an  effort.  Active  conges- 
tion is,  however,  diagnosed,  although  there  has  been,  after  all,  an  attack  of 
epilepsy  or  of  eclampsia.  Physicians  who  devote  themselves  specially  to 
diseases  of  parturient  women  and  of  infants  will  no  doubt  remember  such 
cases,  and  will  probably  share  my  opinion. 

My  regretted  friend  Dr.  Meniere,  physician  to  the  Deaf  and  Dumb  In- 
stitution of  Paris,  had  long  ago  observed  a  good  many  cases  in  which  an 
individual  seized  suddenly  with  vertigo,  nausea,  and  vomiting,  after  walk- 
ing as  if  he  were  intoxicated,  fell  down,  got  up  with  difficulty,  and  re- 
mained for  a  time  pale,  bathed  in  cold  perspiration,  almost  in  a  state  of 
syncope.  On  similar  attacks  recurring  frequently,  they  were  at  first  re- 
garded as  due  to  cerebral  congestion,  and  were  actively  treated  with  bleed- 
ing, leeches,  and  purgatives ;  but  their  frequency  by  degrees  compelled  a 
modification  of  the  diagnosis,  and  excited  considerable  anxiety  in  the 
patient. 

In  the  immense  majority  of  cases,  individuals  so  afflicted  soon  complained 
of  tinnitus  aurium,  and  even  of  hardness  of  hearing,  for  which  they  con- 
sulted Dr.  Meniere.  One  or  both  ears  were  then  found  singularly  affected, 
and  Dr.  Meniere  was  enabled  to  collect  hundreds  of  cases  showing  that 
these  pretended  cerebral  lesions  were  in  reality  affections  of  the  auditory 
apparatus.  He  investigated  this  point  with  extreme  care,  and  succeeded 
in  finding  out  that  the  internal  ear  was  the  starting-point  of  the  phenomena 
in  question,  and  that  disease  of  the  semicircular  canals  was  the  cause  of  the 
vertigo,  tin-  sympathetic  vomiting,  the  paralysis  of  the  limbs,  and  the  sud- 
den loss  of  consciousness. 

Vertigo,  connected  with  gastric  disorders,  is  another  complaint  constantly 
mistaken  for  cerebral  congestion.  This  strange  form  of  neurosis  i>  charac- 
terized by  the  following  symptoms:  On  the  patient  moving  suddenly  in 
bed,  he  feels  the  bed  turn  and  carry  him  round  with  it ;  it'  lie  gets  up,  and 
particularly,  if  he  then  looks  up,  the  giddiness  becomes  much  greater.  He 
sees  everything  turn  round,  he  staggers,  and  is  BOmetimes  unable  t"  remain 
standing,  whil.-t  be  has  all  tin;  time  unbearable  sensations  of  nausea,  and  is 
very  often  actually  sick. 

These  curious  symptoms  arc  attributed  to  a  rush  of  blond  to  the  head. 
and,  let  us  confess  it,  mosl  physicians  hold  that  opinion.  They  bleed  their 
patients,  therefore,  they  cup  anil  leech  them,  ami  prescribe  mustard  foot- 
baths, doing,  in  a  word,  all  in  their  power  to  remove  the  pretended  coi 

tioii,  which   their  strange  treatment   merely  aggravates.      These  attacks  of 

vertigo  are  more  allied  to  Byncope,  and  are  consequently  the  reverse  of 
congestion.  However  incredible  this  may  appear,  it  i-  no  less  true  thai 
too  many  physicians  -till  mil  in  recognizing  the  tendency  to  syncope,  and 
confound  it  with  cerebral  congestion. 


AND    ITS    RELATIONS    TO    EPILEPSY    AND    ECLAMPSIA.        735 

There  is  a  symptom,  however,  which  often  accompanies  cerebral  hemor- 
rhage, and  which  by  all  medical  men  is  regarded  as  indicative  of  conges- 
tion. 

Thus  a  man,  in  whom  cerebral  hemorrhage  takes  place,  sometimes  be- 
comes suddenly  insensible,  aud  this  abolition  of  the  intelligence  and  of  the 
power  of  motion  lasts  from  a  few  hours  to  several  days.  He  then  comes 
round  again,  with  the  exception  of  a  trilling  degree  of  hemiplegia,  which 
slowly  diminishes  and  finally  passes  off,  after  a  period  varying  from  a  few 
weeks  to  several  months.  As  the  first  symptoms  set  in  almost  with  the 
rapidity  of  lightning,  and  as  there  seems  to  be  no  proportion  between  their 
gravity  and  the  subsequent  impairment  of  the  intellectual  faculties  and 
the  power  of  motion  and  sensation,  it  is  said  that  the  cerebral  hemorrhage 
has  been  attended  with  congestion,  and  that  the  congestion,  an  essentially 
transient  phenomenon,  has  caused  the  apoplectic  symptoms  proper,  and  on 
disappearing,  has  left  behind  it  hemorrhage  to  a  small  amount,  and  trifling 
paralysis.  I  do  not  mean  absolutely  to  deny  the  existence  of  this  conges- 
tion, and  I  even  confess  that  I  am  inclined  to  admit  it  within  a  certain 
limitation.  There  is,  however,  another  symptom  to  which  sufficient  im- 
portance has  not  been  attached,  so  far  as  I  know, — namely,  a  kind  of 
stupor,  like  what  follows  on  commotion,  and  to  which  I  have  given  the 
name  of  cerebral  surprise.  When  the  brain  is  suddenly  torn  or  compressed, 
it  bears  such  a  grave  lesion  with  an  impatience  which  varies  according 
to  individuals,  but  which  may  be  very  considerable  in  some  cases.  Wounds 
of  the  brain  give  us  an  illustration  of  this.  When  a  soldier,  for  instance, 
is  wounded  in  the  head  by  a  ball,  or  when  a  man,  in  a  brawl,  is  stabbed  in 
the  head,  and  the  knife  enters  the  brain,  he  drops  as  if  knocked  down  by  a 
blow  from  a  stick ;  but  by  degrees,  notwithstanding  the  intracranial  effu- 
sions of  blood,  which  are  a  consequence  of  the  wound,  and  even  notwith- 
standing the  inflammatory  congestion  inseparable  from  a  laceration  of  the 
tissues,  the  intellectual  faculties,  the  power  of  motion  and  sensation,  are 
sometimes  recovered  with  extraordinary  rapidity,  and  thus  give  the  inex- 
perienced surgeon  hopes  which  are  unfortunately  never  realized.  What  I 
have  called  cerebral  surprise  is  this  instantaneous  stupor.  However  incor- 
rect the  term  I  use  may  be  (and  I  would  gladly  give  it  up),  the  fact  exists 
and  cannot  be  denied. 

Experiments  on  the  lower  animals  give  still  more  positive  results.  Tf, 
after  trephining  the  skull  of  a  dog  or  a  rabbit,  a  small  leaden  ball  be  intro- 
duced, through  an  aperture  in  the  dura  mater,  between  the  skull  and  the 
surface  of  the  brain,  symptoms  of  stupor  are  immediately  manifested,  which 
gradually  pass  off,  and  are  succeeded  by  an  amount  of  hemiplegia  propor- 
tionate to  the  compression. 

In  this  experiment  no  cerebral  congestion  can  be  appealed  to,  and  it 
must  be  admitted  that  the  brain  is  somehow  surprised  by  an  accident  which 
is  accompanied  by  a  transient  disturbance.  Am  I  not  authorized,  then, 
to  suppose  that  when  blood  is  suddenly  effused  into  the  corpus  striatum  or 
the  thalamus  opticus,  the  immediate  stupor  which  is  ordinarily  attributed 
to  a  simultaneous  congestion  can,  in  part  at  least,  be  due  to  cerebral  sur- 
prise f  Does  it  follow,  gentlemen,  that  I  absolutely  deny  the  existence  of 
cerebral  congestion  ?  No,  indeed;  I  admit  cerebral  hyperemia,  for  I  should 
be  insane  if  I  were  to  deny  it ;  but  I  maintain  that  what  has  been  called 
apoplectiform  cerebral  congestion  is,  in  the  greater  number  of  instances,  a 
symptom  of  epilepsy  or  eclampsia,  and,  in  some  cases,  of  syncope.  I  main- 
tain that  very  often  simple  epileptic  vertigo,  and  vertigo  connected  with  a 
disordered  state  of  the  stomach  or  with  diseases  of  the  internal  ear,  are 
wrongly  looked  upon  as  cases  of  cerebral  congestion. 


736  ON    APOPLECTIFORM    CEREBRAL    CONGESTION, 

If  the  propositions  which  I  have  attempted  to  prove  be  true,  it  will  be 
conceded  to  me  that  we  must  less  frequently  have  recourse  to  revulsives  and 
to  antiphlogistic  measures  in  our  treatment  of  these  cases  of  pretended  cere- 
bral congestion,  and  that  we  must  seek  for  other  indications  more  in  con- 
formity with  the  views  that  should  be  entertained  of  the  various  conditions 
too  often  confounded  under  the  same  denomination.  You  remember,  gen- 
tlemen, what  stormy  discussions  were  excited,  in  the  beginning  of  the  year 
1861,  by  the  opinions  I  now  express,  and  which  I  then  communicated  to 
the  Academy  of  Medicine  ("  Bulletins  de  l'Academie  de  Medecine," 
Paris,  1861,  t.  xxvi). 

I  neither  j:>retended  that  I  had  discovered  something,  nor  did  I  mean  to 
teach  my  colleagues  that  attacks  of  epilepsy  and  eclampsia  were  followed 
by  apoplectic  phenomena ;  this  had  been  said  at  all  times  and  by  every 
one.  I  only  stated  and  attempted  to  prove  a  fact  seen  and  recognized  by 
some  physicians  ;  namely,  that  sudden  apoplectic  seizures  were  oftener  than 
is  generally  believed,  connected  with  a.  fit  of  epilepsy  or  eclampsia.  I  spoke, 
indeed,  of  transient  apoplectic  phenomena  occurring  in  an  individual  enjoy- 
ing excellent  health,  with  or  without  the  premonitory  symptoms  which  pre- 
cede an  attack  of  grand-mal,  and  leaving  him,  shortly  afterwards,  in  the 
same  state  as  before  the  seizure. 

To  speak  unreservedly,  gentlemen,  I  must  at  once  declare  that,  in  my 
opinion,  epilepsy  and  eclampsia  are  two  identical  neuroses,  with  regard  to 
their  symptomatic  expression  and  their  proximate  cause.  Wheu  treating 
of  epilepsy,  I  will  show  you  that  an  attack  of  eclampsia  is  exactly  like  one 
of  epilepsy,  and  that  no  physician  will  ever  be  able  to  distinguish  between 
convulsions  occurring  in  a  pregnant  woman,  long  afflicted  with  epilepsy,  and 
convulsions  in  a  woman  seized  with  eclampsia,  at  the  beginning  of  labor. 
So  much  for  the  symptoms.  Xow,  as  to  the  proximate  cause,  I  believe  it 
to  be  identical  in  both  affections.  When  epilepsy  manifests  itself  by 
monthly  attacks  in  an  individual  with  a  tubercular  deposit  in  his  brain, 
there  are  in  the  brain  and  spinal  cord,  apart  from  the  deposit  of  tubercle, 
no  appreciable  lesions  other  than  those  which  exist  in  the  so-called  idio- 
pathic epilepsy. 

On  dissection,  if  we  find  a  deposit  of  tubercle,  a  cancer,  or  a  bony  tumor, 
the  rest  of  the  brain  presents  merely  the  appearances  of  vascular  congestion, 
met  with  in  the  case  of  a  true  epileptic  who  has  died  in  a  tit. 

What  inference  must  we  draw  from  this?  It  is  this,  that  if  the  tumor  in 
the  brain  be  the  cause  of  the  convulsions,  it  is  not  the  proximate  cause  : 
this  does  now,  and  will  probably,  always  escape  us. 

Eclampsia  occurring  in  a  child  who  is  cutting  his  teeth  or  has  worms, 
of  is  suffering  from  scarlatinal  dropsy,  does  not  in  the  least  differ  as  to  the 
convulsions  from  an  epileptic  fit,  and  yet  these  two  affections  are  widely 
distinct  as  to  their  nature.  I  mean  to  say  that  the  molecular  condition  of 
the  brain  and  spinal  cord  is,  perhaps,  the  same  in  both  cases. 

Allow  me  to  explain  myself. 

When  we  see  an  individual  who  for  twenty  years  has  heen  subject  to 
almost  periodical  fits,  and  yel  manifests  no  signs  of  insanity  or  general 
paralysis,  we  Bay  thai  he  La  suffering  from  it/i<i/>at/iic  epilepsy. 

If  in  the  intervals  between  the  attacks  there  he  hemiplegia,  violent 
headache,  or  exclusively  nocturnal  pain,  we  suspect  the  epilepsy  to  be 
symptomatic  of  a  tumor  in  the  brain,  or  of  tertiary  syphilis. 

If  the  convulsive  disorder  occur-  in  a  pregnanl  woman  with  albuminu- 
ria, or  in  an  individual  with  scarlatinal  dropsy,  or  Buffering  from  lead- 
poisoning,  we  call  it  eclampsia. 

We  give   the   sum'   name   to    the   convulsions  which,  LI]   children,  so  fre- 


AND    ITS    RELATIONS    TO    EPILEPSY    AND    ECLAMPSIA.        737 

quently  announce  the  invasion  of  febrile  exanthemata, — of  variola,  for 
instance, — and  to  those  which  supervene  at  the  close  of  cerebro-meningitis, 
or  what  is  termed  cerebral  fever. 

If  the  epileptiform  convulsion  takes  place  in  an  individual  who  hasjusl 
been  hied,  or  in  an  animal  who  is  left  to  die  of  hemorrhage*;  or,  again,  if  it 
occurs,  as  in  that  curious  experiment  of  Brown-S6quard,  after  the  section 
of  a  lateral  half  of  the  spinal  cord,  under  the  influence  of  certain  kinds  of 
external  irritation, — we  also  call  it  eclampsia. 

What  is  the  relation,  then,  of  eclampsia  to  epilepsy,  and  of  epilepsy  to 
eclampsia? 

If  we  look  at  the  convulsive  character  alone  of  the  two  affections,  sympto- 
matic or  idiopathic  epilepsy,  to  use  the  had  divisions  generally  accepted,  is 
only  recurring  eclampsia,  and  eclampsia  is  merely  accidental  and  transitory 
epilepsy. 

Eclampsia  has  been  said  to  differ  from  epilepsy  in  the  continuity  and  the 
occasionally  prolonged  duration  of  the  convulsions  which  it  causes;  but 
although  there  be  some  truth  in  this  distinction,  there  yet  occur  cases  of 
eclampsia  in  which  there  is  but  a  single  attack,  and  cases  of  epilepsy  with 
continuous  seizures. 

Now,  for  an  orr/anicist, — and  I  confess  that  I  am  one,  in  this  sense  at 
least,  that  I  do  not  conceive  a  functional  lesion  without  a  modification  of 
the  organ  which  discharges  the  function, — every  case  of  epilepsy  or  of 
eclampsia  must  be  symptomatic,  either  of  a  tumor,  or  of  some  form  of  poison- 
ing, or  of  a  peculiar  state  of  the  blood,  or  of  some  inappreciable  organic 
condition,  as  happens  in  epilepsy  proper,  in  eclampsia  from  worms,  or 
eclampsia  which  follows  on  venesection  or  hemorrhage  to  a  large  amount. 

In  medical  language  (which  I  do  not  defend,  and  which  I  only  use  from 
want  of  another,  and  in  order  to  be  better  understood)  we  accept  the  name 
of  eclampsia  for  convulsions  occurring  in  the  course  of  the  cerebral  fever  of 
children  ;  and  why  should  we  refuse  to  give  the  same  name  to  convulsions 
due  to  chronic  cerebro-meningitis,  which  according  to  Royer-Collard,  Cal- 
med, and  many  others,  causes  the  general  paralysis  of  the  insane? 

We  give  the  name  of  symptomatic  epilepsy  to  convulsions  which  are  caused 
by  worms,  or  which  are  due  to  tubercle  or  cancer  of  the  brain ;  and  why 
should  we  refuse  the  same  appellation  to  the  convulsions  which  occur  at 
the  onset  of  tubercular  meningitis? 

Let  us  be  logical,  therefore,  and  let  us  admit  that  all  epileptiform  con- 
vulsions, although  depending  on  very  variable  causes,  are  apparently  the 
expression  of  the  same  intimate  modification.  If  we  admit  this,  we  shall 
better  understand  the  relation  of  eclampsia  and  epilepsy  to  what  is,  by 
common  consent,  called  apoplectiform  cerebral  congestion. 

As  I  shall  tell  you  by  aud  by,  during  the  tonic  period  of  an  epileptiform 
seizure,  the  glottis  is  closed,  and  the  patient  makes  a  supreme  effort,  during 
which  the  face,  the  vessels  of  the  neck,  and  necessarily  those  of  the  hrain, 
get  congested.  The  cerebral  congestion  may  in  such  cases,  then,  be  con- 
sidered as  secondary  and  passive. 

But  is  the  profound  bewilderment,  gentlemen,  which  succeeds  an  attack 
of  eclampsia  or  epilepsy  merely  an  effect  of  this  passive  congestion  ?  I  con- 
fess that  I  do  not  believe  it;  for  the  sudden  loss  of  consciousness  which 
occurs  at  the  beginning  of  an  epileptic  fit,  and  which  is  from  the  first  accom- 
panied by  a  deadly  pallor, — as  so  w7ell  pointed  out  by  Calmed,  in  his  excel- 
lent thesis  on  epilepsy, — is  the  sign  of  such  a  deep  modification  in  the 
functions  of  the  brain,  and  perhaps  in  its  intimate  structure,  that  the  stupor 
sequential  to  the  attack  is  more  probably  a  result  of  this  modification  than 
of  the  secondary  passive  congestion. 
vol.  i  — 47 


738  ON    APOPLECTIFORM    CEREBRAL    CONGESTION, 

Mark,  indeed,  that  we  cannot  admit,  as  many  physicians  do,  that  the 
attack  of  eclampsia  is  the  consequence  of  a  primary  congestion,  when,  on 
the  one  hand,  we  see  that  the  severity  of  the  fit  is  by  no  means  proportion- 
ate to  the  degree  of  previous  plethora,  and  that,  on  the  other  hand,  epilep- 
tiform seizures  wliich  follow  on  a  considerable  loss  of  blood  are  as  severe  as 
those  noticed  under  perfectly  different  circumstances.  Add  to  this — as 
you  will  read  in  the  Journal  de  Physiologie  of  Dr.  Brown-Sequard — that, 
at  the  onset  of  an  epileptic  fit,  the  great  nervous  centres  and  the  medulla 
oblongata  of  an  animal  subjected  to  experiment  become  paler,  instead  of 
presenting  signs  of  congestion. 

Hence  it  follows,  that  what  we  all  call  apoplectiform  cerebral  congestion, 
and  the  apoplectic  phenomena  which  succeed  epilepsy  or  eclampsia,  may 
be  nothing  more  than  a  condition  analogous  to  the  apoplectic  stupor  which 
immediately  follows  on  some  severe  cerebral  disturbance,  and  which  cer- 
tainly occurs  independently  of  all  congestion.  Some  think  it  very  natural 
that  cerebral  congestion  should  produce  such  grave  phenomena.  But  see 
what  occurs  in  a  woman  during  labor.  As  the  child's  head  is  going  to  pass 
the  inferior  outlet  of  the  pelvis  and  the  external  organs  of  generation,  the 
woman  often  makes  most  violent  efforts.  Her  face  becomes  blue,  her  lips 
and  eyelids  swell,  her  skin  gets  hot  and  bathed  in  perspiration,  and  there 
can  be  no  doubt  but  that  the  sinuses  of  the  dura  mater,  and  the  whole  sub- 
stance of  the  brain  share  in  this  congestion.  Is  it  under  such  circumstances 
that  women  are  seized  with  eclampsia?  Ask  accoucheurs,  and  they  will 
tell  you  that  eclampsia  manifests  itself  often  before  all  signs  of  labor  have 
shown  themselves,  and,  in  most  cases,  when  there  have  scarcely  been  slight 
uterine  contractions,  which  do  not  even  attract  the  notice  of  the  patient. 

There  was,  it  is  true,  albumen  in  the  urine ;  but  what  has  albuminous 
urine  to  do  with  convulsions,  when  a  rational  explanation  is  sought  for  ? 

It  seems  that  in  such  cases  convulsions  are  excited  by  a  sympathetic 
cause  as  slight  as  the  scarcely-perceived  sensations  which  arise  from  the 
presence  of  worms  in  the  intestines. 

Children  affected  with  hooping-cough  may  have  so  many  fits  of  cough- 
ing in  rapid  succession,  that  an  intense  degree  of  congestion  is  thereby 
brought  on  ;  so  much  so,  indeed,  that  they  may  have  hemorrhage  from  the 
nose,  that  their  face  will  remain  persistently  puffy,  and  ecchymoses  will  in 
some  cases  form  beneath  the  eyelids.  There  can  be  no  doubt  about  the 
brain  participating  in  the  congestion.  The  fit  over,  they  remain  for  a 
while  in  a  state  of  bewilderment ;  but  can  this  be  compared  with  the  light- 
ning-like suddenness  of  an  attack  of  eclampsia,  and  the  apoplectic  phe- 
nomena which  follow  it? 

Acrobats,  who  go  through  many  of  their  performances  with  their  head 
downwards,  never  suffer  from  anything  like  apoplectic  stupor.  The  por- 
ters of  the  Halle,  who  all  day  long  carry  heavy  burdens,  and  who.  con- 
stantly making  powerful  efforts,  gel  almost  blue  in  the  face,  whilst  the 
bloodvessels  of  the  neck  arc  turgid,  and  look  like  knotted  cords,  are 
never  seized  with  sudden  loss  of  consciousness  or  of  muscular  power,  ai  the 
very  moment  when  they  are  exerting  themselves  the  most. 

Let  iis  admit,  then,  thai  so  long  as  the  blood  is  not  altered  in  its  inti- 
mate composition,  and  is  not  extravasated,  it  is  not  so  injurious  to  our  tis- 
sues as  is  commonly  said  ;   and  that  something  more  than  a  purely  physical 

congestion  is  needed  to  produce  the  apoplectic  phenomena  which  succeed 
epilepsy  or  eclampsia.     1  understand  better  the  disturbance  which  follows 

on  that    special   and   essentially  vital    molecular  condition    which  is  termed 

ilux  or  inflammation. 

There  are,  therefore,  and  I  lay  great  stress  on  the  point,  two  very  distinct 


AND    ITS    RELATIONS    TO    EPILEPSY    AND    ECLAMPSIA.        739 

conditions  in  an  attack  of  eclampsia,  or  of  epilepsy,  whether  idiopathic  or 
symptomatic:  1st.  A  cerebrospinal  modification,  unknown  in  its  essence 

and  in  its  nature,  which  in  a  second  abolishes  all  the  manifestations  of 
animal  life.  Of  the  two,  this  is  by  far  the  more  important  condition.  2d. 
A  secondary  cerebral  congestion,  which,  although  less  important,  may  in 
some  extremely  rare  cases  be  carried  so  far  as  to  produce  subcutaneous 
ecehymoses,  cerebral  capillary  hemorrhage,  and  even  meningeal  hemor- 
rhage. 

Apoplectiform  cerebral  congestion  is  a  term  which  has,  in  my  opinion,  been 
wrongly  applied  to  the  state  of  stupor  which  succeeds  the  complicated  dis- 
orders I  have  just  alluded  to  ;  and  this  term  has  had  an  injurious  influence 
on  the  treatment  employed,  and  on  the  notion  medical  men  have  formed 
of  the  disease. 

Without  quarrelling  about  names,  and  about  the  ultimate  alterations 
•which  characterize  what  physicians  call  apoplectiform  cerebral  congestion, 
there  can  be  no  difference  of  opinion  concerning  the  phenomenon  itself.  It 
is  a  state  of  profound  stupor,  analogous  to  that  noticed  in  cases  of  indi- 
viduals struck  down  by  apoplexy,  and  it  is  attended  with  apoplectic  phe- 
nomena ;  its  cause  being  in  a  great  number  of  cases  epilepsy,  idiopathic  or 
symptomatic,  or  eclampsia. 

These  explanations  were  necessary  before  I  could  lay  down  the  following 
proposition  :  The  same  cerebrospinal  modification  which  causes  the  fit  of 
epilepsy  or  eclampsia,  the  insultus,  the  ictus  epdlepMcus,  is  sufficient  to  produce 
the  apoplectic  stupor  xvhich  follows  it. 

In  a  child  suffering  from  cerebral  fever,  there  doubtless  is  some  stupor, 
but  never  to  a  considerable  degree.  Let  an  attack  of  eclampsia  supervene, 
however,  and  in  a  minute,  from  a  state  of  scarcely  appreciable  stupor,  he 
gets  into  an  apoplectic  condition. 

What  applies  to  the  acute  cerebro-meningitis  of  children  applies  also  to 
the  general  paralysis  of  the  insane,  which  is  probably  nothing  more,  after 
all,  than  a  symptom  of  chronic  cerebro-meningitis.  In  the  latter  case,  with 
the  exception  of  delirium,  and  of  some  uncertainty  in  his  speech  and  gait, 
which  do  not  escape  those  familiar  with  the  diseases  of  the  insane,  the 
patient  apparently  enjoys  good  health  ;  but  on  his  having  an  epileptiform 
seizure,  he  is  struck  down  instantly,  and  passes  into  an  apoplectic  condition. 

In  neither  case  is  the  cerebro-meningeal  inflammation  the  proximate 
cause  of  the  convulsive  and  apoplectic  attack ;  it  is  only  an  indirect  cause, 
the  immediate  one  being  the  minute  central  modification  wdiich  brought  on 
the  attack. 

Hence  it  follows  that  the  apoplectic  condition  so  often  observed  in  the  course 
of  the  paralysis  of  the  insane  is  dependent  on  eclampsia,  just  as  the  analogous 
condition  which  folloivs  an  epileptic  fit  is  dependent  on  epilepsy. 

Let  us  pause  awhile,  gentlemen,  and  ascertain  how  far  we  have  got  on 
with  the  discussion.  I  have  proved  that  transitory  apoplectic  phenomena 
occurring  in  an  individual  in  good  health,  and  leaving  him  in  the  same 
condition  after  as  before  the  attack,  were,  in  almost  every  case,  associated 
with  epilepsy  or  eclampsia. 

I  have  just  shown  that  in  cases  of  acute  or  chronic  inflammation  of  the 
brain,  and  even  in  cases  where  the  nervous  symptoms  arise  merely  from 
sympathy,  as  in  typhoid  fever,  and  in  pneumonia,  for  instance,  sudden  apo- 
plectic phenomena  were  almost  always  preceded  by  epileptiform  convulsive 
phenomena.  I  can  therefore  repeat  what  I  stated  just  now,  namely,  that 
the  same  modification  of  the  nervous  centres  which  produces  the  convul- 
sions, is  sufficient  to  account  for  the  apoplectic  stupor,  and  that  the  pre- 


740  ON    APOPLECTIFORM    CEREBRAL    CONGESTION. 

existing  inflammatory  congestion  is  by  no  means  the  cause  of  the  new  symp- 
toms that  set  in  suddenly. 

I  am  accused  of  making  light  of  cerebral  congestion,  and  of  too  easily 
doing  away  with  it  in  Nosology.  This  is  far  from  true,  gentlemen,  for  I  do 
not  deny  the  existence  of  cerebral  congestion,  but  only  of  that  congestion 
which  is  said  to  produce  sudden  and  transient  apoplectiform  phenomena.  I 
admit  determination  of  blood  to  the  brain,  as  to  any  other  organ,  from  irri- 
tation or  inflammation.  I  admit  that  congestion  evidently  accompanies  it, 
and  that  it  is  sometimes  carried  to  such  a  degree  that  symptoms  of  apo- 
plexy may  be  produced  ;  but  those  symptoms  are  neither  sudden  nor  tran- 
sitory. Again  I  repeat,  I  only  meant  to  speak  of  sudden  and  passing 
apoplectic  phenomena,  and,  as  far  as  they  are  concerned,  I  maintain  my 
first  opinion.  If  I  make  light  of  cerebral  congestion,  and  refuse  to  see  it 
where  others  do,  you  will  agree  with  me  that  it  was  formerly,  and  is  still, 
too  lightly  accepted. 

Hemicrania  and  simple  headache  are  said  to  be  due  to  cerebral  conges- 
tion. The  stupor  of  typhoid  fever,  of  typhus,  pneumonia,  the  plague,  va- 
riola, scarlatina,  is  set  down  to  the  account  of  congestion ;  and  so  is  the  de- 
lirium of  pneumonia,  of  hysteria,  St.  Vitus's  dance,  erysipelas,  &c. 

Sleep  itself  has  by  some  physiologists  and  physicians  been  ascribed  to 
cerebral  congestion.  Therefore,  whenever  stupor  and  drowsiness  showed 
themselves,  whenever  delirium  or  a  tendency  to  dreaming  set  in,  cerebral 
congestion  was  admitted  with  a  facility  which  now  appears  strange  to  most 
practitioners.  Nobody  knows  what  sleep  is  ;  and  the  resemblance  between 
two  individuals,  one  of  whom  is  plunged  in  a  deep  sleep  after  great  fatigue, 
and  the  other  after  an  attack  of  apoplexy,  has  probably  led  medical  men 
to  attribute  to  one  and  the  same  cause  conditions  which  have  but  a  decep- 
tive resemblance. 

This  singular  opinion,  however,  which  was  not  based  on  experiments,  has 
strangely  influenced  the  notion  formed  of  the  action  of  poisons. 

If  opium  induced  sleep,  it  was  by  causing  cerebral  congestion.  Solana- 
ceous  plants,  ranunculus,  colchicum,  digitalis,  prussic  acid,  &c,  caused 
stupor,  because  they  induced  cerebral  congestion.  The  same  obtained  with 
viruses  and  with  animal  poisons,  whether  wholly  produced  in  the  living  or- 
ganism, in  the  course  of  toxeemic  diseases,  or  whether  introduced  from  with- 
out: Profound  stupor  was  always  ascribed  to  congestion.  I  have  already 
said  how  innocuous  I  believed  congestion  to  be;  besides  there  is  no  need 
whatever  to  have  recourse  to  congestion  in  order  to  explain  the  action  of 
poisons.  They  are  absorbed  and  circulate  in  the  blood,  and,  therefore, 
come  in  contact  with  all  parts  of  the  system,  disturbing  them  more  or  less 
completely,  independently  of  the  liquid  which  acts  as  their  vehicle:  and 
often,  as  shown  by  the  experiments  of  Magendie,  in  an  inverse  ratio  to  the 
amount  of  blood  accumulated  in  the  brain,  for  example. 

Excuse  me,  gentlemen,  for  having  dwelt  so  long  on  this  point.  The 
opinion  I  expressed  before  you  at  the  beginning  of  this  conference  seemed 
extraordinary  at  first,  but  I  am  sure  that  it  no  Longer  seems  so  to  you  dow, 
and  that  you  are  convinced,  as  1  am  myself,  thai  sudden  and  transient  symp- 
toms "J  tij/oplexy  are  in  most  cases  assoriafcil  irlf/i  t />ilepsy  or  eclampsia. 


ON    EPILEPSY.  7-11 


LECTUEE  XLL 

ON    EPILEPSY. 

Cases  of  Epil&psy. — Description  of  a  Fit. — How  to  recognize  the  Feigned  Dis- 
ease.—  Three  stages:  Tonic  Convulsions,  Clonic  Convulsion*,  and  Stupor. 
— Synonyms:  Morbus  Major,  Morbus  Cormtialis,  Morbus  Hereuleus,  Fall- 
ing Sickness,  Haut-mal,  &c,  &c. — Sequelce :  Subcutaneous  Ecchymoses, 

Cerebral  Hemorrhages,  &c. —  Cerebral  and  Spinal  Lesions  are  Effects, 
not  a  Cause  of  Epilepsy. — Exciting  Causes. — Status  Epilepticus. — 
Petit-mal. 

Gentlemen  :  We  have  lately  had  in  our  clinical  wards  several  patients 
afflicted  with  epilepsy.  One  of  them  was  a  young  man,  aged  18,  who  occu- 
pied bed  18  in  St.  Agnes  Ward,  and  presented  that  peculiar  form  of  the 
disease  which  has  been  called  partial  epilepsy.  It  consisted,  in  his  case,  of 
convulsions  of  the  facial  muscles,  exclusively  limited  to  the  left  side,  and 
unaccompanied  by  any  phenomenon  usually  met  with  in  an  attack  of  haut- 
mal,  or  by  loss  of  consciousness.  On  inquiring  into  his  previous  history, 
we  learnt  that  the  disease  first  set  in  about  six  years  ago,  with  attacks  .of 
haut-mal.  These  were  very  violent  at  the  commencement,  but  gradually 
became  less  so,  and  although  there  occurred  convulsions  from  time  to  time, 
he  generally  suffered  from  epileptic  vertigo  only. 

Before  proceeding  further,  let  me  call  your  attention  to  this  transforma- 
tion of  epilepsy,  a  fact  pointed  out  long  ago  by  the  practitioners  who  spe- 
cially investigated  the  question;  by  Calmeil  among  others.  Let  me  remark, 
however,  that  they  spoke  of  the  transformation  of  petit-mal  into  grand-mal, 
whilst  in  the  case  of  our  patient,  the  reverse  occurred,  the  convulsions 
having  preceded  the  vertigo. 

You  may  remember,  also,  another  of  our  patients,  an  American,  who, 
after  having  tried  the  public  institutions  of  his  native  country,  obtained 
admission  into  different  Paris  hospitals,  and  finally  went  to,  and,  as  I  have 
been  told,  died  in  London.  He  was  tall  and  powerfully  made,  and  had 
been  nicknamed  the  blue  man,  because  of  the  slate-blue  discoloration  of  his 
skin,  due  to  a  prolonged  treatment  with  nitrate  of  silver,  to  which  he  had 
been  subjected  in  the  United  States. 

You  saw  him  in  several  of  his  fits.  On  a  sudden,  he  shrieked  out,  strug- 
gled, and  turned  round  on  his  own  axis,  catching  hold  of  the  bedstead  when 
he  could,  and  losing  consciousness  entirely.  The  fit  lasted  a  few  seconds, 
after  which  the  poor  fellow  recovered  himself,  although  for  several  hours 
afterwards  he  remained  in  a  state  of  bewilderment,  and  almost  stupefied. 
You  remember  the  fixed  idea  he  had :  he  had  heard  that  castration  had 
been  performed  for  the  cure  of  epilepsy,  and  not  a  day  passed  but  he  begged 
to  be  operated  on.  It  was  only  after  he  became  convinced  of  our  determi- 
nation not  to  accede  to  his  request,  that  he  left  the  hospital,  and  soon  after- 
wards quitted  France. 

About  the  same  period  I  had  a  third  patient  in  bed  20,  St.  Agnes  Ward, 
Avhose  history  deserves  to  be  related  in  detail.  He  was  36  years  old,  and 
had  specially  come  from  Bouconville  (in  the  department  of  Ardennes)  to 
be  treated  in  Paris. 


742  ON    EPILEPSY. 

He  had  the  aspect  of  a  man  of  a  robust  constitution,  and  lie  stated  that, 
indeed,  he  had  never  been  ill.  For  four  years  and  a  half  he  had  served, 
as  a  marine  in  Gaadaloupe,  and  had  enjoyed  excellent  health  there.  The 
only  ailment  he  ever  had  "was  chronic  coryza,  dating  many  years  back,  and 
which  ceased  suddenly  at  the  time  when  he  first  became  subject  to  attacks 
of  havi-mal.  This  coincidence  led  him  to  ascribe  his  disease  to  the  sudden 
disappearance  of  the  coryza.  He  affirmed  that  he  had  never  been  addicted 
to  spirituous  liquors.  None  of  his  relatives,  direct  or  collateral,  had  ever 
suffered  from  nervous  disorders;  and  his  own  child,  then  four  years  old, 
was  in  excellent  health,  and  had  never  had  convulsions. 

The  disease  dated  five  years  back.  One  night  he  had  been  suddenly 
awakened  and  frightened  by  horrible  shrieks  from  his  wife,  and  a  few  days 
afterwards  he  had  his  first  attack. 

In  the  beginning,  these  seizures  were  characterized  by  a  sensation  of 
inward  cold,  of  rigors,  and,  to  use  his  own  words,  of  trembling,  seated  some- 
times in  the  arms,  the  legs,  or  thighs,  and  sometimes  in  the  pit  of  the  stom- 
ach, or  various  parts  of  the  body.  This  sensation  spread  all  over  him,  and 
lasted  a  few  minutes,  without  being  attended  with  loss  of  consciousness. 
The  attacks  recurred  at  irregular  intervals,  rarely  longer  than  four  or  five 
days,  and  were  brought  on  by  the  slightest  painful  emotion,  the  least  varia- 
tion of  temperature,  a  draught  of  cold  air,  or  exposure  to  a  hot  sun.  They 
gradually  increased  in  severity,  and  within  the  last  few  months  had  become 
considerably  more  frequent  and  violent.  They  were  now  regular  convul- 
sive seizures,  similar  to  those  he  had  on  admission,  and  several  of  which  we 
witnessed  ourselves.  On  the  day  of  his  admission,  he  had  just  lain  down, 
when  he  suddenly  got  up,  taking  hold  of  the  bar  across  his  tester-bed,  then 
throwing  his  arms  about,  began  to  vociferate  in  the  most  atrocious  manner. 
His  face  was  of  a  purple-red  color,  his  looks  haggard,  his  voice  loud,  and 
his  articulation  rapid.  He  looked  exactly  like  a  delirious  maniac.  The 
attack  had  set  in  with  quivering  of  the  legs,  followed  by  convulsions.  He 
was  so  wildly  delirious,  that  he  frightened  the  patients  in  the  ward.  He 
had  rushed  out  of  bed,  and  had  to  be  confined  in  bed  with  a  strait-waist- 
coat. He  was  perfectly  unconscious  of  his  acts,  and  kept  insulting  those 
who  were  attending  him.  This  fit  lasted  about  twenty  minutes,  and  with- 
out any  transition  he  became  calm.  He  spoke  distinctly,  and  begged  to  be 
unloosed,  as  he  felt  the  fit  was  over.  I  shall  again  call  your  attention 
presently  to  these  phenomena  of  furor,  and  I  will  point  out  to  you  their 
medico-legal  importance  in  determining  the  degree  of  moral  liberty  enjoyed 
by  some  persons,  who,  without  any  motive,  have  suddenly  committed  acts 
of  violence,  and  even  murder. 

On  the  day  following,  the  patient  related  to  us  his  previous  history,  add- 
ing that  within  the  last  few  months  only  had  his  iits  been  accompanied 
with  loss  of  consciousness.  Once  his  wife,  on  returning  home,  was  sur- 
prised to  find  blood  on  the  floor  of  the  room  ;  he  was  astonished  himself, 
and  on  putting  his  hand  to  his  head  he  felt  a  wound  which  he  had  re- 
ceived on  falling  down  during  a  lit,  of  which  he  had  no  recollection. 

His  fits  were  generally  preceded  by  the  sensations  I  have  already  de- 
scribed ;  he  next  lost  consciousness,  was  convulsed,  and  immediately  be- 
came delirious.  Tin'  attack  lasted  from  twenty  minutes  to  an  hour  even. 
He   then    became    calm   again,   but    complained    of  general    lassitude,   and 

usually  of  headache,  which  he  compared  to  the  compression  that  would  be 

produced  by  a  circle  of  iron.      lie  was   oftener  seized  at  oighl    than  in    the 

daytime.  Of  late  his  memory  had  Beemed  t<>  tail ;  Bometimes  he  fell  con- 
fused  and  had  a  difficulty  in  collect ing  and  in  expressing  his  thoughts.  He 
had  become  impotent  also. 


ON    EPILEPSY.  743 

During  his  stay  in  the  ward  I  had  an  opportunity  of  having  him  watched 
carefully,  and  01  observing  myself  what  happened  during  his  fits.  They 
never  occurred  in  the  Bame  way.  Once  he  was  seized  when  walking  ou1  in 
the  garden,  and  a  companion  who  was  with  him  thus  related  the  circum- 
stances: 

He  turned  pale  suddenly,  in  the  midst  of  a  conversation,  looking  hag- 
gard, with  Ids  teeth  chattering  and  his  arms  moving  about  in  a  disorderly 
manner.  He  was  made  to  sit  down  on  a  bench,  and  his  face  then  growing 
red,  he  laid  hold  of  his  companion's  coat,  as  if  he  wished  to  strip  him,  and 
when  asked  what  he  meant  to  do,  answered  that  his  companion  ought  to 
take  it  off.  He  spoke  distinctly,  and  yet  he  was  so  restless  that  he  could 
with  difficulty  be  kept  on  his  seat.  This  attack  lasted  ten  minutes,  and 
was  followed  by  a  condition  of  bewilderment  and  perfect  stupidity.  When 
made  to  go  up  to  the  ward,  he  offered  no  resistance,  his  gait  resembling 
that  of  a  man  under  the  influence  of  liquor.  On  recovering  himself,  he 
remembered  nothing  of  what  had  occurred. 

On  another  occasion,  I  had  just  been  talking  to  him.  He  was  sitting  on 
a  chair  at  the  foot  of  his  bed,  when  I  suddenly  saw  him  beating  the  ground 
with  his  feet.  His  face  was  excessively  pale,  his  features  distorted,  his 
look  haggard.  He  kept  nervously  looking  about  everywhere,  under  his 
sheets  and  under  his  own  clothes,  exclaiming,  "  Where  is  it  ?  ...  .  my 
spoon?"  I  vainly  tried  to  question  him  ;  he  made  no  answer,  and  seemed 
unconscious  of  all  that  passed  around  him.  He  yet  pushed  away  my  hand 
when  I  touched  him.  This  time  he  had  no  convulsions.  The  fit  lasted 
two  or  three  minutes,  and  left  him  in  a  state  of  prostration. 

These  cases,  gentlemen,  may  have  appeared  very  singular  and  excep- 
tional to  some  among  you,  but  they  are  met  with  pretty  frequently,  how- 
ever. I  must  therefore  call  your  attention  particularly  to  them.  In  all 
these  three  cases,  as  in  others  you  have  also  seen  in  my  ward,  epilepsy  was 
the  disease  under  which  the  patients  labored. 

This  is  a  very  important  subject,  and  I  intend  to  investigate  it  with 
you.  By  pointing  out  to  you  the  various  forms  which  it  assumes,  I  will 
try  and  enable  you  to  recognize  this  disease,  one  of  the  most  formidable 
which  afflict  mankind,  by  means  of  imperfectly  developed,  nay  apparently, 
insignificant  symptoms. 

The  term  ejnlepsy  conveys  to  non-professional  persons,  and  we  must  con- 
fess it,  to  many  medical  men  also,  the  notion  of  a  disease  characterized  by 
convulsive  attacks,  generally  of  short  duration,  and  attended  with  loss  of 
consciousness,  swelling  of  the  face,  distortion  of  the  mouth  and  eyes,  im- 
mobility of  the  pupils,  and  a  good  deal  of  foam  at  the  mouth,  tinged  red 
with  blood. 

Such,  in  fact,  is  the  definition,  very  imperfect  though  it  be,  of  an  epi- 
leptic fit. 

But  this  is  only  one  of  the  forms  of  epilepsy,  and  there  are  many  others 
besides,  which  are  perhaps  more  frequently  met  with,  and  which,  however 
different  they  may  appear  at  first  sight,  present  the  greatest  analogies  be- 
tween one  another.  And  I  hope  to  be  able  to  prove  to  you  that  they  are, 
after  all,  the  expression  of  one  and  the  same  disease. 

The  convulsive  form  itself  is  often  mistaken,  or  rather  confounded  with 
other  convulsive  affections,  such  as  hysteria,  and  particularly  the  various 
kinds  of  eclampsia.  These  latter,  it  is  true,  simulate  epilepsy  very  closely, 
but  are  nevertheless  perfectly  distinct  affections. 

But  first,  how  are  you  to  recognize  real  from  feigned  epilepsy  ? 

Thus  army  doctors  will  tell  you  that  individuals  often  feign  epilepsy  in 
order  to  be  exempted  from  military  service.     But  .the  real  disease  is  char- 


744  ON    EPILEPSY. 

acterized  by  certain  phenomena  which  do  not  escape  the  observation  of  an 
experienced  practitioner,  and  could  only  be  feigned  by  individuals  thor- 
oughly familiar  with  them.  Esquirol,  however,  believed  that  even  such  per- 
sons could  not  perfectly  imitate  the  disease.  Yet  he  was  deceived  himself, 
and  on  this  occasion :  One  day,  Dr.  Calmeil  and  I  were  talking  with 
him  on  this  very  subject  at  the  Asylum  of  Charenton,  when  suddenly  Dr. 
Calmeil  fell  down  on  the  floor  in  violent  convulsions.  After  examining 
him  for  a  moment,  Esquirol  turned  round  to  me,  exclaiming,  "  Poor 
fellow,  he  is  epileptic !"  But  he  had  no  sooner  said  so  than  Dr.  Calmeil 
got  up  and  asked  him  whether  he  still  persisted  in  thinking  that  epilepsy 
could  not  be  feigned.  Although  Esquirol  made  a  mistake  in  this  case,  I 
still  maintain  his  proposition,  and  I  believe  that  even  a  physician,  thoroughly 
familiar  with  all  that  takes  place  during  a  fit,  will  only  imitate  it  imper- 
fectly, because  there  are  some  phenomena  which  cannot  be  produced  at  will, 
as  I  will  show  you  as  I  proceed. 

Xow  let  us  see  what  usually  happens  during  a  fit. 

All  of  a  sudden,  without  any  premonitory  symptom,  the  patient  utters  a 
loud  scream,  and  falls  usually  on  his  face.  This  is  already  an  important 
fact,  and  characteristic  of  the  real  disease.  A  man  who  feigns  epilepsy 
takes  good  care  not  to  throw  himself  down  in  that  way,  or  if  he  does  so,  he 
keeps  his  hands  in  front  of  him,  in  order  to  protect  himself  on  falling. 
The  true  epileptic  is  thrown  down  with  such  violence,  that  his  head  knocks 
against  anv  obstacle  in  the  way.  Sometimes  he  falls  backwards,  or  on  one 
flank,  but  in  most  cases,  I  repeat,  he  falls  forwards,  and  it  is,  therefore,  on 
his  nose  principally,  his  forehead,  his  chin,  his  cheeks — in  a  word,  on  the 
prominent  portions'  of  his  face,  that  you  will  find  either  actual  wounds  or 
scars  of  old  ones.  Fractures  of  the  skull,  or  of  the  bones  of  the  extremities, 
dislocations,  may  also  be  caused 'by  the  fall.  In  some  cases  the  patient 
falls  into  the  fire  and  burns  himself  fearfully  ;  instances  even  have  occurred 
of  persons  found  burnt  to  death,  after  falling  into  the  fire,  and  whose  laces 
were  so  charred  as  to  be  no  longer  recognizable. 

When  down  on  the  floor,  the  patient  presents  symptoms  which  should  be 
carefully  studied,  because,  although  they  do  not  last  long,  they  are  yet 
very  characteristic.  As  he  falls  down,  the  epileptic  is  not  red.  as  it  has 
been  wrongly  stated,  but  deadly  pale;  and  this  is  another  phenomenon 
which  is  necessarily  absent  in  feigned  epilepsy.  Convulsions  then  begin 
immediately.  They  are  tonic  at  first,  consisting  in  a  powerful  contraction 
of  the  muscles,  which  are  in  a  state  of  violent  tension,  without  alternate 
relaxation.  They  are  more  marked  on  one  side  than  on  the  other,  a  char- 
acter of  great  value  in  an  epileptic  fit,  because  rarely  absent.  Sometimes 
even  they  are  limited  exclusively  to  one  half  of  the  body.  You  will  Bee, 
for  instance,  one  arm  twisted  on  itself  and  drawn  backwards,  the  hand 
flexed,  the  thumb  forcibly  adducted  and  hidden  by  the  fingers,  which  are 
benl  over  it  into  the  palm.  The  Lower  extremity  is  also  convulsed:  the 
foot  is  arched  and  extremely  tense  :  the  leg  Is  forcibly  extended  and  twisted 
on  itself.  The  muscular  rigidity  is  ool  to  be  overcome,  and  although 
they  contract  convulsively  with  a  certain  degee  of  slowness,  the  muscles 
are  agitated  by  quivering  of  their  fibrillse,  which  can  be  easily  felt. 

To  the  hand  they  feel  aa  hard  as  iron.  The  twisting  and  forcible  pro- 
nation of  the  limbs  arc  so  violent,  that  injuries  may  result  :  and  I  recently 
a  case  of  spontaneous  dislocation  of  the  shoulder,  which  had  nol  oc- 
curred at  the  time  <>i'  falling. 

Such  injuries  may  even  be  inflicted  in  nocturnal  attacks,  occurring  during 
sleep,  and  [  shall  by  and  by  dwell  on  their  significance,  as  regards  diag- 
nosis.    The  following  is  an  instance  in  point : 


ON    EPILEPSY.  745 

At  the  end  of  the  year  1862  I  was  consulted  by  a  gentleman,  aged  50, 
who  told  me  that  he  awoke  one  morning  complaining  of  a  sense  of  fatigue 

and  of  pain  in  the  right  shoulder,  which  was  so  acute  as  to  completely  pre- 
vent him  from  moving  his  arm.  He  had  formerly  suffered  from  acute 
articular  rheumatism,  and  the  medical  man  whom  he  sent  for,  after  exam- 
ining the  painful  joint,  came  to  the  same  conclusion  as  himself,  namely, 
that  it  was  affected  with  rheumatism.  The  pain  in  the  joint  and  its  ex- 
treme rigidity  persisting,  however,  without  abatement,  the  patient,  after 
several  months  had  elapsed,  returned  to  Paris,  and  consulted  Mr.  Maison- 
neuve,  who  recognized  a  dislocation,  which  was  reduced  with  great  difficulty 
on  account  of  its  ancient  date.  Some  time  afterwards  the  same  accident 
occurred  again  under  identical  circumstances,  but  on  this  occasion  the  dis- 
location was  immediately  reduced. 

Certainly,  gentlemen,  uo  dislocation  of  the  shoulder  ever  occurs  in  ordi- 
nary sleep,  and  after  the  patient  had  related  to  me  what  had  happened  to 
him  on  these  two  occasions,  I  did  not  for  a  moment  hesitate  to  ascribe  the 
dislocation  to  nocturnal  attacks  of  epilepsy.  Other  details,  told  me  by  the 
gentleman  himself,  confirmed  my  diagnosis.  He  had,  indeed,  on  several 
occasions  since,  suffered  from  sudden  fainting  fits,  and  from  vertigo,  about 
the  nature  of  which  no  doubt  could  be  entertained. 

Allow  me  to  revert  for  a  moment  to  the  peculiar  circumstance  that  tonic 
convulsions,  in  an  epileptic  fit,  are  generally  more  marked  on  one  side,  and 
sometimes  even  exclusively  limited  to  one  half  of  the  body.  Those  who 
feign  attacks  are  not  aware  of  this,  and  think  they  ought  to  be  convulsed 
ou  both  sides,  although  if  they  knew  the  circumstance  they  might  imitate 
it.  The  muscles  of  the  trunk  are  affected  as  well  as  those  of  the  limbs. 
The  sterno-cleido-mastoid,  for  instance,  is  thrown  into  contraction,  and  as 
a  consequence,  the  head  of  the  patient  is  drawn  down  to  the  shoulder  on 
the  affected  side,  and  the  face  turned  to  the  opposite  side.  This  is  another 
circumstance  not  known  to  impostors.  The  muscles  of  the  thorax  and 
abdomen  are  likewise  in  a  state  of  tetanic  rigidity,  and  the  respiratory 
movements  are  completely  arrested.  The  fibrillary  cpuivering  I  mentioned 
just  now  as  being  felt  on  laying  one's  hand  on  the  chest  of  the  epileptic,  is 
no  longer  perceived.  After  these  tonic  contractions  have  lasted  a  few 
seconds,  and  the  thorax  remained  perfectly  motionless,  the  face  then  begins 
to  redden,  and  it  is  then  and  then  only,  and  not  when  the  individual  falls, 
that  the  veins  of  the  neck  get  distended,  and  that  the  face  turns  livid,  re- 
maining so  for  a  pretty  long  time. 

At  the  time,  however,  when  tonic  convulsions  affected  the  muscles  of  the 
limbs  and  trunk,  the  face  was  distorted  from  the  convulsions  of  its  muscles. 
The  tongue  also,  violently  thrust  forward  from  the  involuntary  contraction 
of  the  genio-hyo-glossi,  protruded  through  the  half-opened  jaws,  swollen 
out  and  purplish,  but  not  yet  cut  or  wounded  by  the  teeth,  as  it  often  is  in 
a  later  stage.  In  some  cases,  however,  even  in  this  first  stage,  the  tongue 
is  caught  between  the  teeth,  and  deeply  bitten,  when  the  mouth  closes 
slowly,  after  having  been  hideously  distorted  and  partially  opened. 

This  may  be  termed  the  first  stage  of  an  epileptic  tit,  or  stage  of  tonic 
convulsions.  It  lasts  from  ten  to  forty  seconds  at  most,  and  the  second 
stage,  or  that  of  clonic  convulsions,  then  begins.  The  limbs  are  alternately 
flexed  and  extended,  and  it  is  this  stage  which  characterizes  the  epileptic 
fit  with  which  everybody  is  familiar,  and  which  is  easily  simulated.  It 
lasts  from  half  a  minute  to  two  minutes  at  the  most,  so  that  the  whole 
duration  of  the  attack  varies  from  two  to  three  minutes,  and  in  most  cases, 
still  less  than  this.  Those  of  you  who  have  witnessed  epileptic  fits  may 
probably  think  that  I  limit  the  time  too  much,  but  it  is  only  because  three 


746  ON    EPILEPSY. 

minutes  of  such  a  horrible  spectacle  as  that  of  a  man  in  a  fit  seem  very 
long  indeed,  and  appear  to  last  three  or  four  times  longer  than  they  really 
do.  But  observations  made  watch  in  hand,  testify  to  the  correctness  of  my 
statement,  and  indeed  Dr.  Calmed  has  himself  pointed  the  fact  out,  and 
laid  it  down  as  a  general  law. 

The  clonic  convulsions  are  more  violent  on  the  same  side  as  those  of  the 
tonic  kind  were.  They  come  on  at  first  every  second,  and  sometimes  at 
still  shorter  intervals.  They  affect  the  muscles  of  the  face,  as  well  as  these 
of  the  limbs  and  trunk  ;  and  from  the  exaggerated  contractions  of  the 
muscles  of  the  chest  which  modify  the  respiratory  movements,  breathing 
becomes  jerking  and  noisy. 

The  convulsive  movements  describe  a  gradually  larger  and  larger  circle, 
until  at  last  the  muscles  are  fully  stretched  out  and  extended  suddenly, 
when  the  patient  draws  a  deep  sigh,  and  the  fit  is  over;  at  least,  the  con- 
vulsions are  over,  for  a  third  stage  now  begins. 

In  most  cases,  it  is  in  the  second  stage  that  the  tongue  is  wounded  : 
thrust  forward  through  the  half-opened  jaws  by  the  contraction  of  its 
extrinsic  muscles,  it  gets  squeezed  and  bitten  by  the  teeth  when  the  muscles 
which  elevate  and  depress  the  lower  jaw  are  thrown  into  clonic  convulsions. 
The  wounds  which  are  thus  produced,  account  for  the  more  or  less  abun- 
dant hemorrhage,  and  the  reddened  foam  noticed  in  a  great  many  cases. 
The  blood  may  also  come  from  the  nostrils,  or  be  poured  out  from  the  gums, 
which  are  bruised  through  the  breaking  of  one  or  several  teeth  occurring 
at  the  time  of  the  fall,  or  during  the  fit  itself. 

AVith  the  clonic  convulsions  ends  the  convulsive  attack  proper;  but  the 
patient  then  falls  into  an  apoplectiform  condition,  and  looks  like  an  animal 
that  has  been  felled,  or  an  individual  in  whom  there  has  occurred  a  con- 
siderable extravasation  of  blood  into  the  brain,  or  who  is  stupefied  by  drink. 
His  breathing  is  stertorous,  and  during  expiration  his  half-opened  lips 
give  issue  to  frothy  saliva,  which  is  tinged  with  blood.  For  a  length  of 
time  varying  from  a  few  minutes  to  half  an  hour,  he  remains  in  this  con- 
dition of  profound  stupor  and  complete  immobility.  His  intellectual 
faculties  and  power  of  feeling  are  entirely  abolished  during  and  imme- 
diately after  the  attack,  so  that  he  may  be  pinched,  pricked,  or  burnt, 
without  being  conscious  of  it.  In  those  cases,  which  are  unfortunately  not 
uncommon,  when  the  patient  falls  into  the  fire,  he  may  be  burnt  in  a  most 
awful  manner  without  expressing  or  feeling  the  slightest  pain.  On  lifting 
his  upper  lid,  his  pupil  may  be  seen  to  be  dilated,  and  ictuses  to  contract 
under  the  stimulus  of  the  brightest  light.  He  neither  hears  nor  smells,  and 
a  bottle  of  strong  ammonia  may  with  impunity  be  held  under  his  nose. 
These  again  are  facts  which  cannot  be  simulated  by  impostors. 

At  length  the  patient  opens  his  eyes:  at  first  he  looks  around  him  in  a 
stupid,  confused  manner.  If  he  be  still  lying  on  the  ground,  he  attempts 
to  get  up;  but  his  movements  resemble  those  of  a  drunken  man:  be  looks 
ashamed,  and  tries  to  avoid  the  observation   of  lookers-on.      [f  questioned, 

be  falters  out  a  few  unintelligible  words,  and  he  can  scarcely  give  the  sim- 
ples! information  concerning  himself,  such  as  giving  Ins  own  name  and 
address,  or  he  even  makes  no  answer  at  all.  He  allows  himself  to  be  led 
about,  however,  to  be  pul  inside  a  carriage  and  taken  home  without  offer- 
ing any  resistance,  bu1  at  the  same  time  with  as  complete  an  indifference 
as  if  he  was  nol  conscious  of  what  was  going  on. 

Fot  a  few  hours  afterwards,  or  a  day,  a  couple  of  day-  sometimes,  he 
complains  of  headache,  and  of  some  mental  confusion,  particularly  of  some 
failure  of  memory.    Sometime-,  also,  he  remains  temporarily  paralyzed  on 


ON    EPILEPSY.  747 

one  half  of  the  body.  But  in  general,  by  the  next  day,  he  has  recovered 
his  usual  condition. 

This  is  what  is  termed  an  epileptic  fit,  gentlemen,  the  grand-mal  or  morhits 
major  of  Celsus,  which  authors  have  designated  by  other  names,  such  as 
morbus  sonMous  (the  fatal  disease),  morbus  lunaticus  astralis,  so  called  because 
the  motions  of  the  stars,  of  the  moon  in  particular,  were  said  to  influence 
the  attacks  ;  morbus  caducus  (falling  sickness) ;  morbus  comitialis,  because  if 
a  man  were  seized  with  epilepsy  during  a  meeting  in  the  forum,  at  Rome, 
the  assembly  was  broken  up;  morbus  herculeus,  heracleus,  so  called  because' 
Hercules  was  said  to  have  been  an  epileptic  ;  morbus  sacer,  divus,  because 
sent  by  the  gods  ;  St.  John's  complaint,  St.  Giles's  complaint,  as  it  was  termed 
in  the  Middle  Ages,  and  as  it  is  still  called  in  some  departments  in  the  south 
of  France ;  and  again,  morbus  demoniacus,  at  the  time  when  epileptics  were 
believed  to  be  posssessed  with  the  devil.  All  these  names  are  applied  to 
the  convulsive  fit,  or  haid-mal,  the  most  striking  and  the  most  familiarly 
known  form  of  epilepsy.  But  what  everybody  does  not  know',  and  what 
must  be  consequently  pointed  out,  is  the  fact  that  epileptic  seizures  very 
often,  in  the  beginning  especially,  occur  during  the  night;  and  that  an  in- 
dividual may  thus  be  afflicted  for  eight  or  ten  years,  although  nobody,  not 
even  himself,  suspects  the  existence  of  this  dreadful  disease.  Certain  phe- 
nomena, however,  and  certain  accidents,  enable  one  to  recognize  a  past 
attack:  such  as  contusions,  and  injuries  of  a  more  or  less  serious  nature, 
inflicted  on  the  patient  as  he  falls  down,  or  caused  by  the  severity  of  the 
convulsions,  of  which  he  bears  traces  at  least  on  some  part  of  his  body. 
Dislocations  of  the  lower  jaw,  of  which  there  are  instances  on  record,  and 
the  mechanism  of  which  is  plain,  dislocations  of  the  shoulder,  although  rare, 
but  of  which  I  quoted  an  instance  myself,  point  in  the  same  way. 

Even  apart  from  these  accidents,  there  are  other  circumstances  more  fre- 
quently met  with,  and  which  have,  on  the  whole,  an  important  significance. 

In  the  beginning  of  the  year  1863,  Drs.  Tardieu,  Legrand  du  Saule,  and 
Caffe,  were  called  upon  by  a  court  of  justice  to  report  on  the  mental  con- 
dition of  a  lady  whose  interdiction  was  applied  for.  Their  inquiries  had 
for  a  long  time  remained  fruitless,  and  although  they  had  ascertained  a  cer- 
tain degree  of  failure  of  memory,  they  yet  could  not  call  it  dementia,  and 
they  felt  great  embarrassment  at  giving  a  categorical  opinion,  when  they 
were  informed  that  the  lady  sometimes  suffered  from  incontinence  of  urine, 
both  by  day  and  by  night.  Now,  indeed,  was  light  thrown  on  the  subject, 
and  on  questioning  the  lady  more  closely  it  became  evident  that  she  fre- 
quently had  nocturnal  fits  of  epilepsy,  during  which  her  urine  escaped  in- 
voluntarily. Frequently  also,  in  the  daytime,  she  had  attacks  of  giddiness, 
which  lasted  a  few  seconds,  and  during  wdiich  her  urine  escaped  involun- 
tarily. When  once  epilepsy  had  been  recognized,  it  was  better  understood 
how,  under  the  influence  of  fits  which  were  not  noticed,  her  reason  was 
sometimes  seriously  disturbed, 

Dr.  Legrand  du  Saule,  who  related  the  above  case  at  a  meeting  of  the 
Societe  de  Medecine  Pratique,  mentioned  also  that  he  had  seen,  at  Contrexe- 
ville,  a  young  lady  who  pretty  frequently  wetted  her  bed,  and  whose  tongue 
was  wounded  in  some  places  from  being  probably  bitten  on  the  same  occa- 
sions. 

Besides  the  urine,  the  motions  may  be  passed  involuntarily,  and  the  in- 
dividual finds  himself  in  a  mess,  on  waking  up  in  the  morning,  without  hav- 
ing been  conscious  of  what  took  place  during  sleep.  These  are  circumstances 
which,  even  if  occurring  in  persons  apparently  enjoying  the  most  perfect 
health  and  unimpaired  faculties,  should  make  a  medical  man  suspect  the 
possibility  of  nocturnal  attacks. 


748  ON    EPILEPSY. 

I  wish  now  to  direct  your  attention  most  particularly  to  other  phenomena, 
which  modern  authors  have  allowed  to  pass  unnoticed. 

If  you  examine  an  epilej:>tic  carefully  after  one  of  his  fits,  or  better  still, 
several  hours  afterwards — the  next  day,  for  example — you  will  often  find 
on  his  forehead,  his  throat,  and  chest,  minute  red  spots,  looking  like  flea- 
bites,  which  do  not  disappear  on  pressure,  and  have  all  the  characters  of 
ecchymoses.  This  is  a  sign  of  very  great  value,  and  if  modern  authors  have 
laid  too  little  stress  on  it,  it  had  not  escaped  the  notice  of  the  ancients. 
"  Yidemus,  post  validos  paroxysmos  epilepticos  [says  Van  Swieten]  vasa 
cutanea  minora  quandocunque  rumpi,  et puneta  rvberrima  per  totam  super- 
ficiem  corporis  dispersa  manere,  qure  sensim  postea  evanescunt ;  ubi  vero 
rupta  vasa.  vel  dilata  eorumdem  extrema,  sanguinem  rubrum  eructaverint 
in  tunicam  cellulosam,  tunc  latiores  maculse  et  ecchymoses  apparent.  Medici 
in  praxi  versati  frequenter  ha?c  symptomata  observaverunt."  Thus,  not  only 
are  the  small  red  puneta?  I  mentioned  observed,  but  large  ecchymoses  also, 
which  are  produced  in  the  same  way,  and  apart  from  all  contusion.  This 
sign  is,  I  repeat,  of  considerable  importance,  for  the  ecchymoses  are  a  sure 
sign  of  an  epileptic  fit.  Thus,  an  individual  will  tell  you  that  on  waking 
in  the  morning  he  felt  pain  and  heaviness  of  the  head,  and  that  during  the 
night  he  passed  his  urine  or  his  motions  involuntarily.  His  speech  will  be 
embarrassed,  not  because  his  tongue  is  paralyzed,  but  because  it  is  painful 
and  swollen  from  having  been  bitten,  and  sometimes  cut  in  several  places  ; 
and,  lastly,  you  may  notice  ecchymoses  on  his  forehead  and  throat.  In 
such  a  case  you  can  affirm  that  the  patient  has  had  an  epileptic  fit  during 
the  night. 

These  ecchymoses  give  us,  besides,  an  explanation  of  the  apoplectiform 
phenomena  which  characterize  the  third  stage  of  the  fit. 

I  have  told  you  already  that  most  of  the  individuals  seized  with  an  epi- 
leptic fit  remained  for  a  variable  period  in  a  state  of  coma,  and,  on  recover- 
ing from  it,  complained  of  headache,  resembling  the  heaviness  of  the  bead 
which  follows  a  debauch.  In  some  cases,  to  which  I  shall  revert  by  and 
by,  the  stupor  is  followed  by  nervous  symptoms  of  another  kind.  They 
have  hallucinations,  become  wildly  delirious  and  maniacal — sometimes  so 
much  so,  indeed,  that  they  attempt  suicide,  or  try  to  murder  the  persons 
around  them.  Some,  again,  suffer  from  cerebral  disorders  for  two  or  three 
days  afterwards,  such  as  complete  or  partial  loss  of  memory,  incoherence  of 
ideas,  and  perversion  of  the  intellect.  Now,  looking  at  these  ecchyn  -  • 
of  the  subcutaneous  cellular  tissue,  one  may  well  ask  whether  some  similar 
lesion  of  the  cerebral  tissue  has  not  occurred,  of  the  meninges,  or  of  the 
spinal  cord,  and  whether  those  lesions  could  not,  in  a  certain  measure, 
account  for  the-  brain  symptoms  which  showed  themselves;  whether,  for 
instance,  tiny  could  not  explain  the  paralysis  which  occurs  in  some  in- 
stances, and  lasts  for  four,  six,  and  even  ten  days  altera  lit,  disappearing 
then,  in  general,  completely,  until  reproduced  by  another  tit,  but  in  some 
cases  persisting  until  death. 

The  existence  of  these  cerebral  or  spinal  lesions  has  been  ascertained  in 
several  post-mortem  examinations.  Calmeil,  and  other  writers  on  epilepsy, 
have-  pointed  them  out.  Not  only  have  there  been  found  on  the  surface  "i' 
the  brain  red  punctse? like  the  subcutaneous  ecchymoses,  bul  blood-effusions 
have  also  been  mei  with  in  the  meninges,  the  substance  of  the  brain  or 
spinal  cord.  Softening,  even,  of  these  organs  has  been  noticed,  ami  an 
instance  of  this  fell  under  my  own  observation,  in  the  case  of  a  young  girl 
who  died  in  the  St.  Bernard  Ward,  four  days  after  her  admission  into 
tie  Hotel-Dieu.  She  was  Bixteen  years  "Id,  and  Looked  ofa  feeble  consti- 
tution.   She  had  been  I'm-  three  months  subject  to  epileptic  attacks, and  a 


ON    EPILEPSY.  749 

near  relative  of  hers  was  affected  in  the  same  way.  Her  fits  were  exces- 
sively violent,  and  recurred  four  or  five  times  in  the  twenty-four  hours. 
One  of  them  occurred  in  my  presence,  and  there  could  he  no  hesitation 
about  the  diagnosis.  The  convulsions  lasted  one  minute  at  the  most,  were 
accompanied  by  contractions  of  the  hands  and  feet,  of  the  muscle-  of  the 
nek,  and  of  rigidity  of  the  base  of  the  chest,  which  rendered  respiration 
anxious  and  difficult. 

On  the  fourth  day  after  her  admission  she  died  in  a  condition  of  pro- 
found stupor,  after  several  attacks  recurring  one  upon  the  other,  and  leav- 
ing rigidity  of  the  limhs  in  the  intervals.  Dissection  disclosed  extreme 
softening  of  the  spinal  cord,  the  substance  of  which  ran  out  through  the 
incision  made  into  the  meninges.  The  spinal  column  had  been  laid  open 
with  the  greatest  care,  so  as  not  to  injure  its  contents  in  any  way,  and  thus 
avoid  all  source  of  error.  On  slicing  the  brain,  a  small  clot,  the  circum- 
ference of  which  was  beginning  to  soften,  was  found  about  the  middle  of 
the  left  posterior  lobe.  The  brain-tissue  was  of  normal  consistency  every- 
where else,  and  slightly  injected.  The  chief  viscera  presented  no  appre- 
ciable structural  change. 

Lasting  apoplectiform  symptoms,  and  paralysis  which  is  more  or  less  per- 
manent, are  in  all  probability,  therefore,  due  in  a  certain  measure  to 
appreciable  material  lesions  of  the  nervous  centres.  I  hasten  to  add,  that 
those  lesions,  congestion,  hemorrhage,  or  softening,  cannot  be  regarded  as 
causes  of  the  epilepsy  itself;  nor  canf  he  serous  effusions  which  are  sometimes 
met  with  in  the  cranial  cavity  or  in  the  cerebral  ventricles  of  individuals 
Avho  have  died  after  a  fit,  be  looked  upon  as  causes  of  the  disease.  These 
anatomical  lesions  are  effects  of  the  complaint,  and  no  more,  as  it  has  long 
ago  been  proved  by  those  who  have  studied  the  question.  I,  of  course, 
allude  to  epilepsy  proper,  for  we  shall  see  that  in  cases  of  so-called  symp- 
tomatic epilepsy  the  epileptiform  phenomena  are  more  or  less  directly 
dependent  on  the  existence  of  brain-lesions,  such  as  bony  tumors,  cancer  of 
the  brain,  syphilitic  or  tubercular  deposits,  &c,  which  it  is  generally  pos- 
sible to  diagnose  during  life,  and  which  are  revealed  by  a  post-mortem 
examination. 

With  regard  to  idiopathic  epilepsy,  some  authors — among  others,  Bou- 
chet  and  Cazauvielh — have  pretended  that  they  have  always  met  with 
characteristic  lesions,  such  as  an  induration  of  the  white  substance  of  the 
brain.  But  the  cases  they  give  by  no  means  prove  their  assertion,  and 
most,  if  not  all,  physicians  are  now  agreed  that  the  most  delicate  post-mor- 
tem investigations  only  give  negative  results  respecting  the  organic  condi- 
tions under  which  the  disease  is  developed.  I  do  not  deny,  however,  that 
the  cerebral  disorders  which  constitute  epilepsy  depend  on  a  material  lesion 
of  the  nervous  centres.  When  speaking  of  apoplectiform  cerebral  conges- 
tion, I  gave  you  my  opinion  on  that  point.  I  then  told  you,  and  I  repeat 
it  now,  that  I  do  not  conceive  a  functional  lesion  without  an  alteration  of 
the  organ  which  discharges  the  function  ;  but  I  maintain  that  we  have  not 
yet  been  able  to  discover  the  nature  of  this  alteration,  and  that  the  ana- 
tomical lesions  which  we  find  on  dissection  are  the  effects,  not  the  causes,  of 
the  disease. 

I  shall  pass  rapidly  over  the  determining  causes  of  epilepsy,  for  the  influ- 
ence of  the  greater  number  of  those  which  have  been  mentioned  as  such  is 
far  from  being  proved.  It  has  thus  been  said  that  epilepsy  sets  in  more 
frequently  in  women  at  puberty,  about  the  first  menstrual  period,  and  that 
the  cessation  of  menstruation  is  also  another  cause  of  the  disease.  The  part 
played  by  menstruation  is  very  doubtful,  however.  Epilepsy  is  met  with 
at  all  ages,  although  it  occurs  more  commonly  during  adolescence  in  both 


750  OX    EPILEPSY. 

sexes.  If  it  occurs  more  frequently  than  is  generally  believed  in  early  life, 
as  I  shall  show  presently,  it  does  not  spare  individuals  advanced  in  years. 
On  May  16th,  1857,  Dr.  Fantin  (de  Seineport)  brought  me  an  old  fanner, 
seventy-three  years  old,  who;  for  the  last  four  years  only,  bad  suffered  from 
epileptic  fits.  They  first  occurred  during  the  night ;  and  on  waking  in  the 
morning  he  felt  stupid,  and  complained  of  soreness  of  the  tongue.  Under 
the  influence  of  belladonna,  perseveringly  administered  for  three  years,  the 
convulsive  fits  entirely  disappeared,  and  he  only  remained  subject  to  fits  of 
absence,  recurring  every  mouth,  and  sometimes  at  shorter  intervals,  and 
lasting  sometimes  from  fifteen  to  twenty  minutes.  During  these  seizures 
he  spoke  incoherently  ;  and  on  recovering  himself  he  felt  no  fatigue,  but 
had  no  recollection  of  what  had  passed  since  the  beginning  of  the  attack. 

One  of  the  most  celebrated  military  men  of  our  time  became  epileptic 
when  eighty  years  old,  and  died  in  a  fit  thirteen  years  afterwards. 

Errors  in  diet,  excessive  drink  and  venery,  masturbation,  prolonged  chas- 
tity, forced  intellectual  labor,  overstraining  of  the  mind,  violent  moral  emo- 
tions, &c,  have  often  been  put  down  as  causes  of  epilepsy,  but  their  real 
share  in  the  production  of  the  disease  is  yet  to  be  proved.  Of  all  these  oc- 
casional causes  the  influence  of  fright  cannot  be  denied,  and  has  been  noted 
by  every  physican. 

I  have  myself  ascertained  the  fact  on  several  occasions,  but  I  am  far  from 
believing  it  to  be  so  frequent  as  stated  by  patients  and  their  friends.  Very 
recently  I  was  consulted  by  a  Brazilian,  whose  first  attack  seemed  to  have 
been  manifestly  brought  on  by  fright.  Whilst  on  a  long  journey  through 
his  country  he  had  gone  to  a  lonely  inn,  where  he  happened  to  witness  a 
quarrel  between  some  individuals  who  were  armed,  and  who,  from  high 
words,  came  to  blows.  One  of  the  men,  mortally  wounded  by  the  discharge 
of  a  gun,  as  wTell  as  stabbed  with  a  knife,  fell  down  dead  in  his  presence. 
He  was  horribly  affected  by  the  scene,  and  a  few  days  afterwards,  whilst 
dining  with  a  friend,  he  was  seized  with  epileptic  vertigo.  Since  that  time, 
and  for  the  next  five  years,  he  was  every  day  affected  in  the  same  way. 
The  attacks  were  ushered  in  by  a  sensation  of  great  heat,  beginning  at  the 
navel,  and  rising  up  the  back,  which  was  followed  by  absolute  loss  of  con- 
sciqusness  for  the  space  of  two  minutes  or  so.  They  sometimes  passed  away 
so  quickly  that  they  were  not  noticed  by  anybody  near  him.  At  the  end 
of  five  years,  convulsive  seizures  supervened,  which  were  at  first  mistaken 
for  apoplexy,  and  recurred  at  intervals  of  from  twenty  to  thirty  days.  The 
vertigo  disappeared  from  that  time.  Pie  was  treated  by  a  physician  at  Rio 
Janeiro,  and  for  the  space  of  four  years  and  eleven  months  he  was  free  from 
an  attack.  After  this  interval  the  convulsive  fits  recurred  again,  as  intense 
and  as  regular  as  before,  persisting  for  six  years.  They  then  became  less 
violent  again, although  more  frequent,  and  occasionally  attacked  him  during 
the  night.  He  stated  positively  that  no  member  of  his  family  had  ever  been 
similarly  affected. 

It  is  not  difficult  to  collecl  analogous  instances.  Thus  Leurel  (in  his 
"Researches  on  Epilepsy,"  Archives  Generales  de  M6decine,  1843)  states 
that  of  sixty-seven  cases  of  epilepsy  observed  by  himself,  the  firsl  Bymptoma 
of  the  disease  phowed  themselves  after  a  frighl  in  thirty-live. 

I  do  not  wish,  however,  to  leave  you  under  the  impression  of  Leuret's 
too  absolute  doctrine.  Whenever  I  see  a  case  of  epilepsy  I  carefully  in- 
quire  into  the  cause;  and  although  the  patient  in  most  cases  imputes  his 
complaint  to  fright,  on  closely  questioning  him  I  6nd,  however,  thai  in 
almost  every  instance  the  attacks  occurred  only  weeks,  month-,  and  even 
years  after  the  fright.  I  besides  ascertain  thai  this  frighl  was  not  more 
severe  or  more  repeated  than  in  the  case  of  a  great  many  children  who  have 


ON    EPILEPSY.  751 

never  had  fits.  The  patients  only  repeal  what  they  heard  from  their  friends, 
ami  in  most  cases  when  I  can  question  the  friends  themselves  and  obtain 
the  truth  from  them,  I  find  that  there  have  bqen  members  of  tlje  family 
affected  with  insanity,  epilepsy,  or  idiocy,  and  that  the  pretended  fright 
only  served  as  a  pretext  to  hide  the  true  cause,  namely,  an  hereditary  taint. 

I  do  not  mean  either  to  deny  the  influence  of  emotions  felt  by  a  preg- 
nant  woman  on  the  foetus  in  utero ;  but  I  believe  that  this  canst;  has,  like 
the  rest,  been  extremely  exaggerated.  Let  us  now  study  the  different  forms 
of  the  disease. 

I  have  already  told  you  that  an  epileptic  fit  lasted  rarely  more  than  two 
or  three  minutes.  I  maintain  this  assertion,  and  I  add  further,  that  an 
attack  lasting  from  four  to  six  minutes  is  of  such  rare  occurrence  that  a 
medical  man  may  live  for  years  among  epileptics  without  observing  a  single 
one.  And  yet  you  have  heard  of  cases  in  which  the  attacks  have  lasted 
two  or  three  days,  and  have  terminated  in  death.  This  is  the  condition 
which  has  been  termed  status  epilepticus  at  Bicetre  and  the  Salpetriere. 
The  contradiction  between  these  facts  and  my  proposition  is  merely  ap- 
parent. The  status  epileptietus  is  characterized,  not  by  a  single  attack,  but 
by  a  series  of  attacks,  and  what  then  happens  is  as  follows :  ; 

The  epileptic  has  a  convulsive  fit,  just  like  a  parturient  woman  is  seized 
with  eclampsia.  In  both  cases,  the  stupor  which  succeeds  the  convulsions 
lasts  from  ten  minutes  to  three-quarters  of  an  hour  at  most.  But  before 
the  stupor  has  passed  away  another  attack,  exactly  similar  to  the  first, 
supervenes,  and  is  confounded  with  it.  Xow,  as  the  third  stage  of  an  epi- 
leptic fit  is  not  usually  regarded  as  distinct  from  the  convulsive  stage,  the 
patient  seems  to  be  still  in  a  fit,  although  his  comatose  condition  is  only  an 
effect  of  the  fit.  He  has  not,  therefore,  got  over  the  disturbances  caused  by 
the  first  attack  before  a  second  occurs,  then  a  third,  a  fourth,  a  fifth  ;  and 
in  proportion  to  the  recurrence  of  the  fits  the  cerebral  congestion  increases, 
the  apoplectic  coma  is  prolonged,  and  extends  over  a  period  varying  from 
two  to  twenty-four  hours,  and  after  a  time  the  patient  does  not  recover  his 
senses  at  all.  In  some  exceedingly  rare  cases  the  convulsions  last  a  longer 
time  than  I  have  stated ;  but  such  cases  are  so  exceptional  that  at  Bicetre 
and  the  Salpetriere,  where  a  considerable  number  of  epileptics  are  gathered 
together,  and  where,  consequently,  from  forty  to  fifty  attacks  may  be  seen 
in  one  day,  as  Dr.  Calmeil  did,  two  or  three  months,  and  even  more,  may 
elapse  without  a  single  one  of  the  kind  occurring. 

In  the  status  epilejiticus,  when  the  convulsive  condition  is  almost  contin- 
uous, something  special  takes  place  which  requires  an  explanation.  The 
patient  has  a  fit  of  haut-mal,  then  eveiy  two  seconds  slight  convulsive  move- 
ments, transient  and  scarcely  visible,  affect  his  face,  his  neck,  and  his  limbs, 
and  these  recur  in  the  same  way  for  the  space  of  from  two  to  five  hours. 
This  is  assuredly  a  continuous  convulsive  attack;  but  it  should  be  observed 
that  it  is  no  longer  an  attack  of  haut-mal,  but  quite  a  different  and  special 
form  of  seizure,  dependent  on  a  peculiar  irritable  condition  of  the  brain 
and  spinal  cord.  This  is  what  should  be  meant  by  a  continuous  attack  ; 
and  this  form,  besides,  occurs  more  frequently  in  cases  of  eclampsia  than 
of  epilepsy. 

I  have  described  epilepsy  to  you  in  its  most  familiar  form,  and  it  now 
remains  for  me  to  say  that  the  haut-mal  varies  in  intensity,  in  violence,  and 
in  suddenness  of  seizure.  Some  individuals  are  struck  down  without  any 
premonitory  symptom,  and  without  uttering  a  cry.  In  others,  whilst  they 
are  being  spoken  to,  their  knees  gradually  bend,  and  they  fall  down  sense- 
less, without  the  least  convulsive  movement.  Although  rare,  such  cases 
are  yet  met  with. 


752  OX    EPILEPSY. 

Some  time  ago,  a  child  affected  with  this  singular  form  of  epilepsy  was 
brought  to  me.  His  friends  were  telling  me  how  he  was  attacked  four,  five, 
and  even  six  times  in  an  hour,  when  he  suddenly  slipped  from  the  arm- 
chair in  which  he  was  sitting,  and  fell  down  on  the  carpet.  I  examined 
him  carefully,  but  detected  nothing  approaching  to  convulsion. 

Another  individual,  about  whom  I  was  also  consulted,  had  similar  at- 
tacks two  or  three  times  a  week.  The  seizures  at  first  set  in  with  hallucin- 
ations which  lasted  half  a  minute,  during  which  time  he  stared  vacantly, 
with  his  arms  hanging  down  by  his  side.  The  symptoms  then  became 
modified,  and  he  lost  his  senses  during  attacks  which  lasted  about  ten 
minutes.  The  case  being  mistaken  for  one  of  cerebral  congestion,  leeches 
were  applied,  but  after  this  a  second  attack  came  on,  which  was  accompa- 
nied by  convulsions  of  the  face  and  rolling  of  the  eyeballs. 

This  form  of  epilepsy  consists,  then,  in  mere  giddiness,  and  seems  to  leave 
behind  it  scarcely  any  consequences,  any  immediate  ones  at  least.  The 
patient,  on  getting  up,  looks  a  little  bewildered,  but  is  soon  able  to  resume 
the  interrupted  conversation,  as  if  nothing  had  occurred.  The  attack  does 
not  proceed  beyond  the  first  stage,  and  although  strong  enough  to  prostrate 
the  patient,  it  does  not  pass  on  to  convulsions. 

In  other  cases,  on  the  contrary,  the  first  stage  is  absent.  The  epileptic 
falls  down,  his  upper  limbs,  sometimes  his  eyes  alone,  are  agitated  convul- 
sively, and  he  then  gets  up  almost  immediately,  scarcely  feeling  a  little 
stupid,  and  somewhat  mentally  confused  for  a  short  time. 

In  other  instances,  again,  the  fit  occurs  as  usual,  but  is  extremely  slight. 
There  are  tetanic  convulsions,  but  only  for  an  inappreciable  time  ;  clonic 
convulsions  follow,  and  after  a  few  seconds  the  stage  of  stupor  comes  on, 
and  is  as  transient  and  as  slightly  marked  as  the  preceding.  The  patient 
then  gets  up,  and  the  attack  has  scarcely  lasted  a  minute. 

These  are  very  different  forms  from  those  which  we  were  studying  just 
now  ;  and  they  are,  as  it  were,  transitions  between  attacks  of  haut-mal  and 
other  manifestations  of  epilepsy  to  which  I  am  now  about  to  call  your 
attention  more  particularly.  Keep  these  facts  well  in  mind.  No  case  of 
epilepsy  is  more  genuine  than  that  in  which  the  fit  occurs  quietly,  without 
any  extensive  movements,  and  without  much  noise.  If  an  attack  of  haut- 
mal  can  be  sometimes  so  well  feigned  as  to  deceive  those  who  arc  not  thor- 
oughly familiar  with  it,  it  is  quite  different  with  the  small  seizures,  with  the 
fit-  of  vertigo,  which  I  am  now  proceeding  to  consider. 


§2.  Epileptic  \'irti</<). — Aura  EpUepUca. — Partial  Epilepsy. — Angina  /'   - 
toris. — Painful  Spasm  of  the  Face. 

Vertigo,  gentlemen,  is  a  manifestation  of  epilepsy  which  is  least  familiar 
tn  medical  practitioners,  and  errors  of  diagnosis  are  committed  every  day. 
which  may  be  followed  by  dangerous  consequences,  through  a  very  grave 
disease  being  represented  as  a  trifling  ailment. 

Let  me  first  cite  a  certain  number  of  instances  of  vertigo,  and  thus  at- 
tempt to  show  you  the  numerous  tonus  which  it  may  assume.  But  remem- 
ber that  however  various  the  tonus  the  disease  is  always  the  same,  and  thai 

these  transienl  strange  phenomena  which  sometimes  consisl  only  in  giddi- 
aess,  in  a  sort  of  astonishment,  in  ecstasy,  or  in  what  has  been  termed  "  fit 

of  absence,  are  identical  in  their  nature  with  the  violent  convulsions  which 
characterize  an  attack  of  haut-mal.  Nay  more,  vertigo  is  to  a  certain  ex- 
tent much  more  characteristic  of  epilepsy  than  convulsions  arc.  The  latter, 
indeed,  may  he   a    symptom   of  other  diseases   which,  however   much    they 


ON    EPILEPSY.  753 

differ  from  epilepsy,  arc  frequently  confounded  with  it.  Thus,  in  females, 
hysterical  fits  resemble  epilepsy  bo  closely  as  to  be  mistaken  for  it,  and 
those  who  have  had  occasion  to  observe  a  good  many  cases  of  hysteria,  as 
at  the  Salpetriere,  know  how  difficult  it  is  in  some  cases  to  distinguish 
between  the  two  affections.  Epileptic  vertigo,  on  the  contrary,  as  well  as 
the  vertigo  of  eclampsia,  has  a  special  physiognomy,  which,  when  once 
studied  and  looked  out  for,  cannot  be  confounded  with  anything  else. 

Inquire  carefully  into  the  case  of  an  individual  suffering  from  this  form 
of  epilepsy,  and  especially  if  the  patient  be  a  youth  or  a  child,  you  will 
recognize  u  more  or  less  distinct  manifestation  of  the  disease  by  the  symp- 
toms he  will  describe  to  you. 

I  have  already  pointed  out  the  transformation  of  the  symptoms  into  one 
another.  Iu  general,  vertigo  precedes  the  convulsive  form,  but  the  reverse 
sometimes  obtains.  The  haut-mal,  which  had  been  the  first  manifestation 
of  the  disease,  becomes  modified ;  the  attacks  diminish  in  violence,  and  the 
individual  becomes  subject  to  pet it-vxal  only  (another  name  given  to  epilep- 
tic vertigo).  An  instance  of  this,  as  you  know,  occurred  in  the  case  of  a 
young  man  lying  in  bed  No.  18,  St.  Agnes  Ward.  Nor  is  it  uncommon  to 
see  convulsive  attacks  and  vertigo  develop  themselves  simultaneously,  or 
the  latter  appear  at  least  in  the  intervals  between  the  former,  or  even  usher 
them  in. 

A  gentleman  came  one  day,  from  Berry,  to  consult  me.  During  the 
short  time  he  remained  in  my  consulting-room,  he  was  seized  with  vertigo, 
characterized  by  jerking  bursts  of  laughter.  The  fit  lasted  a  few  seconds 
only,  and  he  immediately  recovered  himself;  but  he  seemed  very  much  sur- 
prised when  I  asked  him  why  he  had  laughed:  he  was  not  conscious  of  what 
he  had  just  been  doing.  The  convulsive  attacks  to  which  he  was  subject 
were  almost  always  ushered  in  by  these  vertiginous  seizures. 

The  concomitant  existence,  or  alternating  production,  of  these  various 
morbid  phenomena,  clearly  point  out  their  connection  and  their  identical 
nature. 

Let  us  now  rapidly  review  some  of  the  forms  assumed  by  epileptic  ver- 
tigo, keeping  in  mind  that  these  forms  vary  indefinitely,  and  that  it  would 
be  vain  to  try  and  describe  them  -all. 

You  remember  a  young  girl,  aged  16,  who,  for  a  long  time,  was  in  St. 
Bernard  Ward,  and  to  whose  case  I  have  already  alluded  in  a  former  lec- 
ture. You  remember  the  seizures  to  which  she  was  several  times  subject  in 
the  course  of  the  twenty-four  hours,  and  which  I  witnessed  on  several  occa- 
sions with  you,  when  going  round  the  wards.  She  suddenly  lost  all  con- 
sciousness of  her  acts,  and  dropped,  or  more  frequently  threw  away  at  a 
distance,  anything  she  might  be  holding.  Sometimes  she  would  then  jump 
about,  turning  round  her  bed  as  if  she  were  looking  for  something;  at  other 
times,  she  would  fall  down,  whilst  her  face  grew  pale  for  a  moment,  and 
her  eyes  rolled  convulsively  upwards  under  the  upper  eyelid,  and  looked 
strangely  fixed ;  on  other  occasions,  again,  she  would  keep  clapping  her 
hands  rapidly.  If  she  happened  to  be  seized  in  bed,  she  sat  up,  and  took 
hold  of  the  bedclothes,  as  if  she  wanted  to  cover  herself  up.  The  attack 
scarcely  lasted  half  a  minute,  and  as  it  passed  off,  she  called  out,  "  It  is 
over."  Very  slight  and  very  transient  stupor  then  followed.  But  a  very 
remarkable  circumstance  in  this  case  was  that  if  an  attempt  were  made  to 
take  from  her  an  object  which  she  might  be  holding  at  the  time  of  her 
seizure,  she  rushed  on  in  a  kind  of  rage,  in  order  to  gain  possession  of  itr 
and  struggled  until  the  fit  was  over. 

She  stated  that  her  illness  dated  from  the  previous  year  only,  and  had 
set  in  with  vertigo,  or  what  she  termed  "  fits  of  surprise."  She  had  as 
vol.  i. — 48 


754  ON    EPILEPSY. 

many  as  a  hundred  attacks  in  one  day,  and  occasionally  had  convulsive  fits. 
She  had  no  warning  whatever.  Her  father  and  mother  had  never  suffered 
from  any  analogous  complaint,  but  a  sister,  now  dead,  had  been  epileptic. 

Thus,  in  the  majority  of  instances,  suddenly,  and  without  any  premoni- 
tory symptom,  as  in  an  attack  of  haut-mal,  the  individual  subject  to  epi- 
leptic vertigo  feels  a  kind  of  astonishment,  becomes  absent,  as  it  were.  If 
he  is  engaged  in  conversation  at  the  time,  he  suddenly  stops  in  the  middle 
of  a  phrase,  and  with  eyes  fixed,  looking  bewildered,  he  neither  sees,  hears, 
nor  feels  anything.  He  is  in  a  kind  of  ecstasy,  and  yet  he  does  not  fall 
down.  If  he  has  an  object  in  his  hands,  he  drops,  or  convulsively  throws 
it  away  from  him.  The  whole  lasts  from  two  to  four  seconds,  and  some- 
times more ;  the  attack  is  then  over,  the  patient  recovers  himself  com- 
pletely, resumes  his  occupation  or  the  conversation  in  which  he  was  en- 
gaged, and  has  no  suspicion  of  what  has  occurred. 

Dr.  Taupin  once  asked  me  to  meet  him  in  consultation  about  a  little 
girl,  six  years  old,  who  had  been  ill  for  five  weeks,  and  whom  I  had  al- 
ready seen.  He  told  me  that  he  had  himself  witnessed  two  attacks  which 
had  occurred  at  dinner-time,  and  the  girl's  mother  also  gave  an  excellent 
account  of  what  happened.  The  child,  whilst  at  play  or  at  dinner,  stopped 
suddenly,  and  turned  her  head  slowly  to  the  right,  with  her  eyes  open  and 
fixed.  There  were  no  appreciable  convulsions,  and  no  distortion  of  the 
face.  Sensation  was  so  completely  abolished  that  her  skin  could  be  pinched 
or  pricked  with  a  needle  without  her  seeming  to  feel  pain.  She  remained 
in  that  condition  for  the  space  of  four  or  five  seconds,  and  then  recovering 
herself  looked  somewhat  bewildered  and  cross.  Generally  also  she  then 
expressed  a  wish  to  move  about,  requesting  her  mother  to  take  her  into  the 
next  room.  But  in  a  few  seconds  she  was  perfectly  herself  again ;  and, 
after  drawing  a  deep  sigh,  she  returned  to  her  play,  or  went  on  eating,  as 
the  case  might  be.  The  attack  of  vertigo  may  last  a  longer  time,  however, 
and  may  consist  in,  or  be  accompanied  by,  more  or  less  marked  delirium, 
manifesting  itself  by  words  and  acts. 

On  another  occasion,  I  was  consulted  about  a  little  girl,  aged  four,  who, 
for  the  preceding  fortnight,  had  presented  symptoms  like  the  above  on 
every  other  clay.  She  was  otherwise  in  excellent  health,  had  a  precocious 
intelligence,  and  related  very  well  what  she  felt.  She  experienced  some- 
thing like  a  general  shock,  according  to  her  own  account,  and  then  became 
unconscious.  Her  mother,  however,  told  me  that  her  face  then  assumed  a 
singular  expression  of  cheerfulness  and  vivacity  in  some  cases,  whilst  in 
others  the  child  looked  stupid.  After  scarcely  a  minute  had  elapsed,  she 
exclaimed  that  she  was  frightened,  acted  in  a  strange  and  disorderly  man- 
ner, and  spoke  incoherently.  These  hallucinations  were  sometimes  pro- 
longed for  seven,  eight,  and  ten  hours.  Within  two  days  the  at  tucks  had 
recurred  twice  in  the  twenty-four  hours.  The  mother  added  that  she 
thought  her  child's  intelligence  was  getting  impaired. 

A  medical  man,  practicing  at  Versailles,  sent  a  young  girl  to  consull  me, 
in  December,  1-SOO,  whose  mother  and  grandmother  were  healthy,  hut 
whose  aunt  and  great-aunt,  on    her   mother's  side,  were  Bubjecl  to  epilepsy. 

She  herself  suffered  from  attacks  of  vertigo,  which  were  >o  frequeni  thai  I 
saw  four  or  live  of  them  whilst  she  was  in  my  consulting-room.  She 
uttered  :i  plaintive   cry,  and   suddenly  placing  her   hand   on  the  pit  of  her 

stomach,  she  slowly  turned  ber  head  over  to  one  side.     Her  eyes  were  at 

the  same  time  fixed,  ber  face  was  Blightly  distorted.      Before  a  minute    had 

elapsed  all  Beemed  to  be  over,  and  she  then  go1  up,  looking  bewildered, 

Staggered,  and  sometimes  fell  down.  I  f  any  one  came  mar  her,  -he  Beemed 
to  feel  a  sort    of  terror.      I    questioned    her   ipiickly  ;   but    she   opened    her 


ON    EPILEPSY.  755 

mouth  and  made  signs  that  she  could  not  speak;  I  asked  her  to  put  her 
tongue  out,  and  to  move  it  about,  hut  she  was  unable  to  do  so.'  A  few 
moments  afterwards  she  uttered  a  few  inarticulate  words,  and  on  my  insist- 
ing to  make  her  speak,  her  speech  became  gradually  less  embarrassed,  and 
then  perfectly  natural.  The  attack  lasted  four  or  five  minutes  altogether. 
She  was  very  intelligent,  and  described  her  sensations  very  well.  She 
stated  that  on  the  accession  of  the  fit  she  felt  acute  pain  in  the  epigastrium, 
which  almost  instantly  extended  to  the  tongue,  when  it  became  very  in- 
tense. She  then  lost  her  senses  for  one  or  two  minutes,  and,  on  beginning 
to  come  round,  she  was  prevented  from  speaking  by  a  kind  of  painful 
paralysis  of  the  tongue,  which  gradually  passed  off. 

Again,  an  individual  who  is  subject  to  epileptic  vertigo  may,  whilst  play- 
ing at  cards,  and  holding  in  his  hand  a  card  which  he  is  going  to  throw 
down,  suddenly  become  motionless,  shut  his  eyes  or  stare  before  him,  and 
then,  after  drawing  a  deep  sigh,  he  may  continue  to  play.  These,  gentle- 
men, are  types  of  epileptic  vertigo,  and  I  might  multiply  instances  of  the 
same  kind.  But  there  are  other  and  different  forms,  which  I  will  now 
point  out  to  you. 

In  the  above  cases,  the  patient  is  isolated  from  the  external  world  ;  he 
sees,  hears,  and  feels  nothing,  and  remains  perfectly  motionless,  in  a  kind 
of  ecstasy.  In  some  instances  movements  resembling  those  of  mastication 
are  performed,  followed  by  the  same  guttural  sound  as  when  saliva  alone 
is  swallowed.  In  other  instances,  there  is  some  mental  confusion  or  dis- 
order which  lasts  a  few  seconds,  a  few  minutes  even,  but  which  escapes  the 
notice  of  bystanders.  Lastly,  there  are  cases  in  which  the  epileptic  mav 
complete  the  movements  he  has  begun,  and  even  perform  new  ones  with  a 
certain  degree  of  regularity,  although  he  is  perfectly  unconscious  of  his  acts. 

I  have  on  several  occasions  cited  the  case  of  a  priest  who,  whilst 
officiating  as  deacon,  and  incensing  the  bishop  from  the  thurible,  was 
seized  with  epilepsy,  and  still  continued  swinging  the  censer,  although 
his  head  was  so  strangely  twisted  round,  and  his  face  so  contorted,  that 
the  fit  attracted  everybody's  attention.  He  was  subject  to  vertigo, 
and  had  been  often  attacked  in  the  pulpit,  or  at  the  altar,  whilst  offi- 
ciating. The  attacks,  howrever,  were  so  transient,  that  he  had  never 
been  obliged  to  interrupt  his  sermon  or  go  away  from  the  altar.  But  as 
during  the  fit  he  sang  in  a  strange  manner,  and  had  on  some  occasions 
uttered  incoherent  words,  these  acts  being  considered  undignified  in  a  priest, 
he  was  of  necessity  suspended.  He  came  to  consult  me,  and  told  me  him- 
self the  above  details. 

I  have  already  mentioned  to  you,  in  a  preceding  lecture,  the  case  of  a 
young  amateur  musician  subject  to  epileptic  vertigo,  and  who  has  some- 
times a  fit  whilst  playing  the  violin.  Strange  to  say,  he  goes  on  playing 
during  the  attack,  and  although  he  is  perfectly  unconscious  of  everything 
around  him,  and  neither  hears  nor  'sees  those  he  is  accompanying,  he  still 
plays  in  time.  It  would  seem  as  if  his  will  were  powerful  enough  to  direct 
the  movements  of  his  hands  for  a  given,  though  very  short  time,  and  as  if 
those  movements  were  guided  by  memory,  the  patient  performing  without 
a  fault  the  musical  phrase  which  he  had  read  just  as  his  mind  became 
affected. 

Many  of  you  may  recollect  having  heard  me  relate  the  following  case : 
An  architect  who  resides  in  Paris  and  has  long  been  subject  to  epilepsy, 
does  not  fear  to  go  up  the  highest  scaffoldings,  and  yet  he  is  perfectly  aware 
that  he  has  often  had  fits  whilst  walking  across  narrow  planks,  at  a  pretty 
considerable  height.  He  has  never  met  with  an  accident,  although  when 
in  a  fit  he  runs  rapidly  over  the  scaffoldings,  uttering,  or  rather  shrieking 


756  OX    EPILEPSY. 

out  his  own  name  in  a  loud,  abrupt  voice.  A  quarter  of  a  minute  after- 
wards he  resumes  his  occupation,  and  gives  his  orders  to  the  workmen ;  but 
unless  he  be  told  of  it,  he  has  no  idea  of  the  singular  act  which  he  has  been 
committing. 

I  once  knew  a  gentleman  of  superior  intelligence,  the  president  of  a  pro- 
vincial tribunal,  who  was  subject  to  epileptiform  symptoms,  but  had  never 
had  an  attack  of  haut-mal.  Some  of  his  relations  were  of  unsound  mind, 
his  sister  among  others.  One  day,  whilst  the  court  was  still  sitting, 
he  got  up,  muttering  a  few  unintelligible  words,  went  to  the  council-room, 
and  returned  a  few  seconds  afterwards,  unconscious  of  what  he  had  done. 
When  his  colleagues  asked  him  where  he  had  been  to,  he  did  not  recollect 
having  moved  from  his  place.  Shortly  afterwards,  as  he  was  getting  up  in 
the  same  manner,  the  usher  was  told  to  follow  him.  He  was  then  seen  to 
enter  the  council-room,  and  make  water  in  a  corner,  after  which  he  returned 
to  the  court,  perfectly  ignorant  of  his  incongruous  act.  He  noticed  him- 
self, however,  that  for  a  few  minutes  after  these  attacks  his  mental  faculties 
were  somewhat  impaired.  I  heard  of  these  facts  from  himself  and  from  his 
father-in-law.  I  did  not  conceal  from  the  latter  of  what  grave  import  they 
were,  and  I  recommended  that  the  patient  should  resign  his  post.  He  had 
some  difficulty  in  deciding  upon  this  step,  but  one  day  whilst  in  court  he 
got  up,  walked  about,  and  spoke  incoherently  to  the  people  around. 
Almost  immediately  afterwards  he  resumed  his  seat,  and  without  any 
appreciable  mental  disturbance,  continued  to  lead  the  debates.  His  con- 
duct, however,  had  caused  such  surprise  that  his  colleagues  told  him  of  it, 
and  fearing  lest  his  fits  of  absence  should  be  used  as  reasons  for  quashing 
his  judgments,  he  sent  in  his  resignation. 

It  is  this  same  gentleman  who,  as  I  told  you  in  a  former  lecture, 
suddenly  left  a  meeting  at  which  he  was  discussing  some  historical  ques- 
tions, at  the  Hotel  de  Ville,  ran  out  into  the  open  square  outside,  without 
his  coat  and  hat,  avoiding  carriages  and  the  passers  by,  and  on  recovering 
himself  returned  to  the  meeting.  In  a  certain  measure,  his  condition  was 
somewhat  analogous  to  somnambulism.  Sometimes,  when  engaged  in 
reading,  he  would  suddenly  cease,  and  would  repeat  with  volubility  the 
last  verse  or  the  last  portion  of  the  phrase  at  which  he  had  stopped.  His 
physiognomy  wore  an  unusual  expression  a,t  such  times,  but  he  almost 
immediately  took  up  his  book  again  and  resumed  his  reading. 

You  will  not  only  meet  with  persons  who  are  able  to  perform  certain 
acts  during  the  attacks  of  epileptic  vertigo,  but  also  with  some  who  can 
answer  when  spoken  to,  although  they  are  not  conscious  of  their  answers. 
Their  condition  may  be  compared  to  somnambulism,  or,  better  still,  to 
what  happens  in  the  case  of  certain  individuals  who  answer  questions 
during  sleep,  but  do  not  recollect  anything  when  they  wake  up. 

I  attended  some  time  ago  a  young  lady  suffering  from  this  vertiginous 
form  of  epilepsy.  During  the  attack*,  her  face  sometimes  wore  an  expres- 
sion of  terror,  sometimes  of  anger.  She  madeno  answer  when  spoken  to 
quietly,  but  if  addressed  abruptly  and  in  a  com  main  ling  tone,  she  answered 

Curtly  and   in  a  loud  voice.      She   then   suddenly  paused,  and.  if  addi 
in  the  Bame  way  again,  she  looked  bewildered  for  awhile.     Bach  attack 
lasted  from  fifteen  to  thirty  seconds,  and  when  it  was  over  she  had  do  recol- 
lection whatever  either  of  what  .-die  had  been  asked,  or  of  the  answers  die 
had  made. 

I  knew  a  child  who  used  to  exclaim,  "Go  away,  go  away,"  whenever  it 
was  attempted  to  make  him,  during  B  lit,  inhale  some  ether  or  ammonia. 
the  smell  of  which  he  disliked. 

I  shall  next  draw  your  attention  to  oilier  disorder.-  of  innervation  belong- 


ON    EPILEPSY.  107 

iug  to  the  same  group  as  those  we  have  just  studied — I  mean  what  has 
beeu  termed  aura  epileptica. 

These  singular  disturbances  of  the  nervous  system,  which  sometimes  usher 
in  epileptic  seizures,  are  perhaps  more  frequent  in  cases  of  grand-mul  than 
of  petit-mal.  In  some  instances,  however,  which  belong,  therefore,  to  the 
vertiginous  and  not  to  the  convulsive  form,  they  alone  constitute  the  attack. 
A  peculiar  sensation — which  the  individual  compares  to  a  kind  of  wind  or 
of  vapor,  or  to  tingling — starts  from  some  portion  of  his  body,  spreads  up- 
wards, and,  on  it  reaching  his  head,  he  suddenly  falls  down  in  a  fit. 

When  the  aura  begins  in  the  hand  or  in  the  arm,  the  patient  feels  the 
strange  sensation  running  along  the  length  of  the  limb,  which  is  sometimes 
convulsively  agitated  to  a  scarcely  appreciable  degree.  It  rapidly  spreads 
higher  up,  affects  the  head,  and  the  fit  then  begins.  You  will  observe  this 
phenomenon  in  a  large  number  of  cases.  More  or  less  transient  in  character, 
it  lasts  from  one  second  only  to  a  minute  sometimes.  In  some  cases,  it  does 
not  merely  consist  in  a  strange  sensation,  but  in  an  acute  pain,  affecting  the 
hand  or  the  foot,  running  the  same  course  upwards  in  both  cases,  and  fol- 
lowed by  the  fit  when  the  head  is  reached. 

In  other  instances  the  aura  is  attended  with  appreciable  material  changes 
in  the  part  from  which  it  first  started.  A  local  determination  of  blood  may 
occur  in  the  finger,  for  instance,  causing  it  to  swell,  reddening  the  skin,  and 
rendering  it  successively,  within  a  very  short  time,  red,  and  of  a  more  or 
less  deep  violet  color ;  or  again,  the  skin  may  become  excessively  pale  after 
having  been  injected  for  some  time.  The  swelling  is  real,  not  apparent ; 
for  rings,  previously  easy,  suddenly  become  too  tight  for  the  fingers. 

The  aura  epileptica  may  be  again  characterized  by  sudden  convulsive 
phenomena,  as  in  the  case  of  a  little  boy,  who  was  in  my  ward  at  the  Chil- 
dren's Hospital,  in  1848.  On  several  occasions  he  was  seized  whilst  I  was 
going  round  the  ward,  and  I  heard  him  call  out,  "  I  am  taken  with  it." 
His  hands  were  first  moved  involuntarily,  the  muscles  of  his  face  were  nest 
affected,  and  convulsions  followed.  The  case  terminated  fatally,  and,  on 
making  a  post-mortem  examination,  I  found  tubercles  in  the  brain,  which 
were  the  cause  of  the  epileptiform  seizures  I  had  observed  during  life. 

A  year  ago  you  had  occasion  to  see  a  similar  case — that  of  a  young  man 
lying  in  bed  Xo.  9,  St.  Agnes  Ward,  whose  epileptiform  attacks  were  doubt- 
less owing  to  a  cerebral  tumor.  He  remained  in  my  ward  for  a  month,  and 
during  that  period  I  saw  him  in  eight  or  ten  fits.  They  were  ushered  in  by 
pain  suddenly  attacking  the  foot,  which,  on  being  exposed,  was  seen  to  be 
arched  and  agitated  convulsively.  The  convulsions  then  extended  to  the 
leg ;  and  on  his  calling  out  next,  "  My  arm  is  affected,"  I  could  see  the  arm 
jerked  spasmodically.  The  convulsions  lasted  from  fifteen  to  twenty  seconds, 
during  which  his  intellect  was  perfectly  clear,  and  he  continued  to  talk 
quite  rationally.  The  aura  gradually,  but  very  quickly,  extended  to  the 
head,  and  the  poor  fellow  then  became  unconscious.  In  both  these  cases 
the  epilepsy  was  symptomatic ;  but,  as  I  shall  show  you  hereafter,  genuine 
and  symptomatic  epilepsy  bear  the  greatest  resemblance  to  each  other — I 
may  even  say  a  complete  resemblance  with  regard  to  the  manifestations 
which  constitute  the  seizures. 

The  aura  may  be  visceral — that  is  to  say,  it  may  start  from  some  internal 
organ.  It  is  often  misunderstood  in  such  cases,  and  gives  rise  to  errors  of 
diagnosis,  of  which  you  should  be  told,  in  order  to  avoid  th«m.  A  young 
person,  at  the  onset  of  a  fit  of  haut-mal,  used  to  feel  an  acute  pain  in  the 
heart,  soon  followed  by  violent  palpitations,  then  by  giddiness,  and  by  a 
tendency  to  syncope. 

Seven  or  eight  years  ago,  I  was  consulted  for  a  child  about  ten  years  old, 


758  ON    EPILEPSY. 

who,  four  or  five  times  a  day,  before  as  well  as  after  a  meal,  always  with- 
out any  appreciable  cause,  complained  suddenly  of  a  sensation  of  pressure 
in  tbe  pit  of  the  stomach,  soon  followed  by  vomiting.  Immediately  upon 
this  he  felt  violently  giddy,  and  turned  deadly  pale.  These  phenomena 
lasted  altogether  for  about  a  minute.  The  medical  man  who  had  sent  the 
patient  to  me,  believing  him  to  be  suffering  from  dyspepsia,  had  vainly 
tried  every  means  for  combating  it.  The  suddenness  of  the  attack,  the 
violence  of  the  pain,  which  the  child  described  perfectly,  the  accompanying 
sense  of  suffocation,  the  momentary  impairment  of  the  intellect,  the  pallor 
of  the  integuments,  and,  lastly,  the  rapidity  with  which  these  phenomena 
disappeared,  made  me  write  to  the  usual  medical  attendant  that  the  case 
was  certainly  one  of  epilepsy.  I  therefore  advised  him  to  keep  strict  watch 
over  the  boy,  adding  that  I  was  convinced  that  sooner  or  later  this  neurosis 
would  assume  more  distinct  characters,  which  would  clearly  point  to  its 
real  nature.  The  boy's  father  refused  to  believe  in  my  diagnosis,  and  his 
medical  man  concurred  with  him.  The  following  year,  however,  I  was 
again  consulted;  but  this  time  my  fears  had  been  realized,  and  my  diag- 
nosis confirmed,  by  repeated  attacks  of  epilepsy,  from  which  the  boy  had 
suffered. 

This  visceral  aura  escapes  the  observation  of  the  physician  all  the  more 
easily  from  its  simulating  other  affections  in  a  numerous  class  of  cases.  If 
it  begin  in  the  stomach  or  the  uterus,  or  if  it  be  accompanied  by  that  sense 
of  constriction  in  the  throat  which  is  assigned  as  one  of  the  characteristic 
symptoms  of  hysteria,  especially  if  occurring  in  a  young  female,  it  may  be 
confounded  with  the  aura  hysterica.  Careful  observation,  however,  and  a 
rigorous  analysis  of  the  symptoms,  will  enable  the  physician  to  distinguish 
the  one  affection  from  the  other.  Although  the  aura  hysterica  seems  to  start 
from  the  same  point,  from  the  same  organ,  as  the  aura  epileptica,  it  does 
not  spread  with  the  same  rapidity,  nor  does  it  set  in  with  the  same  sudden- 
ness. Hysterical  spasms,  for  instance,  persist  a  longer  time  than  the  epilep- 
tic sensations.  These  latter,  whether  consisting  in  giddiness  or  convulsions, 
scarcely  last  a  few  seconds — one  or  two  minutes  at  the  most — although  they 
leave  behind  them  the  apoplectic  stupor  I  have  already  mentioned.  In 
hysteria  the  duration  of  the  symptoms  is  entirely  different,  and  when  they 
have  passed  off  the  patient  feels  nothing  which  can  be  compared  with  the 
bewilderment  of  an  epileptic. 

In  general,  the  sensations  which  constitute  the  aura  epileptica  spread 
from  In-low  iijiirunls ;  that  is  to  say,  they  begin  either  al  the  extremity  of  a 
limb,  or  in  some  point  of  the  trunk,  and  go  up  to  the  head.  In  some  cases, 
however,  the  aura  runs  a  di  He  rent  course,  from  above  downwards.  It  begins 
ill  the  head,  in  the  shape  of  giddiness  or  of  pain,  and,  descending  with 
rapidity,  spreads  to  the  limbs. 

In  some  rare;  instances,  the  aura  may  be  both  ascending  and  descending 
at  the  same  time. 

Ch.  lionet  (Sepulcretum  Ajoatom,  lib.  i,  sect,  xii,  p.  291)  mentions  the 

case  of  a   man,  aged   50,  whose    left    inguinal    region    first  swelled,  and  who 

next  Celt  a  sort  of  creeping  sensation  descending  gradually  along  the  thigh 

and  affecting  the  loot  ;   once  there  il  ax-ended  with  extreme  rapidity  to  the 

head.  These  singular  phenomena  have  been  long  ago  pointed  out  by  ob- 
servers. Morgagni,  in  the  third  letter  of  his  work,  De  Sedibus  el  Causis 
Morborum,  cites  several  cases  observed  by  himself,  or  reported  by  con- 
temporary  or  former  authors,  and  has  a  long  dissertation  on  the  subject 
He  quotes,  among  others,  a  case  of  Tulpius,  in  which  a  lit  was  b  rough  I  on 
by  pressing  with  one  finger  the  region  of  the  spleen. 
1  have  told  you  that  the  aura  epileptica  is  sometimes  the  only  manifesta- 


on  epilepsy.  759 

tion  of  epilepsy.  Indeed,  it  sometimes  happens  that  it  is  entirely  limited  to 
the  point  where  it  first  shows  itself,  or  at  least  does  not  spread  far.  It  docs 
not  spread  to  the  brain,  and  causes  none  of  the  phenomena  which  more  essen- 
tially characterize  the  disease.  Those  are  cases  of  what  might  he  termed 
partial  epilepsy.  When  I  was  physician  to  the  Necker  Hospital,  I  had 
under  my  care  a  woman,  who  suffered  from  these  attacks  of  convulsive  aura, 
four,  five,  and  even  seven  times  in  an  hour.  The  aura  began  in  her  leg,  and 
was  limited  to  one-half  of  the  body;  the  convulsions  were  violent,  painful, 
and  affected  the  trunk,  the  arm,  and  the  face.  Whilst  they  lasted,  she 
cried  out  with  the  awful  pain  she  felt.  Her  mind  remained  perfectly  clear, 
although  her  speech  was  somewhat  embarrassed,  owing  to  the  convulsion  of 
the  muscles  of  her  face,  and,  probably,  also  those  of  the  tongue.  The  at- 
tack lasted  from  a  minute  to  a  minute  and  a  half;  after  which  time  she  re- 
covered completely.     She  was  rapidly  cured  by  belladonna. 

A  good  many  cases  of  angina  pectoris  are  certainly  a  form  only  of  par- 
tial epilepsy,  as  I  shall  prove  to  you  hereafter,  when  treating  of  that  dis- 
ease. I  shall  show  you,  that  if  the  awful  pain  which  characterizes  this 
affection  generally  starts  from  the  precordial  region,  and  from  there  shoots 
through  the  chest  to  the  throat  and  to  both  arms,  mostly  the  left  arm, 
causing  numbness  of  the  limb  in  which  it  has  been  most  intense,  and  at- 
tended with  a  feeling  of  anxiety  and  undescribable  terror,  the  pain  may, 
in  certain  instances,  follow  a  contrary  course — may,  for  instance,  begin  in 
the  arm,  and  subsequently  radiate  to  the  throat,  attack  the  precordial 
region,  and  bring  on  the  sense  of  anxiety. 

The  young  man,  lying  in  bed  18,  St.  Agnes  Ward,  presents  us  with 
another  instance  of  partial  epilepsy ;  and  in  his  case,  the  order  in  which 
the  phenomena  occur  can  escape  nobody.  His  complaint,  as  you  remember, 
set  in  at  first  with  convulsive  attacks,  wdiich  gradually  became  less  and 
less  violent,  and  at  present  they  consist  in  convulsions  of  the  face,  exclu- 
sively confined  to  the  left  side,  and  unattended  with  loss  of  consciousness. 
He  feels  at  the  top  of  the  chest  a  painful  sensation,  which  suddenly  extends 
from  the  trunk  to  the  face,  producing  a  quivering  of  the  latter.  In  this 
case  there  is  also  embarrassment  of  speech,  due  to  the  involuntary  contrac- 
tion of  the  muscles  of  the  tongue  and  cheeks. 

Perhaps  we  ought  to  place  by  the  side  of  these  partial  epilepsies  an  affec- 
tion the  study  of  which  is  highly  interesting,  and  which  I  mean  to  bring 
before  you  at  a  future  period.  It  is  that  affection  which  I  have  named 
epileptiform  neuralgia,  between  which  and  the  different  forms  of  aura,  and, 
consequently,  the  other  forms  of  epilepsy  which  I  have  pointed  out  to  you, 
a  connection  may  in  some  measure  be  traced. 

I  have  thus  spoken  at  great  length,  gentlemen,  of  epileptic  vertigo,  of 
the  various  kinds  of  aura,  and  of  partial  epilepsy,  because  it  seemed  to  me 
of  the  highest  importance  that  your  attention  should  be  drawn  to  them  ; 
more  particularly  as,  generally  speaking,  the  vertiginous  form  of  epilepsy 
is  the  one  more  frequently  observed. 

Another  characteristic  of  this  form  of  the  disease  is  the  great  frequency 
of  the  fits.  The  patient  may  have  as  many  as  fifty  and  one  hundred 
attacks  in  the  course  of  the  twenty-four  hours,  whilst  this  is  never  the  case 
with  the  convulsive  form.  Besides,  epilepsy  presents  the  greatest  irregu- 
larity in  its  course  and  its  progress,  in  the  frequency  of  the  seizures,  not 
only  in  different  individuals,  but  also  in  the  same  person. 

I  shall  not  revert  to  what  I  have  already  told  you  concerning  the  exclu- 
sive preponderance  of  the  convulsive  attacks  in  some  individuals,  and  of 
vertigo  in  others,  or  of  their  respective  transformation,  or  again, 'their 
simultaneous  existence.      You  recollect  my  telling  you  also  of  patients 


760  ON    EPILEPSY. 

being  attacked  in  the  daytime  only,  or  alternately  at  night  and  in  the  day- 
time ;  whilst  others,  in  much  more  numerous  instances  than  is  generally 
believed,  are  only  seized  at  night. 

With  regard  to  the  frequency  of  seizure  :  some  persons  may,  in  the  whole 
course  of  their  lives,  have  very  few  attacks,  these  attacks  recurring  at 
variable  intervals ;  or  they  may  have  a  single  attack  only.  Sometimes  the 
fits  come  on  periodically,  at  nearly  equidistant  intervals,  or  they  follow  one 
another  in  rapid  succession,  as  in  a  series,  and  then  cease  for  a  pretty  long 
time.  In  other  instances,  they  recur  every  two  months,  every  month, 
every  fortnight,  every  week,  and  even  every  day.  They  may  again  be  so 
frequent,  as  in  the  condition  termed  status  epileptmis,  that  they  run  into 
one  another  as  it  were,  and  simulate  a  continued  attack  which  lasts  over 
two  or  three  days. 

The  fits  of  petlt-mal  being  so  considerably  more  frequent  than  those  of 
grand-mal,  it  is  perfectly  conceivable  then,  that  dementia  should  be  more 
rapidly  brought  on  in  such  cases,  since  the  central  disorders  which  precede, 
follow  or  accompany  the  epileptic  seizures,  being  repeated  at  shorter  inter- 
vals, more  quickly  produce  impairment  of  the  intellectual  faculties,  as  an 
almost  fatal  consequence. 


§  3.   On  the  Relations  of  Epilejjsy  to  Insanity. 

"Epilepsy,"  says  Esquirol,  "  is  a  dreadful  complaint,  not  only  on  ac- 
count of  the  violence  of  its  symptoms  (in  the  convulsive  form),  and  not 
only  driving  one  to  despair  on  account  of  its  incurability,  but  also  because 
of  its  fatal  influence  on  the  physical  and  moral  condition  of  its  victims. 
The  functions  of  organic  life  are  impaired  and  become  languishing.  Epi- 
leptics are  subject  to  cardialgia,  flatulence,  spontaneous  lassitude,  and 
trembling  ;  they  take  little  exercise,  and  become  either  obese  or  emaciated  ; 
they  have  a  tendency  to  venery  and  onanism.  Perhaps  the  excesses  they 
commit  are  the  cause  of  the  organic  lesions  and  of  the  disorders  which 
manifest  themselves  when  epilepsy  has  lasted  a  long  time.  They  do  not, 
as  a  rule,  live  to  an  advanced  age.  The  cerebral  functions,  the  intellectual 
faculties  become  more  and  more  degraded."* 

You  are  well  aware  that  this  fatal  influence  of  epilepsy  on  the  intellec- 
tual faculties,  of  which  dementia,  idiocy,  and  general  paralysis  are  the 
ultimate  expression,  is  a  well-known  fact,  which  has  been  long  ago  pointed 
out  by  observers. 

If  there  have  been  epileptics,  who,  in  spite  of  more  or  less  frequent 
attacks,  have  retained,  to  the  end  of  even  a  pretty  long  carer,  not  only  die 
fulness  of  their  reason,  but  also  the  full  force  of  their  intellect,  and  like 
those  men  of  genius,  whose  names  history  has  handed  down  to  us,  have 
preserved  that  superior  intelligence  which  enabled  them  to  rise  above  the 
ordinary  level  of  their  fellow-men,  instances  of  this  kind  are  too  exceptional 

to  invalidate  in  the  least  the  general  law.  Enthegreal  majority  of cases, 
although  at  the  beginning,  and  when  the  attacks  are  infrequent,  the 
patients  are  in  full  possession  of  all  their  faculties,  although  "a  marvel- 
lous aptitude  lor  conceiving  things  quickly,  or  viewing  them  under  their 

most  brilliant  and  poetical  aspects,  may  distinguish  some  of  them,"'  as   Dr, 

Morel  ha-  remarked, yel  in  proportion  as  the  lits  rctair  and  increase  in  fre- 
quency, in  proportion  as  the  disease  progresses,  the  faculties  fail,  are  im- 
paired, become  gradually  extinct,  and  insanity  follows. 

*  Esquirol:  "On  Mental  Diseases,"  70I.  L,  art.  Epilepsy,  pp.  282,  288. 


ON    EPILEPSY.  761 

Often,  also,  in  individuals  whose  intellectual  activity  is  perfect,  a  singu- 
lar changeableness  of  feeling,  of  temper,  and  of  character,  violent  fit-  of 
passion  which  they  cannot  master,  point  to  a  particular  mental  condition, 
winch,  in  the  greater  number  of  cases,  will  be  followed  by  physical  phe- 
nomena of  a  more  distinct  character,  hut  always  of  the  same  order,  as  well 
as  by  more  serious  cerebral  disorders,  such  as  attacks  of  delirium,  some- 
times transient,  sometimes  prolonged,  and  then  specially  deserving  the 
name  of  epileptic  insanity. 

In  general  the  cerebral  disturbance  is  connected  with  the  so-called  phys- 
ical symptoms  of  the  disease,  namely,  the  attacks  of  convulsions  or  vertigo, 
and  manifests  itself  in  the  interval  between  the  seizures,  at  their  onset,  or, 
moi'e  commonly,  more  or  less  immediately  after  them.  In  some  cases, 
however,  these  psychical  phenomena  seem  to  be  the  only  manifestations  of 
epilepsy.  On  the  whole,  the  course  which  they  run  is  very  characteristic, 
and  possesses  considerable  medico-legal  importance. 

This  point  in  the  history  of  epilepsy  has,  within  the  last  few  years,  been 
the  subject  of  special  study,  and  has  given  rise  to  numerous  memoirs, 
among  which  I  shall  mention  that  of  Dr.  Jules  Falret.* 

"  The  intellectual  disorders  observed  in  epileptics,"  says  the  author  f from 
whom  I  borrow  the  greater  part  of  what  I  am  now  going  to  tell  you), 
"  may  be  divided  into  three  principal  categories :  1st,  those  which,  mani- 
festing themselves  in  the  intervals  between  the  attacks,  are  independent  of 
these,  and  constitute  the  habitual  mental  state  of  epileptics  :  2d,  those 
which  occur  temporarily  before,  during,  or  after  the  attack,  and  may  be 
considered  as  epiphenomena  of  the  attack  itself;  3d  and  last,  intellectual 
disorders,  more  or  less  prolonged,  which  coming  on  in  paroxysms,  either 
directly  connected  with  the  convulsive  or  vertiginous  phenomena,  or  occur- 
ring independently  of  these,  specially  deserve  the  name  of  epileptic  insanity." 

Although  some  epileptics  may,  through  life,  be  in  full  possession  of  all 
their  faculties,  and  may  manifest  in  their  conduct  no  sensible  change,  at 
least  in  the  beginning,  or  when  they  are  subject  to  infrequent  attacks  only  ; 
in  the  vast  majority  of  instances,  however,  those,  pai-ticularly,  who  are 
subject  to  more  or  less  repeated  attacks,  present  in  the  interval  between  the 
seizures,  certain  phenomena  manifestly  dependent  on  a  particular  mental 
condition,  which  cannot  yet  be  termed  insanity. 

The  predominating  element  in  these  phenomena  is  an  extreme  change- 
ableness of  temper  and  of  mental  dispositions;  a  true  intermittence  of  the 
psychical  phenomena  referable  to  the  affections  and  the  temper,  or  belong- 
ing to  the  intellectual  faculties. 

Thus  they  sometimes  look  sad,  peevish,  desponding,  as  if  under  the  influ- 
ence of  grief  or  of  shame,  arising  from  their  awful  complaint ;  at  other  times, 
on  the  contrary,  they  have  inward  sensations  of  ease  and  satisfaction  which 
prompt  them  to  harbor  thoughts  of  rash  undertakings,  or  to  conceive  pro- 
jects which  they  can  least  realize  in  their  sad  condition.  Sometimes  they 
are  querulous,  inclined  to  controversies,  to  discussions,  to  quarrels,  and  even 
to  acts  of  violence  ;  at  other  times,  on  the  contrary,  they  evince  a  gentle, 
benevolent,  and  affectionate  disposition,  and  religious  sentiments  of  sub- 
mission and  humility  as  exaggerated  as  their  previous  behavior  had  been. 

"  The  same  contrasts  which  are  observed  in  their  feelings,  are  also 
noticed  in  the  degree  of  their  intelligence,  and  in  the  nature  of  the  ideas 
which  occupy  their  minds.  Nothing  is  more  mobile  than  their  mental  dis- 
positions and  the  level  of  their  intelligence :  they  sometimes  suffer  from 

*  Jules  Falret  :  "  Be  l'etat  mental  des  Epileptiques,"  Archives  Generates  de 
Medecine,  Decernbre,  1860,  Avril  et  Octobre,  1861. 


762  ON    EPILEPSY. 

mental  confusion,  failure  of  memory,  difficulty  of  attention  and  comprehen- 
sion. They  have  great  difficulty  in  collecting  their  thoughts,  and  are 
themselves  conscious  of  the  obtuseness  of  their  intellect  and  the  confusion 
of  their  ideas.  At  other  times,  on  the  contrary,  they  evince  real  intellec- 
tual activity,  a  rapid  circulation  of  ideas,  which  corresponds  with  a  certain 
degree  of  cerebral  excitement.  They  can,  at  such  times,  devote  themselves 
to  uninterrupted  study,  of  which  they  are  incapable  at  other  times,  and 
remember  certain  facts  and  certain  ideas  which,  on  other  occasions,  they 
seemed  to  have  completely  forgotten. 

"  This  irregularity  in  the  state  of  their  feelings  and  the  degree  of  their 
intelligence  is  necessarily  reflected  in  their  talk  and  in  their  acts.  Hence 
the  excessive  variability  of  their  behavior  towards  those  about  them.  For 
a  certain  period  of  their  lives  they  are  laborious,  punctual,  attentive  to  the 
duties  of  their  profession,  obedient  and  docile,  and  those  who  live  with  them 
or  who  employ  them  find  their  intercourse  agreeable,  or  are  pleased  with  their 
services.  But  at  other  times,  their  conduct  becomes  suddenly  modified,  and 
presents  the  greatest  irregularities.  They  are  then  incapable  of  fulfilling 
the  duties  confided  to  them,  become  negligent,  lazy,  and  indolent.  They 
forget  the  most  elementary  things,  waste  their  time,  or  wander  here  and 
there,  without  aim  or  object  in  view ;  and  are  themselves  conscious  of  the 
vagueness  and  confusion  of  their  ideas.  The  most  deplorable  tendencies 
and  the  worst  inclinations  develop  themselves  in  them  at  the  same  time : 
they  become  liars  and  thieves ;  they  pick  up  quarrels  with  those  around 
them,  complain  of  everything  and  of  everybody;  are  very  easily  irritated 
for  the  slightest  cause,  and  even  frequently  commit  suddeu  acts  of  violence, 
which,  in  most  cases,  have  not  the  excuse  of  provocation  on  the  part  of  the 
victims  to  those  acts."* 

We  have  seen,  gentlemen,  that  in  the  vast  majority  of  cases,  if  not  in  all, 
epileptics  are  completely  unconscious  during  their  seizures,  and  that  this 
loss  of  consciousness  is  even  one  of  the  characteristics  of  the  malady.  We 
have  also  seen  that  in  some  cases,  instances  of  which  I  related  to  you,  the 
patients,  although  uncognizant  of  the  outer  world,  utter  certain  words  and 
perform  certain  actions  as  what  obtains  in  natural  somnambulism.  I  will 
add  that,  whilst  some  individuals  have  no  recollection  whatever  of  what  has 
occurred,  others  remember  more  or  less  vaguely  the  ideas  which  occupied 
their  mind,  and  have  a  confused  notion  that  they  were  then,  as  it  were, 
"  under  the  influence  of  a  painful  dream,  of  intense  pain,  or  of  deep  remorse; 
or,  again,  of  a  sense  of  some  unavoidable  misfortune,  which  they  could  not 
account  for."  These  singular  intellectual  disturbances  principally  occur 
in  those  epileptic  attacks  which,  according  to  J.  Falret,  hold  a  medium 
place  between  simple  vertigo  and  convulsive  fits,  and  which  are  incomplete 
with  respect  to  the  disorders  of  movement  as  well  as  the  loss  of  conscious- 
ness. But  the  psychical  phenomena  which  may  show  themselves  before  or 
after  the  fits  are  much  more  interesting  to  study,  and  much  more  important 
to  know.  By  the  side  of  individuals  who  are  seized  suddenly,  without  any 
premonitory  symptoms,  you  will  observe  others  in  whom  appreciable  changes 
of  temper  foretell,  like  clouds,  forerunners  of  a  storm,  that  a  lit  will  occur 
more  or  less  shortly.  "Thus,  for  example,  certain  epileptics  become  sad, 
peevish,  quarrelsome,  irritable,  often  lor  several  hours  before  a  lit  ;  others 
complain  of  slowness  of  conception,  of  failure  of  memory,  of  obtuseness  of 

ideas,  of  a  kind  of  hebetude,  or    physical    and  moral    prostration,  which  to 

I  hose  used  to  their  society  or  to  themselves  are  sure  signs  of  an  approaching 

lit.     Others,  on  the  contrary,  are  unusually  gay,  have  an  exaggerated  sense 


*  Jui.ks  Palrbt:  /<»■<;  citato,     Dec,  I860,  p.  669,  et  acq. 


ON    EPILEPSY.  763 

of  physical  and  moral  wellbeing,  an  excessive  confidence  in  their  own 
Btrength,  and  sometimes  even  get  into  a  state  of  loquacious  restlessness 

which  may  be  pushed  on  to  maniacal  excitement  or  to  violent  bursts  of 
passion. 

"  Apart  from  these  premonitory  symptoms,  which  may  come  on  at  a  vari- 
able time  previous  to  an  epileptic  seizure,  there  are  other  prodromata  of  the 
same  order,  a  sort  of  intellectual  aura  which  precedes  the  convulsion  by  a 
few  minutes  only,  and  constitutes  its  first  symptom  in  a  certain  measure." 
These  prodromata  consist  in  hallucinations,  illusive  sensations,  varying 
indefinitely  in  different  individuals,  but  recurring  in  the  same  person  with 
singular  uniformity.  Thus,  a  young  person,  subject  to  epilepsy,  told  me 
that  at  the  beginning  of  a  fit  she  heard  voices  and  sounds  which  were  re- 
markably harmonious  and  melodious. 

Other  patients  declare  that  they  hear  sounds  of  bells,  or  a  voice  uttering 
the  same  word  in  a  determined  tone.  Others,  again,  always  smell  a  par- 
ticular smell,  or  see  a  ghost,  flames,  fiery  circles,  frequently  red  or  purple 
objects,  or  (as  in  the  case  of  the  Brazilian  whose  history  I  related  to  you) 
the  objects  around  them  look  unusually  bright  and  beautiful,  and  form  a 
magic  spectacle.  These  strange  and  excessively  variable  sensations  resemble 
those  of  individuals  under  the  influence  of  hashish.  Lastly,  in  other 
cases,  the  intellectual  aura  consists  in  the  recollection  of  a  fact,  or  the  re- 
production of  an  idea,  which  on  a  former  occasion  either  caused,  or  at  least 
accompanied  the  fit.  "  Many  persons,"  says  Dr.  J.  Falret,  "  who  have 
become  epileptics  after  strong  moral  emotions  or  intense  terror,  see  again 
in  spirit,  or  before  their  eyes,  on  each  succeeding  seizure,  the  painful  cir- 
cumstances or  the  dreadful  scene  which  first  produced  their  complaint." 

A  young  man,  aged  seventeen,  who  was  in  the  wards  of  my  esteemed 
colleague,  Dr.  Carl  Potain,  presented  us  with  an  example  of  these  singular 
phenomena.  His  father  had  on  several  occasions  manifested  suicidal  ten- 
dencies; his  mother  was  said  to  have  been  subject  to  convulsive  attacks, 
perhaps  of  epilepsy,  but  at  the  very  least  of  hysteria ;  and  his  first  fit, 
which  had  occurred  when  he  was  eleven  years  old,  had  been  caused  by  the 
deep  impression  made  on  him  by  his  mother's  decease.  On  the  accession 
of  every  fit,  which  now  returned  frequently,  this  painful  circumstance  in- 
variably recurred  to  his  mind.  "lam  seized  through  my  thoughts"  he  used 
to  say,  and  he  explained  to  us  that  his  thoughts  were  always  the  same,  and 
constantly  referring  to  his  loss. 

Epileptics  usually  remain  after  their  attacks,  for  a  length  of  time  vary- 
ing from  a  few  minutes  to  several  hours,  in  a  state  of  more  or  less  marked 
torpor  or  semi-hebetude.  They  have  a  difficulty  in  co-ordinating  their  ideas, 
in  recognizing  the  persons  or  objects  around  them,  and  their  mental  confu- 
sion, especially  the  failure  of  their  memory,  lasts  for  one  or  two  days. 
But  if  this  be  the  usual  state  of  things,  it  does  not  infrequently  happen 
that  this  perturbation  of  the  intellect,  after  having  expressed  itself  by 
stupor  and  prostration  more  or  less  prolonged,  suddenly  manifests  itself  by 
cerebral  excitement,  by  a  furious  delirium  which  prompts  the  unfortunate 
patient  to  the  commission  of  acts  of  the  most  violent  character,  so  much  so, 
indeed,  that  no  madman,  as  everybody  knows,  is  more  vicious  or  more 
dangerous. 

"  No  one,"  says  the  author  of  the  excellent  memoir  which  I  recommend 
you  to  read,  "no  one  can  form  an  accurate  notion  of  the  sort  of  rage  which 
suddenly  possesses  the  epileptic,  and  drives  him  to  strike  or  to  break  any- 
thing which  he  can  lay  hold  of.  During  these  transient  attacks  of  furor, 
he  is  so  dangerous  to  those  around  him,  as  well  as  to  himself,  that  the  at- 
tention of  persons  in  authority  and  of  medical  men  cannot  be  too  earnestly 
drawn  to  these  conditions  of  instinctive  and  blind  violence,  which  all  au- 


764  ON    EPILEPSY. 

thors  have  pointed  out  as  frequent  results  of  epileptic  fits.  They  may  lead 
to  the  infliction  of  grave  wounds,  to  the  commission  of  suicide,  of  homicide 
and  arson,  and  yet  the  individual  cannot  be  held  responsible  in  any  degree 
for  the  acts  of  violence  perpetrated  by  him  during  this  perfectly  automatic 
though  short-lived  delirium.*  In  a  former  lecture  on  apoplectiform  cere- 
bral congestion,  I  related  a  few  instances  of  this  kind.  I  need  not  revert 
to  the  subject,  but  will  merely  add  the  following  case,  which  many  of  you 
will  doubtless  remember : 

At  the  end  of  December,  1860,  a  young  woman  was  admitted  under  my 
care  into  the  St.  Bernard  Ward,  in  a  state  of  wild  delirium,  which  was  said 
to  have  commenced  a  few  hours  previously.  I  told  you  at  the  time  that  she 
was  epileptic,  and  on  the  next  day  her  husband  communicated  to  me  some 
important  facts  which  entirely  confirmed  my  diagnosis.  He  told  me  that 
his  wife  had  suffered  from  epilepsy  for  moi'e  than  a  year,  and  that  on  the 
day  preceding  her  admission  into  the  hospital  she  had  been  seized  with 
transient  vertigo,  followed  by  wandering  for  a  few  minutes.  During  the 
night  she  had  a  severe  epileptic  fit,  after  which  the  delirium  had  set  in. 
This  attack  lasted  five  or  six  days. 

"  In  some  cases  the  delirium,  which  may  last  a  few  hours  only,  persists 
for  twelve  or  fifteen  days,  although  it  generally  passes  off  after  two  or  three 
days.  In  some  individuals  the  temporary  intellectual  disorder  which  suc- 
ceeds an  epileptic  fit  does  not  show  itself  in  its  usual  form  of  instinctive, 
blind  violence,  but  assumes  the  form  of  more  or  less  marked  simple  ma- 
niacal excitement.  The  patient  talks  incessantly  and  incoherently.  He 
moves  about  restlessly,  and  executes  movements  that  are  more  disorderly 
than  violent.  He  is  sometimes  under  the  influence  of  delirious  ideas  of  an 
agreeable  nature,  which  rapidly  alternate  with  conceptions  of  a  painful 
kind,  and  frightful  hallucinations,  chiefly  of  vision.  But  this  temporary 
maniacal  delirium  consists  in  a  rapid  succession  of  incoherent  thoughts, 
and  in  great  disorder  of  actions,  rather  than  in  extreme  violence,  as  is  on 
the  contrary  observed  in  the  class  of  patients  we  spoke  of  before. "t 

I  now  pass  on,  gentlemen,  to  the  consideration  of  the  morbid  psychical 
phenomena,  which,  in  the  division  I  borrowed  from  Dr.  Falret,  are  com- 
prised in  the  third  category.  They  are  those  intellectual  disturbances 
which  occur  either  in  direct  connection  with  convulsive  and  vertiginous 
symptoms,  or  independently  of  them,  in  the  form  of  more  prolonged  at- 
tacks, and  deserve  more  especially  the  name  of  epileptiG  insanity. 

A  detailed  description  of  these  phenomena  is  of  such  vast  importance  to 
the  practitioner,  that  I  will  quote  in  full  the  following  extract  from  Dr. 
Fal rot's  memoir  : 

"Two  forms  of  well-characterized  intellectual  disturbance,  constituting 
genuine  attacks  of  insanity,  may  occur  in  epileptics  at  various  intervals, 
and  as  irregularly  as  the  convulsive  seizures  themselves.  They  are  some- 
times directly  connected  with  those  seizures:  but  may  at  other  times  be  in- 
dependent of  them.  They  are  often  confounded  together  in  a  common  de- 
scription, but  thev  deserve  to  be  described  separately,  in  spite  of  the  points 
of  resemblance  between  them.  In  order  clearly  to  distinguish  one  form 
from   the  other,  we   shall    give   them    names  which  will    have    the    peculiar 

advantage  of  recalling  the  striking  analogy  which  exists  between  them  and 

the  two  kinds  of  seizures  which  authors  have   pointed    out.      We  shall  call 

one  form  petit-mal,  and  the  other  grand-mal ;  meaning  thereby  to  indicate 
the  close  relationship  observed  between  the  physical  ami  the  mental  mani- 
festations of  epilepsy." 

*  Jules  Falret:  loco  tit.,  p.  ;"''7.  f  Up.,  p.  *">'.* T . 


ON    EPILEPSY.  765 

"Petit-Mai. — The  patient  suffers  at  intervals  from  a  more  marked  intel- 
lectual disturbance,  which  lies  midway  between  the  slight  degree  of  impair- 
ment characteristic  of  his  habitual  state,  and  the  attacks  of  furious  mania 
,of  which  we  shall  speak  presently.  This  intellectual  disturbance, the  dura- 
tion of  which  varies  from  t  few  hours  t<>  several  days,  recurs  in  paroxysms. 
It  consists  principally  in  a  great  confusion  of  ideas,  accompanied  in  most 
cases  by  sudden  instinctive  impulses  ami  by  acts  of  violence,  phenomena 
entirely  special  to  epileptics,  and  intermediate  between  the  mental  lucidity 
of  partial  delirium  and  the  complete  disturbance  of  general  delirium. 

"  Epileptics  subject  to  this  particular  form  of  delirium  generally  become 
at  first  sad  and  morose  without  cause;  then  suddenly  get  into  a  state  of 
great  despondency,  attended  with  obtusion  of  ideas  and  feelings  ot  irritation 
against  everything  around  them.  They  feel  somewhat  giddy,  they  say; 
they  are  partly  conscious  of  the  vagueness  of  their  ideas,  of  the  failure  of 
their  memory,  of  the  difficulty  they  have  in  collecting  their  thoughts  and 
in  fixing  their  attention,  as  well  as  of  their  involuntary  violent  impulses. 
The  majority  of  them  have  in  addition,  from  the  beginning  of  the  attack, 
a  deep  feeling  of  their  inability  to  resist,  a  superior  force  which  holds  their 
will  in  subjection,  and  drives  them,  in  spite  of  themselves,  to  acts  of  violence. 
They  express  this  feeling  differently  according  to  their  education  and  social 
position  ;  but  in  nearly  every  case  analogous  expressions  are  used  to  describe 
the  same  inward  feeling.  They  say,  for  instance,  that  they  are  no  longer 
themselves ;  that  the  disease  drives  them  on  ;  that  they  have  within  them 
an  evil  spirit  which  commands  them,  &c.  They  all,  in  one  form  or  another, 
speak  of  their  will  being  driven  on,  a  circumstance  which  seems  to  be  a 
characteristic  feature  of  this  form  of  delirium,  and  which  persists,  to  a  vari- 
able degree,  during  its  entire  duration. 

"  Under  the  influence  of  this  mental  condition,  such  patients  suddenly 
cease  their  occupations,  or  leave  their  homes  and  wander  here  and  there  in 
the  streets  or  in  the  fields.  This  impulsive  want  to  wander  about  is  nearly 
constant  in  this  mental  state,  and  deserves  to  be  particularly  pointed  out. 
The  victims  of  a  vague  sense  of  anxiety,  of  an  instinctive  and  groundless 
terror,  of  a  want  of  automatic  and  undetermined  motion,  these  unfortunates 
feel  sick  of  life,  and  wander  about  without  any  aim  or  object  in  view.  In 
their  mental  confusion  they  recall  to  memory  all  the  painful  thoughts  which 
they  have  had  at  various  periods  of  their  lives,  and.  which  spontaneously 
recur  to  them  unchanged  whenever  they  are  attacked.  They  feel  intensely 
miserable.  They  believe  themselves  to  be  victimized  and  persecuted  by 
their  relatives  or  their  friends.  They  accuse  all  those  with  whom  they  have 
been  in  contact  of  being  the  cause  of  their  trouble.  If  they  have  previously 
harbored  any  feelings  of  hatred  or  thoughts  of  revenge  against  any  one, 
these  feelings  are  quickened  by  their  complaint,  and  suddenly  roused  to  a 
pitch  of  intensity  which  prompts  them  to  immediate  action.  The  essentially 
impulsive  and  spontaneous  character  of  the  epileptic  delirium  is  really  very 
remarkable.  In  this  state  of  extreme  mental  disturbance,  of  general  anxiety 
and  instinctive  impulses,  the  patients  are  apt,  in  a  most  sudden  and  unex- 
pected manner,  to  commit  all  kinds  of  violence — suicide,  theft,  arson,  and 
homicide.  Some,  in  order  to  escape  their  inward  anxiety,  attempt  to  com- 
mit suicide  ;  others,  under  the  influence  of  a  similar  despair,  and  of  a  similar 
desire  to  escape  their  intolerable  inward  sensations,  knock  their  heads  against 
walls;  or,  seizing  hold  of  the  first  instrument  they  can,  strike,  or  break 
everything  around  them,  and  thus  exhaust  their  rage  on  inanimate  objects. 
Others,  again,  rush  with  fury  on  the  first  individual  they  meet,  strike  him 
repeatedly,  and,  if  others  come  to  his  help,  strike  them  also.  This  circum- 
stance, namely,  that  repeated  bloivs  are  struck,  and  several  wounds  inflicted, 


766  ON    EPILEPSY. 

or  several  persons  injured,  deserves  to  be  especially  noticed,  in  our  opinion, 
and  seems  to  us  to  characterize  the  condition  of  furor  epilepticus;  hence  it 
may  be  of  considerable  importance  in  a  medico-legal  point  of  view. 

"  Immediately  after  the  commission  of  an  act  of  violence,  epileptics  sub- 
ject to  this  form  of  delirium  may  get  into  one  of  two  moral  conditions  widely 
differing  from  one  another.  In  some  cases,  what  they  have  done  eases  them 
as  it  were,  and  at  once  puts  an  end  to  their  undefined  anxiety  and  their 
mental  confusion.  They  are  like  drunken  individuals  who  suddenly  become 
sober  again  ;  they  partially  recover  their  consciousness,  and  begin  to  under- 
stand, although  very  imperfectly,  the  gravity  of  their  act.  In  other  cases, 
they  continue  to  run  forwards  in  a  state  of  great  excitement  and  general 
disturbance — a  state  in  which  they  are  only  very  imperfectly  conscious  of 
the  act  which  they  have  just  committed,  or  even  retain  no  recollection  of  it. 
TJte  very  great  confusion  of  the  memory,  amounting  almost  to  complete  forget- 
fulness  of  a  great  number  of  facts,  is  therefore,  in  both  cases,  an  almost  con- 
stant symptom  of  this  kind  of  delirium. 

"  When  the  patients  recover  themselves,  either  immediately  after  the 
act  of  violence  which  forms  the  crisis  of  their  attack,  or  after  a  certain 
length  of  time,  they  sometimes  succeed,  by  dint  of  exertion,  in  recalling 
to  mind  many  details  of  the  facts  which  occurred  during  their  seizures, 
especially  those  which  happened  towards  the  close  ;  but  their  recollections 
are  always  very  indistinct.  This  indistinctness  has  been  erroneously  re- 
garded as  simulated  ;  but  it  is  perfectly  real  and  characteristic  of  this 
mental  condition.  The  epileptics  are  then  in  a  state  comparable  to  that 
which  succeeds  a  painful  dream.  The  principal  circumstances  of  the 
attack  have  at  first  escaped  them.  They  begin  by  denying  the  facts  im- 
puted to  them  ;  but  by  degrees  they  remember  certain  details  which  they 
at  first  seemed  to  have  forgotten.  On  the  whole,  however,  they  recollect 
the  facts  very  incompletely. 

"  Grand-Mai. — In  all  asylums  there  are  found  epileptics  subject  to  this 
form  of  delirium,  which  we  shall  call  the  intellectual  grand-mal,  and  which 
is  generally  known  under  the  .name  of  furious  mania.  All  authors  have 
noted  the  extreme  violence  of  individuals  suffering  from  this  particular 
form  of  mental  disease.  Several  of  them  have  even  pointed  out  some  of 
the  characters  which  allow  of  a  distinction  being  made  between  this  and 
other  analogous  maniacal  conditions.  We  have  no  intention  of  describing 
it  here  in  detail,  but  will  only  indicate  its  chief  distinctive  characters. 
Thus,  a  character  special  to  epileptic  mania  is  the  greater  rapidity  of  its 
invasion  compared  with  that  of  other  forms  of  mania.  Sometimes,  in  fact,  it 
is  preceded  by  no  premonitory  symptom  whatever.  In  other  cases  there 
are  some  physical  prodromata — such  as  cephalalgia,  vomiting,  injection  or 
brilliancy  of  the  eyes,  alteration  of  the  voice.  Blight  convulsive  movements 
of  the  face  or  limits;  or  mental  symptoms,  consisting  in  sadness,  irritability, 
or  slight  excitement.  But  these  prodromata  precede  at  the  most  for  a  few 
hours  only  the  explosion  of  epileptic  mania  in  its  most  violent  form. 
Another  equally  important  character  of  epileptic  mania  (common,  after 
all,  to  most  intermittent  kinds  of  mania)  lathe  absolute  r<  .<>  mblanCi  of  aU 
the  attacks  in  the  same  patu  nt ;  not  only  on  the  whole,  but  <  w  n  '"  <  w  ry  d<  tail. 
When  the  various  pha.-es  of  a  lir-l  attack  of  epileptic  mania  arc   carefully 

observed,  one  i-  really  struck  with  the  fad  that  the  same  patient  expresses 
the  same  idea-,  utters  the  same  words,  performs  the  same  acts— in  a  word, 
goes  through  the  same  physical  and  moral  phenomena,  on  the  occurrence 

of  every  fresh  seizure.  His  ideas,  his  language,  and  his  act-  are  fated,  a- 
it  were,  and   recur  with  surprising  uniformity  whenever  he  is  attacked. 

"During  these  paroxysms,  epileptics  manifest    most   of  the  psychical 


ON    EPILEPSY.  767 

phenomena  which  characterize  the  maniacal  state  in  general.  Their  ideas 
succeed  one  another  with  great  rapidity.  They  talk  incessantly-  They 
pass  without  interruption  through  the  most  varied  series  of  ideas,  and  their 
acts  are  as  disorderly  as  their  language  is  incoherent.  A  peculiar  feature 
of  their  agitation,  noted  by  all  authors,  consists  in  the  excessive  violence 
of  their  acts,  which  violence  prompts  them  to  strike  and  break  with  a  kind 
of  rage  all  surrounding  objects — to  bite,  tear,  and  cry  without  ceasing — 
and  to  knock  their  own  heads  with  violence  against  the  wall.  This  state 
of  agitation,  which  passes  on  to  furious  excitement,  is  sometimes  carried  so 
far  that  such  patients  constitute  the  most  dangerous  class  of  madmen,  are 
universally  dreaded  in  asylums,  and  can  be  restrained  and  protected  only 
by  the  most  coercive  measures — such  as  the  strait-waistcoat,  or  lengthened 
confinement  in  a  cell. 

"  But  extreme  violence  is  not  the  sole  characteristic  which  distinguishes 
epileptic  mania  from  other  maniacal  conditions.  An  equally  remarkable 
fact  is  the  terrifying  nature  of  their  predominating  ideas,  and  the  frequency 
of  hallucinations  of  a  similar  kind  to  which  they  are  subject — hallucinations 
of  hearing,  of  smell,  and  particularly  of  sight.  They  have  visions  almost 
constantly  :  they  see  frightful  objects,  ghosts,  assassins,  armed  men  who 
rush  on  them  to  kill  them.  They  constantly  see  luminous  objects,  flames, 
fiery  circles  ;  and  a  circumstance  worthy  of  note  is  that  the  sight  of  blood 
and  red  colore  frequently  predominates  in  their  visions.  These  attacks  of 
mania,  again,  present  another  very  important  peculiarity.  In  spite  of  the 
disorder  and  violence  of  their  acts,  their  language  is,  in  general,  consider- 
ably less  incoherent  than  that  of  many  insane  individuals.  It  is  surprising 
how  easily,  in  spite  of  their  state  of  agitation,  one  can  follow  the  train  of 
ideas  expressed  by  epileptics.  Their  delirium  is  more  connected  and  com- 
prehensible than  is  usual  in  mania.  They  understand  better  the  questions 
that  are  put  to  them  ;  they  answer  them  more  directly,  more  exactly  ;  and 
notice  what  goes  on  around  them  more  frequently  than  most  insane  persons 
suffering  from  general  delirium  with  excitement.  The  less  marked  inco- 
herence of  the  delirium,  and  the  greater  distinctness  of  ideas  during  the 
attacks,  are  all  the  more  remarkable  that  they  singularly  contrast  with 
the  nearly  total  obliteration  of  all  recollection  of  the  fit  after  it  is  over — 
a  defect  of  memory  which  is  also  an  almost  constant  symptom  of  the 
attacks  of  epileptic  mania. 

"  Before  concluding  this  rapid  enumeration  of  the  principal  characters 
which  distinguish  epileptic  from  common  mania,  let  us  add  that  the  attack 
generally  lasts  a  few  days  only  ;  and  therefore  less  than  in  the  other  forms 
of  mania.  Lastly,  its  termination  is  in  general  as  sudden  as  its  invasion. 
In  a  few  hours,  sometimes  even  in  less  time,  these  patients  return  to  their 
normal  condition.  Scarcely  ever  do  they  in  some  cases  remain  for  a  short 
time  in  a  state  of  slight  stupor,  or  of  physical  and  moral  torpor,  before 
they  regain  their  reason  completely.  They  recover  from  their  attacks  like 
a  man  who  wakes  up  after  a  dream  or  a  painful  nightmare  ;  and  they  have 
scarcely  any  recollection  of  what  has  occurred  during  their  seizure."* 

These  two  forms  of  epileptic  delirium — the  intellectual petit-mal  and  grand- 
mal — although  presenting  differential  characters,  as  distinct  as  those  we 
find  in  cases  of  insanity,  between  partial  and  general  delirium,  have  also 
many  points  of  resemblance  which  denote  their  common  origin.  In  both 
the  delirium  comes  on  in  paroxysms  of  relatively  short  duration  when  com- 
pared with  those  which  characterize  other  mental  diseases.  Its  explosion 
is  sudden,  its  disappearance  no  less  so ;  and,  after  it  has  passed  off,  the  pa- 

*  Jules  Falret  :  loco  cit.,  p.  671,  et  $eq. 


768  ON    EPILEPSY. 

tient  has  totally,  or  almost  totally,  lost  all  recollection  of  the  ideas  which 
have  passed  through  his  mind,  and  of  the  acts  which  he  has  committed — 
of  his  painful  thoughts,  his  frightful  hallucinations,  and  his  instantaneous 
acts  remarkable  for  their  extreme  violence. 

The  identical  nature  of  these  two  varieties  of  epileptic  insanity  is  proved, 
first,  by  their  frequently  occurring  alternately  in  the  same  individual ; 
secondly,  by  the  fact  that  either  in  the  same  or  in  different  individuals,  a 
great  many  intermediate  conditions  may  be  observed,  varying  from  a  sim- 
ple transient  cloudiness  of  the  intellect  up  to  the  most  furious  maniacal 
excitement ;  and  thirdly,  by  the  more  or  less  direct  and  immediate  connec- 
tion, in  the  case  of  petlt-mal,  with  attacks  of  vertigo,  and  in  that  of  the 
intellectual  grand-mal  with  the  convulsive  form  of  epilepsy.  The  intellec- 
tual impairment  increases  in  proportion  to  the  number  of  epileptic  seizures, 
the  rapidity  with  which  it  sets  in  depending  on  the  frequency  of  the  fits, 
for  the  first  period  of  the  disease  is  almost  always  free  from  delirium,  this 
happening  more  frequently  during  the  middle  period,  that  is  to  say,  when 
for  some  years  already  there  have  been  manifestations  of  epilepsy,  at  more 
or  less  distant  intervals.  In  the  last  period,  when  the  attacks  have  recurred 
frequently  and  for  a  long  time,  the  patients  fall  by  degrees  into  a  continu- 
ous condition  of  dementia  and  idiocy,  only  interrupted  from  time  to  time 
by  phases  of  agitation  of  short  duration. 

This  dependence  of  intellectual  deterioration  on  the  duration  of  the  dis- 
ease and  the  frequency  of  recurrence  of  the  attacks,  explains  how  it  hap- 
pens that  all  ages  are  liable  to  mental  failure. 

I  lately  saw  a  remarkable  instance  of  this  in  a  child  aged  four  years  and 
a  half.  He  had  been  epileptic  since  the  age  of  18  months,  when  he  had 
first  presented  vertiginous  symptoms,  consisting  in  a  kind  of  hebetude,  or 
bewilderment,  which  suddenly  came  over  him,  and  lasted  a  few  seconds. 
In  the  space  of  two  months  he  had  five  or  six  attacks,  and,  after  passing  a 
year  without  any,  he  became  subject,  when  three  years  old,  to  convulsive 
paroxysms,  and  to  attacks  of  vertigo,  recurring  at  intervals.  When  I  -aw 
him  he  had,  for  the  previous  three  weeks,  been  frequently  seized  with  con- 
vulsions, and  the  vertigo  was  almost  constant.  In  the  intervals  between 
the  fits  his  reason  was  impaired  ;  he  uttered  savage  cries,  spoke  incoherently, 
and  he  often  bit  the  persons  who  waited  on  him,  not  excepting  his  mother. 

In  consequence  also  of  this  dependence,  to  which  I  attach  great  impor- 
tance, we  can  understand  why,  in  cases  of  epilepsy  occurring  late  in  lii'e, 
insanity  may  not  be  brought  on  by  it.  Calmed  has  recorded,  however,  the 
case  of  a  woman,  aged  73,  who  became  insane  alter  a  first  attack  of  epilepsy. 
The  reason  is,  gentlemen,  that  like  the  physical  phenomena  of  epilepsy,  its 
psychical  manifestations  present  the  same  diversities  in  their  course,  their 
frequency,  and  the  order  of  their  sequence.  Thus,  in  some  cases — but  very 
rarely  indeed — the  convulsive  or  the  vertiginous  attacks  are  invariably  at- 
tended with  delirium;  in  others,  and  this  is  what  more  frequently  happens, 
the  convulsions  or  the  vertigo  are  alone  present;  in  a  third  class  of  cases, 
again,  paroxysms  of  mania  alone  attracl  attention,  whether  these  occur  in 
the  intervals  between  the  attacks  of  grand-mal  or  petit-mal  in  known  epilep- 
tics, or  in  individuals  whose  complaint  is  unknown,  as  in  case-  of  noctur- 
nal  epilepsy  lor  instance;  or  lastly,  whether  they  affect  persons  who,  at 

the  lime  of  observation,  have  not  for  a  long  period  Keen  .-cized  with  con- 
vulsions or  vertigo,  in  consequence  of  a  real  transformation  of  the  die 

If  it  may  be  stated  as  a  general  law,  that  epileptic  attacks  recurring  fre- 
quently, and  over  a  long  period  of  time,  bring  on  as  a  consequence  an  ab- 
solute impairment  of  the  intellect,  the  last  term  of  which  is  dementia  ami 
idiocy,  you  will  meet,  however,  with  epileptics  who,  in  spile  of  (he  intensity 


ON    EPILEPSY.  769 

and  frequent  recurrence  of  their  attacks,  preserve  their  faculties  in  all  their 
integrity,  and  present  only  slight  perturbations  of  the  intelligence  and  of 
the  temper,  which  cannot  be  termed  insanity.  Then,  also  by  the  side  of 
patients  whose  paroxysms  of  delirium  return  at  very  short  intervals,  you  will 
see  others  whose  mind  is  perfectly  sound,  and  is  disturbed  only  by  very  few 
attacks,  separated  by  very  long  intervals,  or,  perhaps,  by  a  single  attack 
only  throughout  their  whole  life. 

Setting  aside  exceptional  facts,  I  shall  now  conclude  what  I  had  to  say 
on  this  important  question,  with  another  quotation  from  Dr.  J.  Falret's 
memoir : 

"  The  most  favorable  conditions  for  the  production  of  delirium  are  the 
following : 

"  When  the  disease  has  been  for  a  long  time  suspended,  it  often  bursts 
out  with  fresh  intensity,  both  in  the  convulsive  and  the  delirious  form. 

"  When  the  fits  recur  at  very  short  intervals,  in  a  series,  and  as  it  were 
one  upon  the  other,  delirium  frequently  sets  in,  especially  when  the  seizures 
are  imperfect,  incomplete,  when  the  disease  does  not  find  a  vent,  according 
to  an  expression  used  by  the  patients  themselves  and  by  their  friends.  Thus, 
in  our  opinion,  can  we  reconcile  the  two  apparently  contradictory  opinions 
expressed  on  this  point  by  several  authors  who  have  especially  studied  this 
subject. 

"  Delasiauve,  for  instance,  thinks  that  '  maniacal  symptoms  are  more 
likely  to  show  themselves,  in  proportion  as  the  fits  recur  at  shorter  inter- 
vals, more  frequently,  and  with  greater  intensity,  and  in  proportion  to  the 
duration  of  the  disease.'  " 

On  the  other  hand,  Morel*  says :  "  I  have  noticed  that  epileptic  fits  are 
complicated  with  exaltation,  which  is  more  marked  in  proportion  as  the 
attacks  are  separated  by  longer  intervals,  and  as  the  individuals  enjoy 
their  reason  more  completely  during  those  intervals."  In  the  next  page, 
Morel  declares  that  he  also  adopts  Dr.  Cavalier's  opinion,  touching  the 
greater  influence  of  imperfect  epileptic  attacks  on  the  production  of 
delirium. 

These  opinions,  wThich  are  apparently  contradictory,  may,  however,  we 
believe,  be  included  in  the  following  proposition :  Delirium  chiefly  occurs  as 
a  consequence  of  epileptic  attacks  recurring  at  short  intervals,  after  a  prolonged 
suspension  of  the  disease. 

§  4.   On  Hereditary  Taint,  as  a  Predisposing  Cause  of  Epilepsy. — Influence 
of  Marriages  of  Consanguinity. 

In  a  former  lecture,  I  mentioned  some  of  the  reputed  exciting  causes  of 
Epilepsy.  I  wish  now  to  draw  your  attention  to  its  most  powerful  predis- 
posing cause. 

Hereditary  taint  has  certainly  a  great  influence  on  the  production  of 
epilepsy,  and  I  hardly  understand  how  trustworthy  authors  can  have 
doubted  such  a  fact,  which  has  been  accepted  by  the  generality  of  prac- 
titioners. They  may  have  been  misled  by  the  circumstance  that  disorders 
of  the  nervous  system  assume  the  form  of  epilepsy  in  some  individuals,  and 
in  others  of  phenomena  of  an  apparently  different  character.  This  trans- 
formation of  nervous  affections  into  one  another  is  a  vast  subject,  which  I 
cannot  consider  now ;  but  if  you  question  your  patients  scrupulously,  if 
you  carefully  inquire  into  their  previous  history,  you  will,  in  many  cases,  , 
discover,  either  in  their  direct  or  collateral  relatives,  symptoms  analogous 
to  those  which  they  themselves  present,  or  mental  alienation  in  one  of  its 

*  Morel:  "Etudes  Cliniques,"  t.  11,  p.  319. 
vol.  i. — 49 


770  ON    EPILEPSY. 

various  forms,  or  mere  eccentricities  of  character  or  of  manner,  or,  again, 
disturbances  of  innervation  characterized  by  strange  symptoms,  by  peculiar 
nervous  phenomena,  which  indicate  au  unfortunate  predisposition  trans- 
mitted from  generation  to  generation. 

I  will  give  you  a  few  instances  in  illustration.  The  first  one  which  I  am 
going  to  relate  struck  me  particularly,  and  from  special  circumstances  I 
was  enabled  to  study  it  carefully.  A  gentleman,  now  88  years  old,  was 
affected,  at  the  age  of  64,  with  melancholia,  of  which  he  is  at  present  per- 
fectly cured.  He  had  three  children,  two  sons  and  a  daughter.  The 
eldest  son  is  of  a  melancholic  temperament,  but  of  perfectly  sound  mind  ; 
the  second  was  affected  with  locomotor  ataxy,  and  died  mad.  A  son  of  the 
latter,  at  jDresent  30  years  old,  is  as  yet  of  sound  mind,  but  has  a  child  who 
is  an  idiot.  The  daughter,  who  is  devoid  of  intelligence,  and  is,  besides, 
somewhat  strange  in  her  ways,  has  had  two  sons,  the  eldest  of  whom  died 
insane  and  paralyzed,  whilst  the  younger  one  is  almost  idiotic. 

This  gentleman  had  also  a  sister  who  became  mad  at  the  age  of  30. 
This  lady  had  a  son  and  a  daughter ;  the  first,  from  infancy,  has  suffered 
from  night-blindness,  and  is  now  afflicted  with  epilepsy ;  the  second  was 
amaurotic,  and  died  insane,  leaving  also  a  son,  who  has  already  given 
proofs  of  a  notable  impairment  of  the  intellect. 

I  was  once  asked  to  see  a  child  suffering  from  epileptic  vertigo.  His 
father's  intelligence  was  below  the  common  average,  manifestly  owing  to 
a  defective  mental  organization,  and  his  mother  informed  me  that  a  brother 
of  his  had  for  two  months  been  troubled  with  a  strange,  convulsive  cough, 
somewhat  like  hooping-cough,  but  essentially  different  from  it  in  many 
respects.  This  cough,  which  had  worried  him,  and  incessantly  prevented 
him  from  sleeping,  ceased  suddenly  after  the  administration  of  two  granules 
of  santonin,  which  brought  away  some  ascarides  lumbricoides. 

Those  nervous  symptoms,  that  convulsive  cough,  were  not  in  themselves 
extraordinary.  They  have  been  long  ago  pointed  out  as  belonging  to  the 
train  of  morbid  phenomena  caused  by  the  presence  of  worms ;  and,  among 
other  instances,  some  of  you  may  perhaps  know  the  case  related  by  Dr. 
Graves  in  his  clinical  lectures. 

A  young  girl  was  for  several  months  troubled  with  a  constant  cough, 
accompanied  by  fever  and  unpleasant  general  symptoms.  She  lost  flesh 
considerably ;  so  much  so,  indeed,  that  Dr.  Graves  ami  Sir  W.  Cramptou, 
who  saw  her  in  consultation,  believed  her  to  be  consumptive,  although  they 
never  could  find  any  sign  of  phthisis.  The  cough  persisted  ;  hectic  fever 
and  the  loss  of  flesh  became  more  marked ;  but  one  day,  after  having  for 
some  little  time  taken  oil  of  turpentine,  which  an  old  nurse  gave  her,  she 
passed  a  tapeworm,  and  was  at  once  cured. 

In  the  case  of  the  boy  to  whom  I  just  now  alluded,  the  nervous  symp- 
toms were  not  therefore  extraordinary  ;  but  they  indicated  an  hereditary 
taint  which  could  not  be  referred  to  the  father's  imbecility,  and  which  in 
the  other  boy  manifested  itself  by  epileptic  vertigo. 

Such  examples  of  predisposition  to  various  nervous  disorders,  transmitted 
from  parent  to  offspring,  abound  in  the  records  of  medicine;  and,  among 
those  which  have  fallen  under  my  own  observation,  I  will  mention  the  till- 
low  ing : 

A  gentlemen,  the  son  of  a  celebrated  painter,  and  himself  an  excellent 
draughtsman,  and  a  pupil  ofGros,  had  t<>  give  up  painting — or,  at  Least,  i" 
confine  himself  to  sepia  drawings — in  consequence  of  a  peculiar  defecl  of 

vision,  with  which  he  hail  Keen  afflicted  from  birth  — namely,  inability  to 
distinguish  red  from  green.  Thus,  the  red  fruits  and  red  flowers  in  his  gar- 
den looked  to  him  of  exactly  the  same  color  as  the  grass  mi  his  lawn  ami 


ON    EPILEPSY.  771 

the  leaves  on  his  trees.  He  was  incapable  also  of  seeing  the  difference  be- 
tween the  red  ribbon  of  the  Legion  of  Honor  Which  he  wore,  and  the  green 
ribbon  of  another  order.  In  all  other  respects  his  sight  was  excellent,  so 
that  the  defect  was  as  strange  as  inexplicable,  and  must  probably  have 
been  due  to  a  defective  organization  of  his  nervous  system,  although  he  had 
never  suffered  from  any  nervous  complaint.  This  peculiar  defect  of  vision 
has,  by  ophthalmologists,  been  described  under  the  name  of  Daltonism; 
and,  in  his  treatise  on  Diseases  of  the  Eye,  Mackenzie  has  recorded  several 
examples  of  it. 

Now,  this  gentleman  was  the  father  of  seven  children,  six  of  whom  had 
convulsions  in  infancy,  whilst  in  one  of  them,  whom  I  attended  for  a  long 
period,  symptoms  of  eclampsia  complicated  attacks  of  acute  catarrh,  pneu- 
monia, measles,  and  scarlatina,  from  which  he  suffered  at  different  periods, 
and  showed  themselves  as  well  during  his  rather  difficult  dentition.  A  few 
years  afterwards  he  was  seized  with  well-characterized  epilepsy,  which  car- 
ried him  off  at  the  age  of  twenty. 

Not  long  ago  I  had  under  my  care,  in  the  St.  Bernard  Ward,  a  woman, 
aged  40,  who  for  the  last  three  years  had  been  subject  to  epileptic  vertigo. 
Whenever  she  was  seized  she  ran  quickly  straight  before  her,  fell  down 
after  a  few  seconds,  but  was  only  partially  insensible.  When  she  got  up 
she  looked  stupid,  and  continued  so  for  several  hours.  One  of  her  sisters 
suffers  from  similar  attacks  ;  and  her  father  had  such  a  violent  temper  that 
he  attempted  to  kill  her  with  an  axe  for  some  trifling  cause  only  eight  days 
before  his  death,  which  was  preceded  by  nervous  symptoms. 

The  hereditary  predisposition  of  an  epileptic  may  therefore  be  traced 
merely  to  strange  nervous  phenomena,  perfectly  different  from  epilepsy 
itself,  whilst  similar  disorders  may  alone  be  manifested  by  his  posterity,  di- 
rect or  indirect.  I  wish,  gentlemen,  to  draw  your  attention  particularly  to 
this  fact — namely,  that  the  hereditary  transmission  of  epilepsy,  and  more 
generally  of  various  nervous  affections  (in  fact,  as  is  the  case  with  all  hered- 
itary diseases),  may  be  direct  or  indirect.  In  a  great  many  cases,  for  in- 
stance, on  inquiring  into  the  family  history  of  an  epileptic  you  will  find,  on  the 
father's  or  on  the  mother's  side,  sometimes  (but  very  rarely)  on  both  sides, 
either  original  traces  of  epilepsy,  in  one  of  its  various  forms,  or  one  of  those 
affections  of  which  epilepsy  may  be  merely  a  transformation,  and  into  which  it 
may  in  its  turn  be  transformed  ;  or,  again,  cerebral  diseases — such  as  soften- 
ing, hemorrhage,.  &c.  In  other,  and  perhaps  more  common  cases,  you  do 
not  find  these  primitive  traces  of  epilepsy  in  the  parents  themselves,  but  you 
have  to  seek  for  them  in  the  grandparents,  in  the  direct  or  distant  relatives, 
in  the  maternal  or  paternal  uncles,  aunts,  and  cousins.  The  hereditary  trans- 
mission may  have  spared  a  generation,  although  the  disease,  at  first  latent 
in  the  parents,  may  show  itself  at  a  later  period  in  them,  after  the  children 
have  been  first  attacked. 

Besides,  cannot  the  same  thing  happen  in  epilepsy  as  in  other  diseases  ? 
Very  trustworthy  authors  state  that  "  individuals,  born  of  a  second  mar- 
riage between  a  perfectly  healthy  woman  and  an  equally  healthy  man,  have 
been  seized  with  the  same  complaint  as  the  children  born  of  a  former  mar- 
riage, a  complaint  to  which  the  woman's  first  husband  was  subject." 

According  to  Dr.  Olgive,  quoted  by  Dr.  Boudin,  a  woman  at  Aberdeen, 
had  married  twice,  and  had  borne  children  both  times.  All  of  them  were  scrof- 
ulous, as  her  first  husband  had  been,  although  she  herself  and  her  second  hus- 
band were  perfectly  free  from  all  scrofulous  taint* 

*  J.  Ch.  M.  Boudin  :  "  Dangers  des  unions  consanguines  et  necessite  du  croise- 
ment  dans  l'espece  humaine  et  parmi  les  animaux  (Annales  d'hygiene  publique  et 
de  medecine  legale."     2e  Serie,  t.  xviii.     18G2). 


772  ON    EPILEPSY. 

Vidal  (de  Cassis),*  also  cited  by  Boudin,  relates  that  a  woman  whose 
first  husband  had  suffered  from  very  obstinate  syphilis,  gave  birth  to  a  child, 
who  died,  after  presenting  the  most  marked  signs  of  syphilis.  After  the 
death  of  her  husband,  this  woman,  who  was  perfectly  healthy,  married 
again.  Her  second  husband  was  perfectly  healthy ;  but,  although  she  knew 
him  alone,  she  gave  birth  to  a  syphilitic  child,  four  years  after  her  first 
marriage. 

However  inconclusive  these  facts  may  be  when  taken  singly,  and  how- 
ever strange  they  may  appear,  they  suggest  reflections  at  the  very  least, 
because  what  happens  as  a  biological  phenomenon  may  occur  as  a  patho- 
logical fact,  both  in  man  and  the  various  classes  of  animals.  Xow  it  is  well 
known  to  zoologists  (and  the  experiment  has  been  often  repeated  in  domestic 
animals),  that  females  do  sometimes  give  birth  to  individuals  which  bear  a 
marked  resemblance  to  the  males  by  which  they  were  fecundated  on  a 
former  occasion.  To  give  you  an  ordinary  instance  of  this.  Many  of  you 
doubtless  know  that  it  is  not  uncommon  to  see  puppies  resembling,  in  form 
or  color,  those  of  a  previous  litter,  and  in  nothing  looking  like  their  father. 

As  regards  the  human  species,  Dr.  Nottf  gives  cases  of  negro  women, 
who,  after  having  borne  children  for  a  white  man,  continued  to  have  mu- 
latto children  with  a  negro  husband. 

According  to  Dr.  Sirupison,  of  Edinburgh,  a  young  woman,  born  of  white 
parents,  and  who  had  a  mulatto  brother  born  before  marriage,  had  un- 
doubted traces  of  black  blood.  J 

Dr.  Dyce  says  that  he  knew  a  half-caste  woman  who  had  fair  children 
with  a  European ;  and  who,  on  being  married  to  a  mulatto  afterwards, 
gave  birth  to  children  resembling  her  first  husband  both  in  face  and  com- 
plexion. 

Whether  they  be  explained  by  the  impression  made  on  the  female  gen- 
erative organs  when  first  impregnated,  which  impression  persists  even 
through  succeeding  impregnations,  or  whether  they  be  regarded  as  inexpli- 
cable, such  facts  exist  nevertheless,  and  open  up  a  vast  field  to  the  etiology 
of  diathetic  diseases,  and  we  should  take  them  into  account  in  our  present 
inquiry. 

With  this  question  of  the  hereditary  transmission  of  disease  is  connected 
another  which  engages  the  attention  of  serious  men,  and  is  more  than  ever 
now  the  order  of  the  day.  I  mean  the  fatal  influence  of  marriages  of  con- 
sanguinity on  the  propagation  of  the  species.  These  influences  play  some 
part  in  the  history  of  epilepsy,  and  it  behooves  us  therefore  to  say  a  few  words 
on  them. 

You  doubtless  know  some  of  the  curious  and  interesting  results  obtained 
from  statistical  researches  made  in  America,  Germany,  England,  and  France. 
From  these  researches  and  especially  from  those  which  my  learned  confrere, 
Dr.  Boudin,  has  recorded  in  his  memoir,  it  appears  that  intermarriages  may 
cause  either  complete  sterility,  or  a  greater  frequency  of  miscarriages;  or  thai 
they  may  give  birth  to  children  who  die  in  infancy  in  a  greater  proportion 
than  those  born  under  other  circumstances,  or  who  are  less  apt  to  resist  dis- 
ease if  they  live  beyond  the  first  period  of  life,  or  who  are  of  a  lymphatic 
temperament,  with  a  predisposition  to scrofhlo-tubercular  affections.§  These 
intermarriages  may,  again,  beget  individuals  suffering  from  degenerations, 

*  "Traitedes  Maladies  Veneriennes;"  2d  ed.     PariB,  1855,  p.  680. 

f  "  Types  of  Mankind ;  "  4th  ed.  p.  806  (cited  by  Boudin). 

I  "Gazette  Medical  e  de  Paris,"  L6  Avril,  I860;  p.  281  (quoted  by  Boudin). 

\  Kn.r.i  kt  (de  Geneve) :  "  Note  Bur  1'influence  de  la  consanguinity  sur  lea  produits 
du  mariage"  (Journal  de  Chimie,  kledecine  et  Phurroacie,  20Juin,  1850),  quoted 
by  Dr.  Boudin,  p.  01 


ON    EPILEPSY.  773 

and  physical  or  moral  infirmities;  from  monstrosities — such  as  polydactvlia, 
spina  bifida,  talipes,  hare-lip,  as  in  the  cases  reported  by  Dr.  Devay,  in  hi.-* 
Trait  e  special  d'Hygiene  des  Families,  who  adds  also  retarded  dentition  as 
another  consequence  of  the  same  cause. 

In  the  lower  animals  albinism  may  almost  at  will  be  produced  by  suc- 
cessive unions  between  near  relatives  ;  and  this  singular  degeneration  in 
man,  of  which  pretty  numerous  examples  are  on  record,  may  perhaps  have 
the  same  origin.  Diseases  of  the  organ  of  vision  may  be  produced  ;  consist- 
ing sometimes  in  strange  defects  of  sight,  at  other  times  in  total  blindness, 
or  in  that  affection  described  under  the  name  of  pigmentary  retinitis,  which 
is  characterized  during  infancy  by  a  failure  of  the  sight  in  the  twilight,  and 
a  diminution  of  the  field  of  vision  by  a  feeble  light;  later,  at  about  the  age 
of  thirty  or  forty,  by  the  abolition  of  vision,  or  at  least  of  the  faculty  of 
guiding  oneself,  although  the  smallest  type  may  still  be  distinguished  within 
very  narrow  limits  of  the  field  of  vision.  The  ophthalmoscope  detects,  in 
such  cases,  grave  alterations  of  the  choroid  and  of  the  optic  nerve ;  the 
retina  is  more  or  less  ati'ophied,  and  is  covered  with  cells  of  black  pigment, 
which  unite  and  form  a  plexus.  *  In  order  to  prove  to  you  the  relation  of 
these  morbid  conditions  to  the  intermarriages  from  which  spring  the  unfor- 
tunate patients,  allow  me  to  quote  a  few  figures  from  Dr.  Boudin's  memoir. 

"  Among  the  issue  of  27  intermarriages  observed  in  America,  Dr.  Bemiss 
(of  Louisville)  found  two  children  that  were  blind,  and  six  who  were  afflicted 
with  various  defects  of  vision. 

"  Dr.  Liebreich,  of  Berlin,  thinks  that  nearly  one-half  (27  out  of  59)  of 
the  individuals  suffering  from  pigmentary  retinitis  are  born  of  intermar- 
riages."  Of  these  59  cases,  retinitis  coincided  with  deaf-mutism  in  18,  and 
in  2  with  idiocy.  This  coincidence  is  all  the  more  striking  that  pigmentary 
retinitis  is  very  rare ;  and,  as  Liebreich  remarks,  that  both  diseases  simul- 
taneously attack  children  belonging  to  families  in  which  they  show  them- 
selves together,  but  never  separately,  f 

Of  all  the  fatal  consequences  of  intermarriages,  the  most  frequent  is, 
without  doubt,  deaf-mutism.  "  The  proportion  of  individuals  who  are  deaf 
and  dumb  from  birth,"  says  Dr.  Boudin,  "  increases  with  the  degree  of  rela- 
tionship between  the  parents.  If  we  assume  the  risk  of  giving  birth  to  a 
deaf  and  dumb  child  in  an  ordinary  union  to  be  represented  by  1,  that  risk 
will  be  equal  to  18  in  marriages  between  cousin-germans,  to  37  in  mar- 
riages between  uncles  and  nieces,  and  to  70  in  marriages  between  nephews 
and  aunts."| 

That  hereditary  predisposition  has  a  very  small  share  in  the  production 
of  deaf-mutism  is  shown  by  the  fact,  that  the  hereditary  transmission  of  the 
infirmity  is  the  exception,  not  the  rule.  Nay,  more :  "  Usually,  and  in  the 
immense  majority  of  cases,  deaf  and  dumb  men  married  to  deaf  and  dumb 
women  have  children  who  can  hear  and  talk.  This  is,  a  fortiori,  true  in 
cases  of  mixed  marriages,  that  is,  when  only  one  of  the  parents  is  a  deaf 
mute."§  Such  was  Meniere's  opinion,  whose  authority  on  such  matters  is 
not  to  be  disputed. 

"  Deaf-mutism,"  says  Dr.  Boudin  again,  "  is  not  always  directly  brought 
on  by  intermarriages;  it  is  sometimes  produced  indirectly  in  cross-marriages, 
in  cases  of  perfectly  healthy  individuals,  free  from  all  infirmity,  but  one  of 
whom  was  the  issue  of  an  intermarriage." 

*  "  Annates  d'Oculistique,"  Avril,  1861  (quoted  by  Dr.  Boudin,  p.  55). 
f  Boudin:  op.  cit.,  pp.  54,  55,  56,  57,  and  58. 
%  lb.,  p.  80. 

|  Pr.  Meniere  :  "  Kechercbes  sur  la  Surdi-Mudite  "  (Gazette  Medicale  de  Paris, 
3e  serie,  t.  1,  p.  243). 


774  ON    EPILEPSY. 

In  support  of  this  statement  the  author  quotes  the  following  case  bor- 
rowed from  a  thesis  by  Dr.  Chazarain  :* 

"Mr.  L ,  the  mayor  of  C (Dordogne)  married  his  cousin's  daugh- 
ter, by  whom  he  had  a  son  and  a  daughter  not  only  free  from  all  infirmity, 

but  also  enjoying  excellent  health,  like  their  parents.     Miss  L ,  in  her 

turn,  married  a  young  man,  a  few  years  older  than  herself,  to  whom  she 
was  not  in  the  remotest  degree  related,  and  gave  birth  to  a  daughter  afflicted 
with  congenital  deaf-mutism.  The  parents  of  the  child  reside  in  a  dry  and 
healthy  locality,  high  above  the  level  of  the  sea,  and  their  means  allow 
them  to  live  in  easy  affluence.     There  is  no  other  case  of  deaf-mutism  at 

C ,  nor  has  there  been  another  case  in  the  family.     Lastly,  the  mother's 

pregnancy  was  not  marked  by  anything  special." 

Now,  might  not  what  applies  to  deaf-mutism  in  this  case  be  applied  also 
to  all  the  fatal  consequences  of  intermarriages  ? 

A  merchant  in  Paris  marries  his  first  cousin ;  his  sister  also  marries  a 
first  cousin,  but  belonging  to  another  branch.  The  sister  has  no  children ; 
the  brother  has  three  daughters,  perfectly  formed  and  in  excellent  health. 
Of  these  three  girls,  the  youngest,  seven  years  younger  than  the  second 
daughter,  has  three  well-formed  children.  The  second  girl  has  only  one, 
however  much  she  desires  to  have  many;  and  the  eldest,  married  for  more 
than  ten  years,  remains  sterile,  to  her  extreme  chagrin. 

These  facts,  especially  the  last,  are  of  doubtful  import,  I  admit;  but  were 
they  to  be  found  more  frequently,  now  that  careful  inquiries  are  made  into 
everything  bearing  on  the  question  of  intermarriages,  they  would  become 
of  some  value,  and  on  this  account  the  most  insignificant  deserve  to  be 
noted. 

To  conclude  this  digression,  it  has  never  been  said  that  unions  between 
near  relatives  were  necessarily  and  fatally  followed  by  evil  consequences. 
Medical  observation  proves,  however,  beyond  doubt  (agreeing  in  this  with 
the  experience  of  legislators,  who  in  a  great  many  countries  have,  on  that 
account,  proscribed  marriages  of  consanguinity),  that  the  bad  results  which 
we  have  enumerated  above,  are  relatively  much  more  frequent  in  indi- 
viduals born  of  intermarriages,  than  in  those  born  of  mixed  marriages,  and 
that  both  in  man  and  in  the  lower  animals  which  have  been  largely  experi- 
mented on  ;  "  intermarriages  endanger  the  species  through  the  sterility,  the 
infirmities,  and  diseases,  which  may  affect  the  issue  of  such  unions,  when 
fruitful ;  and  in  the  case  of  man,  such  marriages,  when  repeated  during 
several  generations,  bring  on  physical,  moral,  and  intellectual  degeneracy, 
and,  finally,  the  extinction  of  the  family."  Such  is  Dr.  Chazarain's  opin- 
ion, and  a  great  many  physicians  concur  with  him. 

The  fatal  influence  of  intermarriages  is  a  frequent  cause  of  mental  dis- 
eases. Esquirol,  and  after  him,  all  writers  on  mental  diseases,  have  pointed 
out  that  in  many  eases  idiocy  and  mental  alienation  had  resulted  from 
unions  between  near  relatives.     Epilepsy  is  another  of  these  results. 

Among  others  I  will  relate  to  you  the  following  instances.  1  once  at- 
tended the  family  of  a  Neapolitan  gentleman  who  had  married  his  niece. 
There  was  no  hereditary  taint,  and  yet  of  his  four  children,  the  eldest,  a 
girl,  was  very  eccentric;  the  second,  a  boy,  was  epileptic;  the  third  was  of 
perfectly  sound  mind;  whilst  the  fourth  was  epileptic  and  an  idiot. 

A  friend  of  mine,  who  also  married  his  nine,  had  four  children,  one  of 

*  L.  T.  Chazarain:  "Du  mariage  entre  consanguins,  consider^  corame  cause  do 
degenerescence  organique,  et  particulidremenl  <!<■  Burdi-tnudit6  congdnitale."  Thdse 
de  Montpellier,  L859. 


ON    EPILEPSY.  775 

whom  was  seized  at  birth  with  grave  convulsions,  and  another  son  is  epi- 
leptic and  an  idiot. 

Not  long  ago,  I  saw  with  Messrs.  Moynier  an  epileptic  boy,  the  son  of 
first  cousins ;  and  shortly  afterwards  I  had  the  opportunity  of  observing 
two  analogous  cases,  one  that  of  a  young  man,  aged  32;  the  other,  that  of 
an  idiotic  child,  subject  to  epilepsy. 

Now  that  I  carefully  inquire  into  the  epiestion  of  consanguinity,  when- 
ever I  see  deaf  and  dumb  individuals,  idiots,  and  epileptics,  I  can  scarcely 
tell  you  how  great  a  share  this  influence  seems  to  me  to  possess  in  the 
causation  of  these  affections. 


§  5.  Diagnosis  between  Epilepsy  and  Eclampsia. — Transformation  of  Eclamp- 
sia into  Epilepsy. — Differential  Diagnosis  from  Hysteria. — Symptomatic 
Epilepsy. —  Treatment  of  Epilepsy. 

Of  all  convulsive  disorders,  Eclampsia  is  the  most  difficult  to  diagnose 
from  Epilepsy.  These  two  affections  are  frecpuently  confounded  together, 
as  I  have  told  you  already,  and  this  confusion  is  unavoidable,  if  we  only 
take  into  account  the  convulsive  phenomena  which  characterize  them  both. 
Look,  for  example,  at  a  woman,  seized  with  eclampsia,  in  the  eighth  or  ninth 
month  of  pregnancy,  or  during  labor ;  see  a  child  in  convulsions,  either  at 
the  outset  of  an  eruptive  fever,  or  during  the  period  of  teething;  and 
however  much  you  may  be  forewarned,  however  careful  you  may  be  in 
observing  the  case,  you  shall  not  be  able  to  discover  any  difference  between 
those  attacks  and  the  convulsive  form  of  epilepsy. 

Recall  to  mind  an  attack  of  eclampsia  occurring  in  a  pregnant  woman, 
for  instance,  who  is  suddenly  seized  with  convulsions,  sometimes  after 
having  first  uttered  a  loud  cry.  Her  limbs  are  distorted,  on  one  side 
chiefly,  her  head  inclines  to  one  shoulder,  whilst  her  face  is  turned  to  the 
opposite  side;  her  tongue  is  thrust  out  of  her  mouth,  and  may  be  wounded, 
cut,  or  lacerated  by  her  teeth  ;  froth,  tinged  with  blood,  soils  her  lips  and 
cheeks,  exactly  as  in  an  individual  who  has  an  epileptic  fit.  The  convul- 
sions last  from  one  to  two  minutes,  and  are  succeeded  by  apoplectiform 
stupor,  as  in  epilepsy  again.  But  we  shall  be  enabled  to  distinguish 
eclampsia :  first,  by  the  usual  recurrence  of  the  seizures,  these  following 
one  another  pretty  rapidly;  secondly  and  chiefly,  by  the  circumstances 
under  which  the  attack  comes  on;  and  thirdly,  by  certain  phenomena 
which  precede  and  accompany  the  seizure. 

Whereas  epilepsy,  when  it  assumes  the  convulsive  form  very  distinctly, 
recurs  at  pretty  distant  intervals — (I,  of  course,  set  aside  the  status  epilepj- 
ticus) — at  intervals  varying  generally  from  a  year  to  six,  three,  and  two 
months,  or  a  week  only :  eclampsia,  on  the  contrary,  runs  a  more  continu- 
ous course,  recurs  at  very  short  intervals,  and  is  always  imminent  so  long 
as  the  cause  on  which  it  depends  persists  in  full  force.  On  the  other  hand, 
when  once  this  cause  is  removed,  the  recurrence  of  the  convulsions  is  in 
general  no  longer  to  be  feared,  whilst  a  first  attack  of  epilepsy  is  always  a 
reason  for  suspecting  others,  and  almost  fatally  mortgages  the  future. 

In  a  pregnant  woman,  for  example,  or  a  woman  in  labor,  eclampsia  may 
recur  from  eight  to  twenty  times  in  the  twenty-four  hours;  thus  resembling, 
in  some  measure,  the  status  epilepticus  I  spoke  of  just  now.  The  patient  is 
not  yet  out  of  one  attack  before  she  has  another,  the  convulsions  beginning 
even  while  she  is  still  in  the  state  of  stupor  characterizing  the  second  stage. 

The  same  thing  happens  in  infantile  convulsions.  The  attacks  succeed 
one  another  rapidly,  and  when  they  do  not  consist  in  extensive  muscular 


776  ON    EPILEPSY. 

movements,  the  phenomena  described  under  the  name  of  inward  convulsions, 
and  which  are,  to  some  extent,  the  analogues  of  epileptic  vertigo,  are  mani- 
fested for  two  or  three  days  in  succession. 

There  is  rolling  upwards  of  the  eyeballs,  or  distortion  of  the  face,  or 
spasm  of  the  respiratory  organs,  causing  momentary  interruption  of  the 
respiration,  which,  after  a  few  seconds,  goes  on  with  the  same  regularity  as 
before. 

This  frequency  of  repetition  and  continuity  of  the  attacks  are  a  frequent 
cause  of  death,  which  is  then  due  to  the  commotion  of  the  nervous  centres 
caused  by  the  convulsions,  or  to  asphyxia  brought  on  by  the  tonic  con- 
vulsions persisting  for  too  lengthened*  a  period  in  the  respiratory  muscles, 
and  thus  interfering  with  the  oxygenation  of  the  blood. 

You  understand,  therefore,  how  it  happens  that  death  is  much  more  fre- 
quently an  immediate  consequence  of  eclampsia  than  of  epilepsy.  It  very 
rarely  happens,  indeed,  that  an  epileptic  is  carried  off  in  an  attack,  setting 
aside  those  cases  of  accidental  death,  the  result  of  grave  and  fatal  injuries 
sustained  in  his  fall.  It  too  often  happens,  on  the  contrary,  that  women 
die  of  eclampsia,  and  still  more  frequently  that  children  are  carried  off  by 
convulsions. 

What  I  said  just  now  of  eclampsia,  occurring  in  a  pregnant  woman,  or 
of  infantile  convulsions,  applies  equally  well  to  saturnine  eclampsia,  and 
to  eclampsia  depending  on  albuminuria.  Nothing,  as  far  as  regards  the 
form  of  the  convulsions,  distinguishes  them  from  epilepsy.  They  are  pretty 
distinctly  separated  from  it,  however,  by  the  frequent  repetition  and  the 
continuity  of  the  attacks ;  this  being  the  rule  in  eclampsia,  and  the  excep- 
tion in  epilepsy.  The  latter  affection  particularly  differs  also  in  that,  in 
the  vast  majority  of  cases,  it  strikes  an  individual  in  the  midst  of  the  most 
perfect  health.  Nothing  announces  the  attack  ;  a  minute  before  it  occurs, 
whether  preceded  by  an  aura  or  not,  the  patient  was  as  well  as  a  week 
before.  This  is  the  rule,  and  the  exceptions  to  it  are  much  more  apparent 
than  real,  generally  occurring  in  cases  of  symptomatic  epilepsy,  which, 
strictly  speaking,  should  not  be  separated  from  eclampsia. 

Eclampsia,  on  the  contrary,  only  supervenes  under  certain  given  cir- 
cumstances, more  or  less  easily  discoverable.  It  is  dependent  on  a  patho- 
logical condition  characterized  by  other  symptoms,  and  shows  itself  at  the 
onset,  in  the  course,  or  towards  the  termination  of,  some  acute  or  chronic 
disease,  and  frequently  it  is  even  possible  to  foresee  it.  Thus  albuminuria, 
whether  idiopathic,  or  due  to  Bright's  disease  or  to  antecedent  scarlatina, 
or  whether  occurring  in  a  pregnant  woman  (in  the  two  latter  conditions 
particularly),  makes  us  dread  the  possible  occurrence  of  eclampsia.  After 
this  has  shown  itself,  independently  of  the  other  general  or  local  symptoms 
which  belong  to  albuminuria,  the  mere  presence  of  albumen  in  the  urine 
sufficiently  indicates  the  disease.  In  some  cases,  of  course,  this  diagnosis 
cannot  be  made,  as  when  individuals,  that  were  previously  subjeel  to  epi- 
lepsy, are  seized  with  eclampsia.  Thus  again,  in  eases  of  convulsions  oc- 
curring in  a  child  who  is  teething,  or  who  is  at  I  he  beginning  of  an  acute 
febrile  affection,  you  will  at  omv  recognize  eclampsia,  or  at  least  epilepsy 
will  occur  to  you  on  second  thought  only.  Vet,  gentlemen,  some  reserva- 
tion should  l>c  made.    These  eclamptic  convulsions,  whatever  their  exciting 

cause  may  have  been,  are  often  indeed  true  epileptic  fits.  It  is  especially 
in  children  above  live  or  six  years   of  age,  ami    even  in  younger  children, 

that  epilepsy  may  be  dreaded  for  the  future,  when  the  attacks  of  eclampsia 

OCCUr  frequently  and  for  the  least  thing.  I  have  sometimes  also  seen  epi- 
lepsy in  women  who  at  some  more  or  less  distant  period  had  been  seized 
with  eclampsia  during  labor.     1  have  always  asked  myself  whether  there 


ON    EPILEPSY.  777 

may  not  be  some  connection,  in  such  cases,  between  eclampsia  and  the  epi- 
leptic fits,  and  I  have  felt  inclined  to  answer  the  question  in  the  affirmative. 
These  considerations,  in  cases  of  infantile  convulsions,  apply  particularly 
to  that  form  of  partial  convulsion  which  affects  the  muscles  of  the  larynx, 
and  has  been  very  improperly  called  thymic  asthma.  You  saw  an  instance 
of  this  some  time  ago  in  a  baby  eight  months  old,  whose  health  was  very 
good  in  other  respects.  His  mother  said  that  frequently,  whether  he  was 
at  the  time  sitting  in  his  crib,  or  was  being  nursed  in  her  arms,  he  suddenly 
uttered  a  loud  cry,  as  if  he  felt  acute  pain.  This  cry  resembled  that  of  a 
fit  of  anger,  but  was  immediately  followed  by  a  noisy,  hissing  inspiration, 
similar  to  that  of  hooping-cough.  The  face  was  red,  the  veins  of  the  neck 
were  swollen.  After  a  few  seconds,  however,  the  child  became  calm  again, 
and  recovered  his  previous  condition.  He  had  also  suffered  from  regular 
convulsive  attacks. 

In  such  cases — and  I  shall  some  day  revert  to  this  point,  which  is  of  the 
highest  practical  importance — be  veiy  reserved  in  your  prognosis.  Although 
these  symptoms  be  not  serious  in  general,  the  patient's  life  may,  however, 
be  in  immediate  danger  when  the  laryngeal  spasm  is  prolonged  beyond  a 
certain  period,  for,  if  it  lasts  two  minutes,  asphyxia  is  produced.  Moreover, 
I  repeat,  these  partial  convulsions  may  be  a  manifestation  of  epilepsy, 
which,  sooner  or  later,  is  attended  with  more  distinct  and  more  character- 
istic phenomena. 

I  next  pass  on  to  the  differential  diagnosis  between  Hysteria  and  Epilepsy. 
This  is,  in  some  cases,  attended  with  great  difficulty,  as  I  have  already 
pointed  out.  Thus,  although  in  general  preceded  by  very  characteristic 
nervous  symptoms,  a  convulsive  attack  of  hysteria  may  sometimes  set  in 
suddenly  /or  the  patient  may,  at  the  beginning,  have  felt  a  kind  of  aura,  a 
spasmodic  sensation,  which,  starting  from  some  point  of  the  body,  becomes 
general,  and  bears  some  resemblance  to  the  aura  epileptica.  I  hasten  to 
add,  however,  that  such  cases  are  exceptional.  In  the  great  majority  of 
instances,  hysterical  convulsions  are  ushered  in  by  phenomena  which,  when 
once  observed,  can  no  longer  be  mistaken.  As  to  the  aura  hysterica  itself, 
it  differs  widely  from  the  aura  epileptica.  I  have  already  drawn  attention 
to  the  fact,  but  it  is  of  such  importance  that  I  do  not  fear  to  revert  to  it. 
The  aura  hysterica  starts  almost  constantly  from  the  same  point,  and  is 
compared  by  the  patient  to  the  sensation  of  a  foreign  body,  of  a  ball  press- 
ing on  the  umbilical  and  epigastric  region,  and  which,  extending  upwards 
along  the  oesophagus,  produces,  on  reaching  the  throat,  a  feeling  of  chok- 
ing. However  short  may  be  the  time  during  which  this  sensation  lasts,  it 
persists  generally  much  longer  than  the  aura  epileptica,  the  rapidity  of 
which  may,  in  almost  all  cases,  be  compared  to  that  of  lightning. 

Another  important  point  is,  that  hysteria  affects  the  female  sex  almost 
exclusively,  so  that  the  fact  of  a  patient  being  a  female  should  put  you  on 
your  guard,  and  make  you  suspect  the  nature  of  the  symptoms. 

The  aspect  of  hysterical  persons  is  besides  very  different  from  that  of 
epileptics.  As  to  the  attack  itself,  it  is  tumultuous  in  hysteria,  more  silent 
in  epilepsy.  An  individual  in  an  epileptic  fit,  is  convulsed  for  a  few 
moments,  "but  after  a  few  seconds  he  becomes  motionless  and  passes  into  a 
state  of  stupor ;  the  deadly  pallor  of  his  face  is  replaced  by  redness,  of  a 
more  or  less  livid,  bluish  tint.  Hysterical  convulsions  are,  if  I  may  use 
the  expression,  more  demonstrative :  they  consist  in  extensive  movements, 
which  do  not  affect  one  side  especially,  as  in  epilepsy,  but  both  sides  nearly 
equally,  except  in  cases  complicated  with  catalepsy  or  paralysis.  The 
patient  can  be  restrained  by  several  persons  only.  If  an  epileptic  be  seized 
whilst  lying  down,  he  remains  in  his  bed;  if  whilst  standing,  he  falls  down, 


778  ON    EPILEPSY. 

and  rarely  quits  the  place  where  he  fell.  An  hysterical  patient,  on  the 
contrary,  throws  herself  about  in  all  directions ;  if  in  bed,  she  rises  and 
throws  herself  to  the  right  and  to  the  left.  An  epileptic,  again,  after  having 
uttered  the  cry  which  generally  precedes  a  fit, remains  silent;  an  hysterical 
woman  keeps  crying  during  the  attack,  and  goes  on  moaning,  or,  towards 
the  close,  bursts  into  tears  or  into  a  laugh,  without  any  reason. 

Lastly,  whilst  a  fit  of  haut-mal  rarely  lasts  three  minutes,  hysterical  con- 
vulsions are  prolonged  for  a  much  longer  period. 

Such  are,  speaking  very  generally,  the  distinctive  characters  between  an 
epileptic  seizure  and  an  hysterical  fit.  As  to  the  fundamental  differences 
between  the  two  diseases,  I  need  not  insist  on  them  now. 

There  are  cases,  however,  gentlemen,  in  which  the  symptoms  observed 
are  really  on  the  confines  between  the  two  diseases.  You  may  remember  a 
nurse  who  was  formerly  in  my  female  ward,  and  who  is  at  present  at  the 
Salpetriere.  She  was  certainly  hysterical,  but  her  attacks  sometimes  pre- 
sented, at  the  onset,  the  characters  of  epileptic  seizures.  You  could  see  at 
the  same  time,  and  in  the  same  ward,  that  young  girl  whose  history  I  have 
already  related  to  you,  and  who,  during  her  epileptic  fits — which  lasted,  it 
is  true,  one  minute  only — was  frequently  agitated  with  the  same  violence 
and  the  sort  of  jactitation  which  belong  to  hysteria. 

Let  me  add  again  (and  there  are  pretty  numerous  instances  of  this  at  the 
Salpetriere)  that  some  women  are  at  the  same  time  hysterical  and  epileptic; 
and,  indeed,  there  is  no  reason  why  epilepsy  should  protect  against  hysteria, 
or  vice  versa. 

I  now  proceed  to  the  consideration  of  another  point  as  regards  the  diag- 
nosis of  epilepsy. 

An  individual,  with  a  tumor  of  the  brain,  of  tubercular,  syphilitic,  or 
cancerous  nature,  is  seized  with  convulsions — should  they  be  called  epileptic? 
A  great  many  physicians  will  reply  in  the  affirmative,  but  will  add  the 
qualification  of  symptomatic  to  the  name  epilepsy.  It  is  true  that  these 
epileptiform  convulsions  differ  in  nothing  from  those  of  genuine  epilepsy, 
but  the  seizure  is  sometimes  preceded  by  more  or  less  violent  headache, 
which  is  exactly  localized  by  the  patient.  Sometimes  also,  there  exists 
more  or  less  complete  paralysis,  limited  to  one  side  of  the  trunk,  the  muscles 
of  the  face,  the  eyes,  the  soft  palate, — a  paralysis  of  movement  to  which  is, 
in  some  cases,  superadded  a  paralysis  of  sensation ;  lastly,  there  may  be  also 
impairment  of  the  intellect.  Now  all  these  symptoms  indicate  the  existence 
of  some  more  or  less  profound  organic  lesion  of  the  brain. 

The  following  case  is  a  remarkable  instance  of  this,  and,  although  it  was 
one  of  the  first  of  the  kind  which  came  under  my  observation,  and  although 
more  than  thirty  years  have  elapsed  since  then,  I  still  remember  it  perfectly. 
A  gentlemen  was  one  evening,  for  the  first  time  in  his  life,  seized  with 
epilepsy  whilst  at  the  British  Embassy.  Shortly  after  this  he  had  a  second 
attack,  and  on  one  occasion,  whilst  riding  in  the  Champs-Elysees,  he  till 
down  from  his  horse  in  a  fit,  and  severely  injured  his  head.  From  that 
time  he  gave  up  going  into  society,  and  consulted  Dupuvtren,  who  prescribed, 
but  without  success,  the  remedies  vaunted  againsl  epilepsy,  lie  next  placed 
himself  under  the  care  of  Dr.  A.  Lebreton,  who,  on  carefully  inquiring  into 
his  previous  history,  ascertained  that  he  had  suffered  from  violent  and 
chiefly  aocturnal  headache.     I  was  then  asked  to  meet    Dr.  Lebreton  in 

consultation,  and  we  together  made  OUl  that  the  pain  was  almost  exclusively 
limited  to  one  side  of  the  head.  The  periodical  recurrence  of  the  headache 
and  its  nocturnal  exacerbation  pointed  clearly  to  syphilis;  and  indeed,  we 
ascertained  on  inquiry  that  the  patient  had  had  a  venereal  all'ection  live  or 
six  years  previously,  to  which  he  had    never   paid   attention.     Suspecting, 


ON    EPILEPSY.  779 

then,  an  intracranial  exostosis,  or  a  syphilitic  tumor,  we  recommended  a 
treatment  chiefly  consisting  of  Liq.  Van  Swieten.  The  symptoms  disap- 
peared completely  from  that  time,  and  a  radical  cure  was  obtained. 

This  case,  then,  was  one  of  epileptiform  convulsions,  or  of  eclampsia,  to 
use  the  expression  which  is  current  in  the  profession,  but  it  was  certainly 
not  a  case  of  epilepsy  in  the  sense  usually  meant. 

In  some  cases  the  form  of  the  seizure  resembles  epilepsy  still  more  closely. 

Last  year  I  was  consulted  by  a  lady  71  years  old,  who,  since  the  age  of 
40,  had  been  subject  to  attacks  recurring  with  a  daily  increasing  frequency, 
and  so  much  so  that  she  had  as  many  as  twenty-one  in  the  twenty-four 
hours.  The  diagnosis  of  her  case  was  written  in  large  type  on  her  face,  for 
she  had  on  the  forehead  a  broad,  deep  scar,  which  began  above  and  outside 
of  the  right  eyebrow,  and  penetrated  the  frontal  bone,  which  had  necrosed. 
There  had  also  been  necrosis  of  the  nasal  bones,  for  the  nose  was  broken 
down  and  depressed. 

Under  the  influence  of  mercury  and  iodide  of  potassium,  rapid  improve- 
ment followed,  so  rapid  indeed  that  she  had  only  one  attack  in  the  very 
first  month,  and  this  proved  the  last. 

In  some  cases,  the  lesion  which  is  the  exciting  cause  of  the  attacks  is 
so  trifling,  that  its  importance  is  with  difficulty  suspected.  Dr.  Foville 
saw,  with  Alph.  Robert,  my  excellent  colleague  at  the  Hotel-Dieu,  a  young 
notary's  clerk,  who,  for  several  years,  had  been  subject  to  monthly  attacks 
of  epilepsy.  Many  remedies  had  been  tried  in  vain,  when  Dr.  Foville 
suggested  the  extraction  of  some  carious  teeth  which  ached  constantly. 
The  suggestion  was  acted  upon,  and  from  that  day  the  fits  disappeared. 

On  March  2d,  1861,  Dr.  Monnier,  of  Saint-Paul  (Eastei*h  Pyrenees), 
communicated  to  me  a  no  less  interesting  case,  which  somewhat  resembles 
the  case  of  Graves  which  I  quoted  a  short  time  ago.  A  man  40  years  old, 
tall,  and  of  a  robust  constitution,  was  seized  on  several  occasions,  and  at 
very  short  intervals,  with  violent  epileptic  attacks.  Dr.  Monnier,  on  learn- 
ing that  the  patient  often  passed  fragments  of  taenia,  gave  him  large  doses 
of  castor  oil.  A  whole  taenia  came  away,  and  from  that  time  the  convul- 
sive attacks  ceased. 

The  little  success  which  attended  the  treatment  of  epilepsy  had,  among 
the  ancients,  obtained  for  it  the  appellation  of  morbus  saeer,  a  scourge  sent 
by  the  gods  in  their  anger.  The  unfortunate  patient  was  fatally  doomed 
to  convulsions,  and  nothing  short  of  a  special  intervention  of  the  gods 
could  save  him  from  the  fate  which  awaited  him.  The  progress  of  science 
has  little  changed  matters  in  this  respect,  and  epilepsy  is,  in  general,  as 
incurable  now  as  formerly.  I  say  in  general,  and  I  make  this  reservation, 
because  there  is  no  medical  man,  of  large  experience,  who  has  not  seen 
some  epileptics  get  well.  You  shall  have  occasion  also  to  see  a  certain 
number  of  patients  remain  seven,  eight,  ten  years,  and  more,  without  any 
fresh  fits,  although  these  recurred  frequently  before.  Now,  in  a  complaint 
of  this  nature,  a  long  truce  looks  very  much  like  a  cure. 

When  a  disease  admits  of  so  fatal  a  prognosis,  the  number  of  remedies 
vaunted  for  its  cure  increases  indefinitely.  And  as,  in  some  rare  cases,  a 
spontaneous  cure  takes  place,  the  credit  is  given  to  the  treatment,  and  not 
to  nature,  until  repeated  failures  show  the  inefficacy  of  the  remedy. 

Epilepsy  could  not  escape  the  common  law.  Its  incurability  necessarily 
led  medical  men  to  use  against  it  all  the  resources  of  their  therapeutic 
arsenal,  so  that  known  drugs,  as  well  as  unknown  remedies,  some  appar- 
ently rational,  others  empirical,  others  again  of  the  most  extraordinary 
character,  were  tried  in  succession.  And  it  would  be  difficult  indeed  to 
give  a  complete  list  of  all  the  remedies  which  have  in  turn  been  vaunted 


780  ON    EPILEPSY. 

against  epilepsy,  and  soon  justly  given  up,  beginning  with  those  mentioned 
by  ancient  authors,  some  of  which  were  abominable,  and  invented  by  super- 
stition, "  qucedam  satis  abominanda,"  and  " superstitiosa  plurima"  and  not 
forgetting  those  of  which  ignorance  and  bad  faith  dare  exaggerate  the  vir- 
tues, even  to  this  day. 

Is  medicine,  then,  entirely  powerless  against  this  terrible  disease?  Not 
completely  so, — for  there  is  a  mode  of  treatment,  the  treatment  by  belladonna, 
which,  if  it  cures  epilepsy  in  very  rare  cases  only,  procures  at  least  a  pretty 
large  number  of  patients  a  real  alleviation  of  their  sufferings. 

Although,  from  the  difficulty  we  have  of  judging  of  its  effects,  the  same 
objections  apply  to  this  treatment  as  to  all  the  rest,  yet  skepticism  should 
not  go  beyond  certain  limits,  and  we  cannot  refuse  to  believe  the  testimony 
of  grave  physicians.  Long  ago,  according  to  Murray,  Greding  had  several 
times  administered  belladonna — either  in  the  form  of  powder  or  of  extract 
— to  patients  afflicted  with  simple  or  complicated  epilepsy  ;  and  if  they  did 
not  get  well,  they  improved  remarkably  at  least.  These  observations  were 
confirmed  by  Leuret  at  Bicetre,  and  by  Ricard  ;  but  it  is  Bretonneau  who, 
in  our  time,  has  handled  this  remedy  with  the  greatest  perseverance  and 
success. 

Almost  simultaneously  with  the  illustrious  physician  of  Tours,  Father 
Debreyne,  physician  to  the  Trappe  of  Mortagne,  and  a  Trappist  himself, 
obtained  similar  results.  As  to  myself,  I  have  employed  it  for  more  than 
thirty  years,  and  it  has  seemed  the  least  inefficacious  of  those  I  have  ever 
tried  or  seen  tried.  Indeed,  I  can  now  count  a  certain  number  of  real 
cures,  and  in  many  cases  I  obtained  an  improvement  which  I  dared  not 
expect. 

Above  all,  an  essential  point  must  be  laid  down,  namely,  that  the  remedy 
is  to  be  trusted  only  in  so  far  as  it  shall  be  administered  in  accordance  with 
certain  rules,  which  should  not  be  infringed.  There  is  a  great  principle  in 
therapeutics,  which  should  not  be  forgotten  here,  less  than  ever :  it  is  this, 
that  when  a  disease  has  deeply  penetrated  the  organism,  when  it  masters 
its  whole  substance  as  it  were,  one  cannot  pretend  to  silence  its  manifesta- 
tions, to  cure  it  within  a  short  space  of  time.  A  chronic  disease  requires 
chronic  treatment.  Thus,  when  syphilis  dates  five,  six,  eight,  ten  years 
back,  you  cannot  hope  to  cure  it,  except  on  condition  of  subjecting  the 
patient  to  a  very  prolonged  treatment,  for  five  or  six  months  at  first,  and, 
after  a  short  interruption,  resuming  it  again,  and  so  on  for  several  times. 
On  this  condition  alone  will  you  succeed  in  rooting  up  the  evil,  and  in 
removing  it  entirely. 

Now,  if  syphilis  requires  such  prolonged  treatment,  how  much  more 
must  epilepsy  require  it,  the  germ  of  which  often  exists  in  the  system  from 
birth?  The  treatment  should  be  persevered  in,  therefore,  oof  for  months 
only,  but  for  several  years  in  succession.  The  disease  is  to  he  allowed  DO 
truce,  and  the  system  should  he  kept  constantly  under  the  influence  of  die 
drug,  lest  it  should  be  mastered  again  by  the  disease  which  is  forcibly  kepi 
down.  Of  this,  gentlemen,  you  should  be  firmly  convinced,  and  of  this 
you  should  warn  the  patient  who  places  himself  under  your  care,  and  his 
friends  who  ask  your  advice. 

Let  us  see,  then,  how  belladonna  should  he  administered.  Pills  are  made 
up  according  to  the  following  formula  : 

]&.  Bztracti  Belladonnas,     lgr.  i 
I'ulv.  Pol.  Belladonna?,  I    ftfl 
pro  pil.  j  ;  mitte  KM)  similes. 

During  the  first  month,  the  patient  take-  one  of  these  pills  every  day,  in 


ON    EPILEPSY.  781 

the  morning,  if  his  attacks  occur  chiefly  in  the  daytime  ;  or  in  the  evening, 
if  they  are  chiefly  nocturnal.  One  pill  is  added  to  the  dose  every  month; 
and  whatever  be  the  dose,  it  is  always  taken  at  the  same  period  of  the  day. 
By  that  means,  the  patient  may  reach  the  dose  of  from  five  to  twenty  pills, 
and  even  more.  It  is  impossible  to  say  beforehand  what  should  be  the 
maximum  dose;  this  depends  only  on  the  toleration  of  the  drug  by  the 
patient,  and  its  influence  on  the  disease.  Excessive  dilatation  of  the 
pupils,  and  very  uncomfortable  dryness  of  the  throat,  indicate  toxic  effects, 
beyond  which  the  drug  should  not  be  pushed.  If  the  belladonna  is  borne 
Avith  very  great  difficulty,  the  dose  should  be  increased  only  every  two, 
three,  or  four  months. 

When  an  improvement  seems  to  show  itself,  the  last  dose  given  is  con- 
tinued for  some  time,  and  it  is  then  gradually  diminished.  Lastly,  all 
treatment  is  suspended  for  a  time,  and  is  resumed  again,  after  an  interval 
the  duration  of  which  should  be  proportionate  to  the  degree  of  improve- 
ment. 

I  cannot  too  much  impress  upon  you  that  patience,  both  in  the  physician 
and  the  patient,  is  the  principal  condition  of  success.  A  year  sometimes 
is  scarcely  sufficient  for  discovering  the  influence  of  the  belladonna ;  and 
if  in  the  succeeding  year  some  improvement  follows,  the  treatment  is  to  be 
persisted  in  for  two,  three,  and  four  years,  according  to  the  rules  I  have 
laid  down,  in  order  completely  to  master  the  nervous  system. 

For  some  yeai-s  past  I  have  used  atropia  in  preference  to  belladonna.  I 
prescribe  it  as  follows  : 

R.  Atropine  sulphatis,  1  grain. 

Spiritus  vini  gallici,  100  minims. 

One  drop  of  this  solution,  that  is  to  say  l-100th  of  a  grain  of  atropia,  is 
given  instead  of  one  of  the  above  pills,  and  the  dose  is  increased  by  one 
drop  for  every  succeeding  month. 

Although  this  treatment,  I  repeat,  has  appeared  to  me  the  least  ineffica- 
cious, yet,  in  the  majority  of  cases,  I  must  confess  it,  I  have  seen  it  fail 
completely.  Belladonna,  therefore,  is  far  from  being  a  specific  against 
epilepsy  ;  but  it  is  more  valuable  than  the  preparations  of  silver,  of  copper, 
and  of  zinc,  although,  when  it  has  proved  ineffectual,  I  sometimes  use  these 
with  some  benefit. 

In  most  cases  I  combine  these  various  remedies.  Thus,  I  give  belladonna 
in  the  morning,  and  nitrate  of  silver  in  the  evening,  ten  days  running,  every 
month.     I  prescribe  the  following  pills  : 

R.  Argenti  nitratis,  gr.  ij. 

Pulveris  acacise, ")  ., 

Aquas destillatse,  j  "'    'P      P   •     • 

Even  to  a  child,  between  four  and  ten  years  old,  two  of  these  pills  are 
given  every  day. 

For  the  next  ten  days  I  replace  the  nitrate  of  silver  by  copper. 

R.  Cupri  sulphatis,  gr.  xx. 
Sacchari,  gr.  lx. 
Misce  et  divide  in  pulveres  xx. 

The  patient  takes  at  first  two  of  these  every  day,  and  he  gradually 
increases  the  dose  to  six,  always,  of  course,  taking  care  that  the  stomach 
tolerates  the  drug.  In  the  case  of  a  child,  each  powder  should  contain 
only  from  -^-th  to  ^th  of  a  grain  of  copper. 

For  the  last  ten  days  of  the  month,  I  again  replace  the  copper  by  prep- 


782  OX    EPILEPSY. 

arations  of  zinc,  given  in  pretty  large  doses.  I  give  the  lactate  of  zinc, 
associated  with  sugar,  as  in  the  preceding  formula,  so  as  to  give  it  in  a 
powder,  or  in  pills  made  up  with  confection  of  roses.  The  dose  is  from 
two  to  eight  grains.  After  this,  I  return  to  the  nitrate  of  silver,  then  to 
the  copper,  and  next  again  to  the  zinc. 

Such,  gentlemen,  is  the  treatment  which  I  habitually  recommend.  You 
will  obtain  more  favorable  results  from  it  in  the  convulsive  than  in  the 
vertiginous  form  of  epilepsy.  Petit-mal  is  indeed  considerably  more  intrac- 
table than  grand-mal. 

Quite  recently,  my  excellent  friend,  Dr.  Henry  Gueneau  de  Mussy,  has 
stated  positively  to  me  that  he  had  been  remarkably  successful  in  the  treat- 
ment of  epilepsy  by  bromide  of  potassium. 

On  the  ground  that  modifications  of  the  circulation  often  produce  cor- 
responding modifications  of  innervation,  Dr.  Duclos  (de  Tours)  thought  of 
treating  epilepsy  by  digitalis,  which  so  powerfully  modifies  the  functions  of 
the  circulatory  system.  In  a  certain  number  of  cases  he  has  seen  weekly 
or  monthly  attacks  diminish  in  intensity,  and  even  delayed  for  a  period  of 
twenty-seven  months.  He  has  also  known  epileptics  thus  treated  be  at- 
tacked again  only  five  and  even  seven  years  after  they  had  ceased  the  treat- 
ment. He  gives  the  hydro-alcoholic  extract  of  digitalis  in  pills  containing 
each  one  grain  of  the  extract.  The  first  day  he  gives  one  pill  only  ;  the 
second,  two  pills,  one  in  he  morning,  the  other  at  night ;  on  the  third  day 
three  jfills,  one  in  the  morning  and  two  in  the  evening ;  on  the  fourth,  four 
pills,  two  in  the  morning  and  two  in  the  evening ;  and  lastly,  on  the  fifth 
day,  two  pills  in  the  morning  and  three  in  the  evening.  He  continues  in 
this  way  until  a  sensible  effect  is  produced  on  the  circulation,  as  generally 
happens  after  twelve  days  or  so.  He  then  suspends  the  treatment  for  ten 
days,  after  which  he  begins  it  again,  increasing  the  doses  gradually,  and 
then  withholding  the  drug  again  for  some  time.  He  continues  in  this  way 
for  a  lengthened  period,  taking  care,  in  proportion  as  the  treatment  is  pro- 
longed, to  increase  the  intervals  of  rest  from  ten  to  twenty,  thirty,  and  forty 
days,  ceasing  at  last  after  ten  months.  I  have  gone  into  all  these  details, 
gentlemen,  because  the  art  of  administering  the  drug  has  an  important 
share  in  the  good  results  obtained  from  this  method  of  treatment,  and  be- 
cause the  physician  who  has  jpraised  it,  is  one  of  the  most  skilful  represen- 
tatives of  the  great  school  of  Bretonneau. 

I  told  you  that  some  individuals  had  warnings  of  a  returning  fit  in  a 
peculiar  sensation  constituting  what  has  been  termed  the  aura.  Cases  have 
been  reported  by  most  trustworthy  authors,  in  which  the  fit  was  prevented 
by  firm  compression  applied  between  the  starting-point  of  this  aura  and 
the  nervous  centres,  when  the  aura  began  in  a  limb.  Ingenious  contrivances 
have  even  been  invented  for  facilitating  the  application  of  this  linn  com- 
pression. Thus,  an  instrument-maker  made  for  a  young  epileptic,  who  had 
an  aura  .-tailing  from  the  thumb,  and  from  there  ascending  along  the  arm 
to  the  head,  a  kind  of  leather  bracelet  with  .-naps,  which  could  lie  quickly 
slipped  round  the  wrist,  and  tightened  with  considerable  force.  1  shall  not 
say  much  of  the  surgical  means  employed,  some  of  which  appear  to  me,  at 
the  very  least,  useless.  Thus,  not  only  has  the  actual  cautery  with  the  red- 
hot  iron  been  proposed  along  the  course  of  the  nerves  which  the  aura  was 
Supposed  to  follow,  but  Castration  even  has  been  suggested  ill  the  cases  where 

the  aura  seemed  to  start  from  the  testicles.  Nay  more,  a  singular  theory 
has  been  liroached  which  has  been  called  the  theory  of  laryngismus,  according 
to  which  epilepsy  is  Baid  to  be  caused  by  occlusion  of  the  glottis,  owing  to 

Bpasm  of  the  laryngeal  muscles.  Hence,  say  the  authors  of  this  theory,  if 
a  passage  to  the  air  he  opened  up,  which  cannot  lie  closed  by  the  convulsed 


ON    EPILEPTIFORM    NEURALGIA.  783 

muscles,  all  the  symptoms  will  disappear,  and  they,  therefore,  have  recom- 
mended as  a  "  very  simple  remedy"  ....  "tracheotomy."  If  they  do  not 
pretend  to  cure  epilepsy,  they  at  least  pretend  to  ward  off  the  attacks,  and 
to  do  away  with  the  dangers  consequent  on  them. 

I  should  not  have  spoken  of  this  savage  method,  if  it  had  not,  of  late,  had 
a  certain  amount  of  vogue.  But  whilst  mentioning  it  here,  only  to  stigma- 
tize it,  it  would  be  insulting  you  if  I  thought  it  necessary  to  seriously  dis- 
cuss the  subject,  in  order  to  prove  to  you  the  absurdity  of  so  strange  a 
theory,  and  the  barbarity  of  a  measure  which  no  true  physician  will  be 
tempted  to  employ. 


LECTURE  XLIL 

ON  EPILEPTIFORM  NEURALGIA. 

The  Branches  of  the  Trigeminal  or  Fifth  Cranial  Nerve  are  those  generally 
Affected.— The  Neuralgia  is  in  most  cases  Accompanied  by  Partial  Con- 
vidsions. — Is  nearly  Incurable. — Analogy  between  it  and  the  Aura  Epi- 
leptica. — Differs  from  Epilepsy,  although  sometimes  Observed  in  Epilep- 
tics.— Is  Relieved  by  Section  of  the  Nerve  and  by  Large  Doses  of  Opium. 

Gentlemen  :  Epileptiform  neuralgia  presents  two  varieties.  One  of 
these,  and  the  more  common  of  the  two,  is  characterized  by  neuralgic 
pain,  unattended  with  convulsive  twitches.  The  other  form  is  accompanied 
by  convulsive  movements,  and  I  designate  it  tic  douloureux,  in  order  to  dis- 
tinguish it  from  what  is  generally  and  justly  understood  by  tic.  This  latter 
is  a  kind  of  chorea,  although  in  other  respects  very  distinct  from  St.  Vitus's 
dance,  and  is  a  convulsive  affection,  unattended  with  pain,  which  you  have 
often  had  occasion  to  see.  It  consists  in  rapid,  transitory,  and  involuntary 
movements  of  the  face,  the  neck,  or  the  limbs,  and  which  vary  indefinitely. 
Tic  douloureux,  on  the  contrary,  and  the  non-convulsive  form  of  epilepti- 
form neuralgia  as  well,  always  occupy  the  same  seat,  or  until  now,  at  least, 
I  have  only  found  them  affecting  the  branches  of  the  fifth  cranial  pair. 
An  individual  who,  but  a  moment  ago,  was  perfectly  free  from  pain,  is 
suddenly  seized  with  horrible  pain  whilst  talking.  He  puts  his  hand  up 
to  his  face,  and  presses  it  writh  considerable  force,  sometimes  rubbing  it  so 
much  and  so  often  that  the  hairs  on  that  side  fall  of.  (I  allude,  among 
others,  to  the  case  of  that  man  who  has  been  so  long  in  my  clinical  wards, 
and  to  whose  history  I  shall  again  revert.)  He  goes  on  rocking  himself, 
holding  his  head  between  his  hands,  and  uttering  half-suppressed  groans. 
This  scene  lasts  for  ten  to  fifteen  seconds,  one  minute  at  the  most,  and  all  is 
over  then  without  convulsions.  The  individual  resumes  his  interrupted 
conversation,  until  a  fresh  paroxysm  sets  in  again.  This  is  what  I  mean 
by  simjjle  epileptiform  neuralgia. 

In  another  case,  simultaneously  with  the  accession  of  pain,  all  the  mus- 
cles of  one-half  of  the  face  are  seen  to  be  thrown  into  rapid  convulsive 
action,  and  the  attack,  as  in  the  preceding  case,  is  over  in  about  a  minute. 
This  is  convulsive  epileptiform  neuralgia,  or' tie  douloureux. 

Like  everybody  else,  I  used  to  confound  epileptiform  neuralgias  with  all 
the  cases  in  which  pain  is  felt  along  the  branches  of  the  fifth  pair,  and 


784  ON    EPILEPTIFORM    NEURALGIA. 

which  are  comprised  together  under  the  common  appellation  of  trifacial 
neuralgia ;  but  a  few  years  of  practice  sufficed  for  showing  me  their  nature. 
Whilst  the  latter  were  generally  of  no  gravity,  and  yielded,  some  of  them 
spontaneously  after  a  few  hours  or  a  few  days,  and  others  under  the  in- 
fluence of  proper  general  or  local  treatment,  I  soon  found  out  that  the 
former  resisted  with  a  disheartening  obstinacy  all  therapeutic  measures,  so 
much  so,  indeed,  that  even  now,  after  more  than  thirty-six  years  of  prac- 
tice, I  have  never  known  it  to  be  cured  in  a  single  case  radically. 

I  was  not  long  before  noticing  that  this  form,  which  was  amenable  to  no 
method  of  treatment,  ran  the  same  course  as  epileptic  aura  or  vertigo,  hav- 
ing the  same  suddenness  of  invasion,  lasting  the  same  length  of  time,  and 
being  especially  like  them  almost  incurable.  When  I  compared  it  with 
epileptic  vertigo,  whether  or  not  preceded  by  a  painful  aura,  and  with  epi- 
leptic fits  beginning  in  one  limb  and  remaining  exclusively  limited  to  it,  or 
again  with  angina  pectoris,  I  could  not  but  be  struck  with  the  analogy  and 
the  points  of  resemblance  between  these  various  neuroses. 

The  first  case  in  which  I  studied  this  strange  neuralgia  was  that  of  a 
man  who,  in  1831,  occupied  a  bed  in  the  St.  Bernard  Ward,  at  that  time  a 
male  ward.  I  was  then  physician  to  the  Bureau  Central  des  Hopitaux, 
and  as  such  was  acting  as  the  substitute  of  my  illustrious  master,  Professor 
Recamier.  I  had  the  honor  of  having  for  my  house-physician  A.  Bonnet 
(of  Lyons),  whose  premature  death  science  now  deplores.  This  poor 
patient,  who  filled  some  post  at  th^  Saint  Antoine  Hospital  of  Paris,  had 
for  many  years  been  subject  to  the  convulsive  form  of  neuralgia.  His 
paroxysms  lasted  sometimes  a  few  seconds  only,  and  sometimes  a  minute ; 
they  recurred  whenever  he  spoke,  drank,  or  ate,  or  whenever  one  touched 
with  the  tip  of  a  finger  the  few  teeth  which  he  had  left.  The  pain  was 
seated  in  all  the  branches  of  the  trifacial  nerve  of  one  side,  but  chiefly  in 
the  infraorbital  division.  Several  of  the  nerve-trunks  had  been  divided 
already ;  but  the  relief  had  only  been  temporary,  and  the  pain  had  always 
obstinately  returned  after  an  interval  of  from  a  few  weeks  to  a  few  months. 
The  extraction  of  his  last  remaining  teeth  gave  him  no  relief.  Prolonged 
applications  of  a  solution  of  cyanide  of  potassium  did  some  good.  But 
the  pain  still  returning,  as  awful  and  as  unbearable  as  ever,  I  decided  upon 
dividing  the  infraorbital  branch.  Bonnet  performed  the  operation  with 
great  skill ;  the  patient  was  relieved  instantly,  and  remained  free  from  pain 
for  several  months.  The  following  year,  I  saw  him  again,  suffering  in  the 
same  way  in  the  course  of  another  nerve  of  the  face,  and  with  the  same 
convulsions.  Professor  Roux,  as  far  as  I  can  remember,  again  divided 
several  nerves.  Lastly,  in  1841,  Dr.  Piedaguel  saw  in  his  wards  at  La 
Pitie  this  same  individual,  whom  he  had  known  thirty  years  previously, 
when  house-physician  at  the  Saint  Antoine  Hospital.  The  poor  man's  face 
was  scarred  from  the  surgical  operations  which  he  had  undergone,  for  when- 
ever the  pain  became  intolerable,  he  implored  the  help  of  the  knife,  for 
this  at  least  gave  him  relief  for  a  few  days,  and  sometimes  a  few  months. 

About  the  same  period  I  saw  in  the  Marais  quarter  a  lady  50  years  old, 
who  for  twenty  years  had  been  subject  to  this  epileptiform  neuralgia  <>)'  the 
face.  She  had  from  ten  to  a  hundred  attacks  a  day,  bul  sometimes  passed 
a  day,  a  week,  or  even  a  whole  month  without,  a.  paroxysm.  The  convul- 
sions lasted  only  a  minute  at  the  most,  and  were  confined  to  the  left  side  of 
the  face;  the  pain  was  described  as  awful.  A  little  relief  was  obtained  by 
compressing  the  face  with  both  hands,  and  this  compression,  so  often  re- 
peated during  so  many  years,  had  produced  flattening  of  the  left  side  of  the 
Hice.  The  lower  jaw  and  the  malar  hone  had  been,  as  il  were,  squeezed 
down.     Dr.  Lebaudy  divided  the  temporal  branch  of  the  trigeminal  nerve, 


ON    EPILEPTIFORM    NEURALGIA.  785 

and  temporary  relief  was  thus  given.  But  the  pain  afterwards  returned 
with  renewed  violence  in  the  other  branches  which  had  formerly  been  less 
affected.     This  sad  complaint  persisted  until  the  lady's  death. 

In  1846  I  saw  in  my  consulting-room  a  gentleman  of  about  55  years  of 
age.  He  had  no  sooner  sat  down  near  me,  than  he  suddenly  got  up  as  if 
moved  by  springs,  and  rapidly  raising  his  hands  to  the  right  side  of  his 
face,  which  was  convulsively  distorted,  he  paced  about  the  room,  stamping 
his  foot  with  a  sort  of  rage,  moaning,  and  groaning  like  a  madman.  This 
strange  scene  lasted  about  a  minute,  and  he  then  sat  down.  Before  he 
uttered  a  word,  I  told  him  that  I  knew  what  he  suffered  from,  and  that 
although  I  might  relieve,  I  could  not  cure  him.  He  thanked  me  for  being 
so  candid,  aud  then  informed  me  that  he  had  been,  for  more  than  twenty 
years,  subject  to  this  hateful  neuralgia,  which  had  always  affected  the  same 
nerves,  and  which  after  disappearing  for  a  few  days,  and  sometimes  a  few 
mouths,  returned  with  a  hopeless  obstinacy,  defying  the  most  varied  and 
energetic  treatment.  Six  years  afterwards  I  saw  him  again ;  he  was  still 
in  the  same  state,  for  he  had  refused  to  try  the  palliative  treatment  which  I 
had  recommended,  and  of  which  I  shall  tell  you  presently.  At  this  mo- 
ment, gentlemen,  you  can  see  a  similar  case  in  St.  Agnes  Ward.  You  must 
have  been  struck  with  the  look  of  suffering  stamped  on  his  face.  Although 
he  is  only  48  years  old,  his  face  is  deeply  wrinkled,  in  consequence  of  the 
contractions  by  which  its  muscles  are  almost  continually  agitated. 

He  relates  that  he  has  always  been  subject  to  toothache,  but  that  for  the 
last  four  years  the  pain  has  become  so  intense  that  he  has  been  compelled 
to  consult  a  medical  man.  Flying  blisters,  and  some  pills  of  which  he  does 
not  know  the  composition,  calmed  the  neuralgia  for  a  short  time ;  a  year 
afterwards  he  came  to  Paris,  and  was  admitted  into  Bicetre.  Whilst  there 
he  was  treated  with  flying  blisters,  dressed  with  morphia.  He  next  went 
to  the  Pitie  Hospital,  for,  apart  from  his  habitual  neuralgia,  he  had  inter- 
mittent fever,  which  was  cured  by  quinine,  without  the  slightest  modifica- 
tion of  the  neuralgia.  Eight  months  later  he  was  a  second  time  readmitted 
there,  and  was  treated  by  my  colleague,  Dr.  Marotte.  Quinine  and  iodide 
of  potassium  in  large  doses,  blisters  dressed  with  morphia,  sulphur  baths, 
faradization,  cauterization  with  the  red-hot  iron  of  the  cheek  and  forehead, 
gave  no  relief. 

Two  months  afterwards  he  came  here.  I  at  once  tried  the  effect  of  nar- 
cotics in  large  doses,  which  in  analogous  cases  had  seemed  to  me  to  be  of 
great  utility.  I  prescribed  for  him  the  aqueous  extract  of  opium,  and  be- 
gan almost  at  once  with  ten  grains  taken  in  the  twenty-four  hours,  gradu- 
ally and  rapidly  increasing  the  dose  to  half  an  ounce.  Within  a  few  days 
relief  was  obtained,  and  four  or  five  months  afterwards  he  felt  so  decidedly 
better  that  he  wished  to  be  discharged. 

This  amelioration  did  not  last  long.  For  three  months  the  man  had  only 
a  few  slight  attacks  of  pain,  and  he  could  drink,  eat,  sleep,  and  resume  his 
occupation  as  a  copper-turner,  but  the  pain  then  returned  with  its  former 
intensity.  He  was  readmitted  into  my  wards,  and,  after  being  treated  in 
the  same  way  as  before,  he  left  markedly  relieved. 

Last  year,  however,  he  returned  to  the  Hotel-Dieu,  and  was  admitted  into 
another  physician's  ward,  where  he  was  treated  in  the  same  way  again. 
This  time,  the  pain  being  less  acute  than  before,  the  opium  had  not  to  be 
given  in  as  large  doses. 

Since  then  he  was  free  from  violent  pain ;  but  in  April,  I860,,  the  pain 
having  returned  with  its  former  intensity,  he  was  for  the  third  time  admit- 
ted into  St.  Agnes  Ward,  which  he  now  wishes  to  leave,  feeling  quite  well 
again. 

vol.  i. — 50 


786  ON    EPILEPTIFORM    NEURALGIA. 

With  regard  to  his  previous  history,  he  affirms  that  he  has  never  had 
syphilis.  The  only  grave  disease  which  he  has  ever  had,  is  an  attack  of 
copper  colic,  which  for  a  short  time  compelled  him  to  give  up  his  trade. 
He  also  had  intermittent  fever  of  short  duration.  As  to  his  family  history, 
he  states  that  he  is  not  aware  of  any  instance  of  nervous  disease  among  his 
relations. 

Independently  of  his  paroxysms  of  pain,  he  says  that  he  constantly  ex- 
periences, in  the  affected  side,  an  unpleasant  sensation,  which  he  compares 
to  the  oscillations  of  a  pendulum,  followed  by  seven,  eight,  ten,  fifteen  par- 
oxysms of  excessively  acute  pain,  within  the  space  of  five  minutes.  This 
pain  starts  indifferently  from  three  constant  points,  which  he  indicates  per- 
fectly, namely,  the  points  of  emergence  of  the  trigeminal  nerve,  and  is  ac- 
companied by  spasmodic  contraction  of  the  muscles  of  the  face.  It  is  fear- 
fully intense,  and  drives  him  to  squeeze  the  affected  part  violently,  and  to 
rub  it  with  a  kind  of  rage.  This  relieves  hiin  a  little,  but  it  "has  been 
repeated  so  often  that  the  hair  has  fallen  off  from  that  part.  The  attacks 
recur  day  and  night :  moral  emotions,  passing  from  a  warm  into  a  cold 
place,  or  the  reverse,  excite  them,  and  they  are  more  frequent  and  more 
violent  in  damp  weather  or  during  atmospheric  changes.  They  are  gener- 
ally accompanied  by  a  more  abundant  secretion  of  urine.  This  almost  con- 
stant pain  kept  the  poor  man  in  a  state  of  perpetual  fear ;  his  intellect,  how- 
ever, has  not  been  in  the  least  impaired,  and  his  memory  is  perfect.  A 
remarkable  circumstance  is,  that  when  he  has  been  cured  by  the  prolonged 
use  of  opium,  he  is  warned  of  the  return  of  his  attacks  by  pain  in  the  loins, 
by  an  increase  of  saliva  (particularly  in  winter),  and  by  an  eruption  of 
prurigo,  chiefly  on  t-Je  back,  attended  with  distressing  itching.  His  neu- 
ralgia has  always  occupied  the  same  seat.  His  senses  are  perfect,  but  read- 
ing, if  a  little  prolonged,  brings  on  a  paroxysm.  Chewing  anything  hard 
also  brings  on  an  attack.  His  speech  is  embarrassed,  but  it  is  only  because 
he  dares  not  move  his  mouth  and  throw  the  muscles  of  the  face  into  con- 
traction, lest  he  should  rouse  the  pain.  His  appetite  and  digestion  have 
been  good  always. 

On  this,  as  on  previous  occasions,  I  gave  him  opium  in  large  doses,  and 
under  its  influence  the  same  amelioration  was  obtained.  Id  some  cases, 
the  neuralgic  pain,  after  gradually  becoming  less  and  less,  disappears  for 
two,  three,  or  four  months,  and  when  the  patient  thinks  himself  cured,  re- 
turns with  renewed  intensity,  for  the  space  of  a  few  months,  and  oven 
a  year. 

Very  recently  I  was  consulted  by  an  innkeeper  of  Meaux,  sent  to  me 
by  Dr.  Charpentier.  He  was,  at  the  time,  subject  to  attacks  which  lasted 
from  fifteen  to  twenty  seconds,  and  recurred  every  two  or  three  minutes  at 
the  most.  When  they  ceased,  as  they  sometimes  did  for  a  period  of  two  or 
three  months,  he  was  perfectly  cured,  for  the  inferior  maxillary  nerve,  the 
usual  seat  of  his  pain,  was  completely  insensible. 

But  in  the  great  majority  of  cases, unfortunately,  tlie  relief  is  not  complete, 
and  even  when  there  has  been  DO  fresh  attack  for  several  months,  the  patient 

still  complains  of  a  slight  degree  of  pain  at  the  point  of  emergence  of  the 

affected  nerve.  Whatever  be  the  analogy  between  true  epilepsy  and  thi< 
epileptiform  neuralgia,  I  must  admit,  however,  that  the  two  diseases  are 
merely  analogous,  not  identical ;  for  an  individual,  subject  to  epileptic 
aura  or  vertigo,  rarely  escapes  an  occasional  convulsive  lit,  and  it  rarely 
happens,  especially,  thai  the  intellect  be  not  slightly  disturbed  during  and 

after  the  vertigo.  Now,  in  the  cases  of  epileptiform  neuralgia,  1  have  never. 
as  yet,  found  the  |ea.-l   impairment  of  the  intellect. 

Still,  gentlemen,  a  few  cases  that  have  occurred  in  my  own  practice 


ON    EPILEPTIFORM    NEURALGIA.  787 

Would  seem  to  lead  one  to  believe  that,  in  some  eases,  epileptiform  neural- 
gia is  one  of  the  manifestations  of  true  epilepsy. 

I  once  attended  a  country  practitioner  suffering  from  tic  douloureux.  For 
many  years,  we  combated  this  terrible  affection  with  energy,  and  in  the 
last  period  of  his  life  the  unfortunate  man  had  genuine  epileptic  fits. 

At  this  very  moment,  Dr. Beylard  (formerly  my  clinical  assistant)  and  I 
are  attending  together  an  American  gentleman,  who,  for  more  than  three 
years,  has  been  subject  to  awfully  painful  attacks  of  epileptiform  neuralgia, 
and  to  well-characterized  epileptic  fits. 

Perhaps,  there  has  been  merely  a  coincidence  in  these  two  cases.  But 
were  true  epilepsy  to  be  oftener  met  with  in  connection  with  this  neuralgia, 
the  two  diseases  should  be  less  separated  than  I  have  done,  and  a  kind  of  rela- 
tionship should  be  admitted  between  them. 

I  confess  that  I  neglected  to  inquire  into  the  family  history  of  my  pa- 
tients. But  should  there  be  found  in  this  family  history,  insanity,  progres- 
sive locomotor  ataxy,  hypochondriasis,  &c,  epileptiform  neuralgia  will, 
perhaps,  have  to  be  placed  by  the  side  of  epilepsy,  and  both  these  affections 
be  looked  upon  as  the  expression  of  one  and  the  same  cause.  Although 
from  its  nature,  epileptiform  neuralgia  may  be  considered  as  nearly  in- 
curable, I  have  always  thought  it  my  duty  to  try  and  combat  it  by  the 
least  inefficacious  and  the  most  energetic  remedies  I  had  the  disposal  of. 
I  was  besides  encouraged  by  very  authentic,  although  rare,  instances  in 
which  epilepsy  has  been  cured. 

The  surgical  measures,  the  utility  of  which  I  contested  as  regards  the 
aura  epileptica,  are  sometimes  of  real  service  in  these  cases ;  and  you  must 
at  once  see  the  reason  of  this  difference.  In  the  case  of  an  aura,  nothing 
assures  us  that  one  nerve  is  the  seat  of  the  sensation  instead  of  another, 
whilst  in  epileptiform  neuralgia,  the  seat  of  the  pain  can  be  easily  deter- 
mined. Hence,  division  of  the  affected  nerves  in  the  points  where  they  can 
be  reached  without  danger  almost  certainly  gives  immediate  relief.  But 
I  hasten  to  add  that,  although  I  have  no  hesitation  in  recommending  di- 
vision of  the  painful  branches  of  the  trifacial  nerve,  yet  I  do  not  expect  a 
lasting  good  result.  Even  if  I  were  to  see  a  patient  remain  better  for  a 
pretty  lengthened  period,  I  should  always  dread  a  recurrence  of  the  disease. 
I  formerly  believed,  like  many  others,  in  the  complete  efficacy  of  this  meas- 
ure, but  as  I  grew  older,  I  unfortunately  lost  all  my  illusions  on  that 
score. 

In  1836,  Mr.  N ,  a  clerk  at  the  Finance  Office,  consulted  me  for  an 

epileptiform  neuralgia,  which  had  its  starting-point  in  the  tongue.  The 
aura  began  first  in  the  left  half  of  this  organ  ;  from  there  it  spread  to  the 
lips,  and  then  to  the  whole  corresponding  side  of  the  face,  accompanied  by 
horrible  pain  and  by  slight  convulsions.  I  tried  the  most  powerful  stupe- 
fying drugs.  Local  applications  of  extract  of  belladonna  and  of  stramo- 
nium, blisters  dressed  with  morphia,  the  administration  of  narcotics  in  very 
large  doses,  only  produced  temporary  alleviation ;  the  pain  recurred  with 
disheartening  obstinacy.  I  then  resolved  to  divide  the  lingual  nerve,  and  the 
operation  being  somewhat  perilous  and  difficult,  I  determined  to  avoid  all 
risks,  by  proceeding  in  the  following  manner : 

I  seized  the  tip  of  the  tongue,  taking  care  to  have  a  piece  of  linen 
between  my  fingers  and  the  painful  organ,  and  passed  through  it,  from 
behind  forwards,  a  round  and  curved  needle,  carrying  a  silver  wire.  I 
next  brought  the  two  extremities  of  the  wire  together,  thus  embracing 
within  the  circle  the  left  half  of  the  tongue,  and  I  placed  them  in  a  knot 
fastener,  which  the  patient  screwed  up  every  five  minutes.  The  first  part 
of  the  operation  was  not  very  painful,  and  the  gradually  increased  com- 


788  ON    EPILEPTIFORM    NEURALGIA. 

pression  produced  by  the  tightening  of  the  knot  was  attended  with  much 
less  pain  than  I  had  feared.  Within  five  hours  the  left  half  of  the  tongue 
was  thus  completely  divided,  without  the  least  hemorrhage. 

As  soon  as  the  compression  became  a  little  powerful,  all  painful  aura 
ceased,  and  the  only  pain  felt  was  that  due  to  the  gradual  division  of  the 
organ.  When  the  operation  was  over  all  pain  ceased,  and  the  patient 
believed  he  was  cured.  For  nearly  a  month  the  apparent  cure  was  main- 
tained, and  I  was  congratulating  myself  on  a  success,  which  in  truth  I  had 
somewhat  expected,  when  in  a  short  time  slight  shooting  pain  attacked  the 
upper  lip,  on  the  same  side,  always  retaining  the  epileptiform  character, 
and  attended  with  slight  grimaces  and  jerks,  the  whole  occurring  in  less 
than  a  minute.  A  few  days  afterwards  the  pain  spread  to  the  lower  lip, 
the  edges  of  both  jaws,  and  the  infraorbital  and  mental  branches  of  the 
trifacial  nerve.  Although  considerably  less  intense  than  before,  the  pain 
had  not  the  less  returned,  and  for  several  years  it  recurred  again.  The 
patient  then  left  Paris,  and  I  lost  sight  of  him. 

My  excellent  colleague,  Professor  Nelaton,  does  not  simply  divide  the 
nerve,  but  cuts  away  a  portion  of  it,  about  one-fifth  of  an  inch.  He  has 
often  affirmed  to  me  that  by  this  means  he  had  obtained  two  sound  cures. 
It  is  true  that  two  years  had  not  yet  elapsed  when  he  informed  me  of  his 
success. 

Is  it  to  be  said,  then,  gentlemen,  that  we  can  never  give  relief  in  such  a 
degree  that  it  may  be  almost  equivalent  to  a  cure  ?  I  confess  openly  that 
I  have  never  cured  a  single  patient,  none  at  least  of  those  whom  I  could 
see  during  several  years ;  but  I  have  made  the  life  of  some  bearable,  as 
you  have  yourself  seen  in  the  case  of  the  individual  who  is  still  in  my 
ward,  and  whose  history  I  related  to  you. 

This  is  the  treatment  to  which  I  have  recourse  ;  but  I  must  at  once  tell 
you  that  belladonna,  which  is  of  some  utility  against  the  convulsive  form 
of  epilepsy,  is  almost  completely  powerless  against  epileptiform  neuralgia, 
whilst  opium  procures  decided  relief: 

An  old  lady,  from  Antwerp,  placed  herself  under  my  care,  in  1845,  on 
account  of  epileptiform  neuralgia  of  the  face,  to  which  she  had  been  subject 
for  more  than  ten  years.  At  first  the  pain  had  been  slight,  and  always 
transitory,  affecting  one  of  the  divisions  only  of  the  trifacial.  Afterwards 
it  had  become  excessively  intense,  and  had  resisted  various  remedies.  The 
paroxysms  lasted  from  a  few  seconds  to  three  minutes.  Beginning  some- 
times in  the  infraorbital  division,  and  sometimes  in  the  supraorbital,  or 
the  mental,  the  pain  rapidly  spread  to  all  three  divisions ;  and  when  it  was 
at  its  maximum,  it  produced  spasmodic  grimaces  of  the  face.  There  were 
sometimes  twenty  paroxysms  in  an  hour  ;  the  least  movement  brought 
them  on — speaking,  coughing,  eating,  or  drinking.  In  order  to  diminish 
the  pain  she  squeezed  her  face  with  violence,  and  moved  the  skin  up  and 
down  on  the  bones.  When  the  pain  was  more  acute,  she  got  up  in  a  sort 
of  frenzy,  paced  up  and  down  her  room,  stamping  her  foot,  and  uttering 
muttered  groans.  This  was  of  such  frequent  occurrence,  thai  she  had 
become  a  nuisance  to  her  neighbors,  whom  she  disturbed  at  night. 

The  pain  disappeared  sometimes  for  eight,  lit'teen,  thirty  days,  and  even 
Longer,  but  then  returned  with  renewed  violence.  A  remarkable  circum- 
stance was,  that  when  the  paroxysm  was  over,  the  pain  ceased  entirely. 
leaving  only  a  sensation  of  numbness  behind. 

A  good  many  remedies,  rational  and  empirical,  had  been  tried,  but 
without     success.      Dr.     Sonime     (of     Antwerp)    divided    the    infraorbital 

branch,  and  thus  obtained  an  apparent  cure  ;  bul  a  lew  mouth.-  had  scarcely 
elapsed  before  the  pain  recurred  as  before. 


ON    EPILEPTIFORM    NEURALGIA.  789 

After  having  given  her,  methodically  and  perseveringly,  some  remedies 
which  I  thought  had  not  been  thoroughly  tried,  I  knew  not  what  to  do  in 
presence  of  so  violent  and  obstinate  an  affection.  I  then  determined  on 
administering  opium  internally  as  a  palliative,  encouraged  in  the  idea  by 
the  fact  that  I  had  obtained  very  evident  alleviation  of  the  pain,  in  this 
case  and  in  others,  by  dressing  blisters  with  morphia. 

I  first  gave  morphia  internally,  beginning  with  pretty  large  doses,  from 
3  to  4  grains  a  day,  and  determined  on  increasing  this  quantity  if  the  first 
doses  were  borne  well.  I  thus  came,  in  less  than  a  fortnight,  to  administer 
every  day  a  drachm  of  sulphate  of  morphia.  The  amelioration  obtained 
was  immense;  scarcely  were  there,  in  the  course  of  the  day,  slight 
shooting  pains  felt  in  the  branches  of  the  trifacial.  Digestion  was  slightly 
disturbed  ;  the  intellect  was  normal.  But  a  great  difficulty  now  occurred  ; 
the  patient's  means  were  limited,  and  the  high  price  of  the  morphia  almost 
ruined  her.  I  then  had  recourse  to  opium,  and  in  the  space  of  a  year  she 
consumed  1200  francs'  worth  (£48).  This  was  too  much  again.  The 
pain  recurred  whenever  she  omitted  the  medicine  for  eight  or  ten  days, 
and  she  was  again  obliged  to  diminish  an  expense  which  she  could  not 
bear.  I  then  obtained  of  a  chemist  for  her  crude  opium,  at  trade  price, 
for  which  she  paid  20  or  25  francs  (16  or  20  shillings)  a  pound.  She 
made  boluses  of  a  drachm  each  herself,  and  of  these  she  took,  according  to 
the  pain,  from  5  to  20  a  day. 

It  is  rather  remarkable  that  these  enormous  doses  of  opium  did  not  dis- 
turb digestion  notably ;  they  caused  no  dixwsiness  either,  and  at  night  the 
patient  slept  as  usual.  For  a  period  of  more  than  six  years  I  saw  this  lady 
from  time  to  time,  and  I  ascertained  the  following  therapeutical  results. 
She  was  sometimes  free  from  attacks  for  one,  two,  or  three  months ;  she 
then  suspended  the  opium,  after  having  first  gradually  diminished  the  dose 
in  proportion  as  the  pain  itself  grew  less  and  the  attacks  became  more 
distant.  On  the  neuralgia  returning  of  a  sudden,  with  fresh  violence,  she 
took,  at  once,  and  from  the  first  day,  as  much  as  four  and  five  drachms  of 
crude  opium,  keeping  up  this  dose  until  relief  was  obtained.  She  then 
diminished  it  again,  because  she  could  no  longer  take  it  without  feeling 
nausea  and  considerable  malaise.  A  few  days  sufficed  for  making  the  pain 
bearable,  I  might  almost  say  for  curing  it,  did  not  slight  paroxysms  of  pain 
occasionally  remind  her  that  she  was  not  cured.  By  continuing  the  opium, 
however,  she  obtained  complete  relief  for  a  more  or  less  prolonged  period. 

Opium,  therefoi*e,  gave  immense  relief,  but  did  not  cure  perfectly  ;  and, 
I  repeat,  ever  since  my  attention  has  been  more  especially  directed  to  this 
form  of  neuralgia,  I  have  never  known  a  case  of  lasting  cure. 

It  is  to  opium,  then,  that  I  have  recourse  now,  and  it  is  opium  which  I 
administered  to  the  patient  in  St.  Agnes  Ward,  increasing  the  dose  in  a  few 
days,  as  you  saw,  to  5  and  even  ^  an  ounce  of  the  extract.  But  I  often 
meet  with  patients  who  dread  so  energetic  a  mode  of  treatment,  and  with 
others  who,  being  troubled  with  vomiting,  cannot  bear  sufficiently  large 
doses. 

In  the  beginning  of  the  summer  of  1852  I  was,  strangely  enough,  con- 
sulted on  the  same  day  by  two  old  officers,  both  subject  for  nianjr  years  to 
epileptiform  neuralgia.  One  of  them  was  sent  me  by  Dr.  Pillon,  and  I 
shall  relate  his  history  presently ;  the  other  by  a  person  whom  I  had  cured 
of  simple  neuralgia  by  a  very  simple  treatment  also.  The  paroxysms  re- 
turned nearly  every  10  minutes,  and  lasted  40  or  50  seconds.  The  pain 
affected  the  mental  and  the  infraorbital  nerves,  and  was  accompanied  by 
slight  convulsive  twitches  in  the  whole  side  of  the  face.  I  recommended 
opium,  and  prescribed  pills  containing  one  grain  of  opium  each,  of  which 


790  OH    EPILEPTIFORM    NEURALGIA. 

four  were  to  be  taken  on  the  very  first  day,  the  dose  to  he  augmented  daily, 
until  the  pain  was  notably  diminished  as  to  duration  and  intensity. 

A  dose  of  scarcely  4  grains  a  day  produced  considerable  drowsiness, 
nausea,  and  loss  of  appetite,  but  the  paroxysms  diminished  immediately, 
and  the  pain  became  very  bearable.  I  increased  the  quantity  of  opium  to 
10  and  even  15  grains  a  day.  The  neuralgia  was  marvellously  modified, 
but  the  drug  disordered  the  digestion  so  much,  and  caused  such  disagree- 
able numbness,  that  I  was  not  able  to  increase  the  doses  so  as  to  get  com- 
pletely rid  of  the  neuralgia. 

With  regard  to  the  other  case,  the  following  particulars  were  communi- 
cated to  me  by  Dr.  Pillon,  Jr.     M.  M ,  aged  54,  had  served  in  most 

of  the  African  campaigns,  and  had  suffered  from  obstinate  intermittent 
fevers,  and  pretty  serious  gastric  affections ;  but,  with  these  exceptions,  he 
had  always  enjoyed  good  health.  In  1845,  he,  for  the  first  time,  felt  in  the 
right  cheek  pain,  which  was  slight  in  the  beginning,  and  attended  with 
alternate  sensations  of  heat  and  formication.  This  pain  varied  as  to  the 
seat  of  its  maximum  intensity,  this  being  sometimes  about  the  region  of  the 
canine  tooth,  and  at  other  times  about  the  chin.  It  lasted  from  a  few 
seconds  only  to  two  or  three  minutes.  By  degrees  this  pain  assumed  the 
character  which  it  presented  when  I  first  saw  the  patient.  The  paroxysms 
were  more  or  less  frequent,  but  always  set  in  with  the  same  suddenness, 
making  the  patient  groan  from  its  severity,  and  clutch  the  objects  near 
him.  All  the  muscles  of  the  right  half  of  the  face  contracted  with  vio- 
lence, and  pulled  the  features  over  to  that  side.  After  lasting  from  12  to 
40  seconds,  the  pain,  which  had  been  awfully  intense,  ceased  as  suddenly 
as  it  had  come  on.  The  patient  resumed  his  interrupted  conversation,  and 
was  perfectly  quiet  for  a  period  varying  from  15  minutes  to  several  hours. 

Occasionally  the  disease  assumed  a  slightly  different  form.  For  several 
hours,  several  days  even,  there  was  no  true  paroxysm,  but  slight  warnings 
only,  slight  shooting  pains,  which  were  more  frequent  in  proportion  as  they 
were  less  distinctly  characterized.  Dr.  Pillon,  remembering  that  the  patient 
had  suffered  from  ague,  probably  caught  in  Africa,  gave  him  quinine  in 
large  doses,  but  without  any  benefit.  Electricity  was  employed  by  Dr. 
Duchenne  fde  Boulogne*,  galvanism  by  Delacroix;  Professor  Chomel  pre- 
scribed Dover's  powder,  and  other  physicians  recommended  Meglin's  pills 
(consisting  of  valerianate  of  zinc),  valerian,  belladonna,  cyanide  of  potas- 
sium. 

Everything  failed. 

It  was  under  these  circumstance  that  I  .-aw  the  patient.  At  that  time 
the  paroxysms  had  become  so  frequent,  and  the  pain  so  acute,  that  his 
life  was  thoroughly  miserable.  His  appetite  was  failing  him,  and  whenever 
he  endeavored  to  take  any  food,  the  movements  of  mastication  brought  on 
the  most  awful  pain.  The  interval  between  his  fits  was  only  of  a  few  min- 
utes at  the  outside.  Dr.  Pillon  counted  as  many  a-  seventeen  in  an  hour 
which  he  spent  with  him.  His  life  had  become  bo  insupportable  thai  he 
occasionally  thought  of  committing  suicide. 

I  decided  on  trying  opium  in  large  doses.  In  the  firsl  halt' of  dune,  the 
patient  took  daily  from  eighl  i"  ten  grains  of  crude  opium,  twelve  grains 
in  the  second  half  of  the  month,  and  sixteen  grains  from  the  1st  to  the  15th 
of  August.  During  the  whole  of  August  this  last  dose  was  continued, 
and  the  paroxysms  became  very  distant,  tin'  pain  especially  very  feeble. 
Life  was  bearable  again,  but  violent  diarrhoea,  obstinate  cephalalgia  and 
continued  nausea,  compelled  him  t<»  give  up  the  treatment.  In  spite  of 
this  interruption,  however,  the  amelioration  due  to  these  very  moderate 
doses  of  opium  continued  until  the  end  of  October.     At  that  time  he  had 


INFANTILE    CONVULSIONS.  791 

only  ten  or  fifteen  paroxysms  a  clay,  instead  of  from  fifteen  to  eighteen  an 
hour ;  and  during  the  night  he  had  three  or  four  only. 

These  are  not  excellent  results,  it  is  true ;  but  they  are  favorable  upon 
the  whole.  Of  all  the  therapeutic  agents  which  I  have  used — and  I  have 
tried  a  good  many  with  extreme  perseverance — opium,  then,  is  the  drug 
which  has  least  disappointed  me. 

But  keep  this  well  in  mind,  gentlemen,  that  in  the  treatment  of  epilepti- 
form neuralgia,  opium  should  be  administered  in  large  doses,  which  cannot 
be  well  determined  a  priori.  They  should  be  gradually  increased  until 
the  pain  is  quieted,  so  long  as  no  unpleasant  effects  show  themselves.  It 
may  be  laid  down  as  a  general  rule,  that  the  doses  which,  in  a  state  of 
health,  give  rise  to  very  marked  functional  disturbances,  are  on  the  con- 
trary well  borne  in  proportion  to  the  intensity  of  the  pain.  There  are  also 
idiosyncrasies  which  cannot  be  known  beforehand,  and  which  may  com- 
pletely preclude  the  administration  of  opium  in  sufficient  doses. 

Superficial  electric  excitation  has  been,  in  the  hands  of  Dr.  Duchenne 
(de  Boulogne),  of  great  service  in  the  treatment  of  this  obstinate  neurosis.* 
Almost  instantaneous  relief  is  sometimes  obtained;  but,  unfortunately,  this 
important  remedial  measure  fails  in  the  majority  of  cases  to  relieve  the 
pain,  and  to  prevent  its  recurrence. 


LECTUKE  XLIII. 

INFANTILE    CONVULSIONS. 

The  Organic  Alterations  are  an  Effect,  and  not  the  Cause,  of  the  Convulsions. — 
Yet  those  Secondary  Anatomical  Lesions  should  he  taken  into  con- 
sideration.— Predisposing,  Hereditary,  and  Acquired  Causes. — Exciting 
Causes. — The  Convulsive  Paroxysm  comprises  Two  Stages,  one  of  Tonic 
Contraction,  and  the  other  of  Clonic  Movements. — A  Third  Stage,  that  of 
Collapsus,  is  an  Effect  of  the  Convulsion  itself. — Convulsions  present 
infinite  varieties. —  General  Convulsions. — Partial  Convulsions. — Status 
Convuhivus. — Inward  Convulsions. — Thymic  Asthma. — Sequelce. —  When 
Death  occurs,  it  is  by  Asphyxia,  or  by  Nervous  Syncope. — Prognosis. — 
Treatment. 

Gentlemen:  Scarcely  have  ■  a  few  among  you  had  an  opportunity  of 
seeing  a  baby,  who  was  admitted  into  the  St.  Bernard  Ward  the  day  before 
yesterday,  and  who  died  the  same  evening.  He  was  nineteen  months  old, 
and  had  only  cut  six  teeth.  He  had,  for  the  last  few  days,  been  seized 
with  convulsions,  recurring  in  paroxysms  four  or  five  times  in  the  twenty- 
four  hours.  About  a  year  previously,  when  cutting  his  first  teeth,  he  had 
been  seized  in  the  same  way,  and  the  attack  had  lasted  eight  days,  as  on 
this  occasion,  but  the  symptoms  had  been  different  from  those  witnessed 
this  time,  and  had  constituted  what  are  termed  inward  convulsions. 

When  his  mother  brought  him  to  the  Hotel-Dieu,  the  child  had  there- 
fore been  ill  for  eight  days.     Yet,  he  had  not  been  convulsed  on  Sunday 

*  "  De  l'Electrisation  localisee  et  de  son  application  a  la  Pathologie  et  a  la 
Therapeutique,"  2e  ed.     Paris,  1861,  p.  959. 


792  INFANTILE    CONVULSIONS. 

last,  and  he  seemed  well,  when  the  convulsions  returned  on  the  following 
day  with  renewed  intensity,  so  much  so,  that  since  Tuesday  evening  (he 
was  admitted  on  the  following  Thursday )  they  recurred  almost  uninterrupt- 
edly. Since  that  time  also,  he  refused  the  breast,  and  remained  in  a  con- 
dition of  true  status  convulsivus. 

The  convulsions  returned  eveiy  four  or  five  minutes,  each  paroxysm 
lasting  from  thirty-five  to  eighty  seconds.  Although  they  were  very  rapid, 
I  could  still  observe  that  they  consisted  of  two  very  distinct  periods; 
namely,  first,  a  stage  of  tonic  convulsions,  succeeded  by  clonic  ones,  which, 
in  the  interval  of  the  paroxysms,  still  persisted  in  a  certain  degree,  and 
were  exaggerated  on  the  recurrence  of  the  fit.  The  arms  and  legs  executed 
extensive  movements  through  the  involuntary  contraction  and  alternate 
relaxation  of  their  muscles.  From  the  commencement  of  the  paroxysm, 
there  was  convergent  strabismus,  and  the  eyes  looked  down  towards  the 
lower  eyelid ;  the  urine  also  was  passed  involuntarily. 

There  was  febrile  reaction,  shown  by  heat  of  skiu,  and  acceleration 
of  the  pulse  Q68  in  the  minute),  and  the  child's  mother  stated  that  he  had 
been  feverish  from  the  beginning.  Lastly,  the  child  coughed,  but  on  care- 
fully examining  his  chest,  nothing  abnormal  was  detected. 

The  autopsy  disclosed  no  lesion  of  the  nervous  centres ;  yet  it  seemed  to 
me  that  the  gray  matter  of  the  cerebral  convolutions  was  of  a  slightly 
deeper  tint  than  it  normally  is.  The  lungs  were  slightly  congested  and 
emphysematous,  especially  the  middle  lobe  of  the  right  lung. 

You  will  be  frequently  called  upon  in  the  course;  and  even  at  the  outset, 
of  your  medical  career  to  attend  cases  of  infantile  convulsions,  and  the 
subject  is  of  such  great  importance  that  I  mean  to  devote  a  few  conferences 
to  it. 

Convulsions,  considered  generally — and  I  need  not  insist  on  the  fact — 
are  met  with  in  a  good  many  morbid  conditions  of  very  different  nature. 
In  some  cases,  they  seem  to  arise  from  manifest  anatomical  lesions  of  the 
nervous  system;  in  others,  they  seem  to  be  caused  by  no  matt-rial  change, 
or,  at  least,  the  most  rigorous  examination  after  death  reveals  the  existence 
of  no  organic  alteration  to  which  may  be  ascribed  the  morbid  phenomena 
which  manifested  themselves  during  life.  Hence  a  great  primary  distinc- 
tion between  so-called  symptomatic  and  idiopathic  convulsions. 

These  latter  may  be  the  expression,  and  sometimes  the  sole  expression, 
of  very  different  diseases.  I  have  shown  you  how  of  themselves  they 
characterized  one  form  of  epilepsy,  the  haut-mal;  and  you  know  well  the 
important  part  which  they  play  in  hysteria.  They  again  constitute  the 
predominating  symptoms  in  the  various  forms  of  chorea  ;  and  the  perma- 
nent involuntary  muscular  contractions  of  tetanus,  and  of  the  affection 
described  under  the  name  of  idiopathic  contraction,  are  only  tonic  convul- 
sions. Lastly,  under  the  generic  term,  idiopathic  convulsions,  are  included 
the  various  forma  of  eclampsia,  to  which  inj<titiil>  convulsions  should  he 
ret',  rred. 

One  point  i-  first  to  be  elucidated,  before  I  enter  upon  their  clinical 

study.      1  stated   that    idiopathic   convulsions   could    not    lie   ascribed  tO  the 

pr<  »  ace  of  any  appreciable  anatomical  change,  hut  I  did  not  mean  thereby 
that  they  wen-  independent  of  a  material  affection  undoubtedly  seated  in 
tie-  nervous  centre-;  I  merely  assert  that  the  most  minute  dissections  have 
not  yet  taught  us  -if  they  ever  can  succeed  in  bo  doing)  the  organic  patho- 
logical condition  in  consequeuce  of  which  convulsions  arise. 

[  --ill  less  deny  that  dissection  discloses  in  individuals,  who  have  died 
in  convulsions,  more  or  less  extensive  lesions  of  the  nervous  system,  hut  I 
will  repeat   what  I  have  -:iid  already  when  treating  of  epilepsy,  and  what 


INFANTILE    CONVULSIONS.  793 

I  will  say  of  all  neuroses,  that  those  lesions  are  but  of  secondary  importance 
in  the  history  of  the  disease.  They  are,  for  the  most  part,  the  result  of 
disturbances  of  the  nervous  system,  perhaps  of  those  inappreciable  organic 
modifications  to  which  I  have  alluded,  which  have  taken  place  in  the  ner- 
vous system,  but  they  are  consequences  and  not  a  starting-point. 

Thus,  a  child  is  seized  with  convulsions  and  dies.  On  dissection,  a  more 
or  less  marked  congestion  of  the  meninges,  the  brain,  and  spinal  cord,  and 
serous  effusion  into  the  ventricles  or  into  the  arachnoid  sac,  sometimes  even 
one  or  more  hemorrhagic  centres,  are  met  with.  Now  are  the  congestion 
and  the  effusion  to  be  regarded  as  the  causes  of  the  convulsions?  Surely 
not.  They  no  more  caused  them  than  the  cerebral  congestions  and  hemor- 
rhages which  take  place  in  epileptic  fits  are  the  cause  of  the  fits ;  no  more 
than  the  pulmonary  engorgement  and  serous  effusions  into  the  pleural 
cavities,  sequential  to  paroxysms  of  asthma,  caused  the  asthma.  What  we 
see  is  the  analogue  of  that  transient  congestion  which  brings  color  into  the 
cheeks  of  an  individual  who  is  under  the  influence  of  anger  or  of  a  deep 
mental  emotion,  and  which  is,  in  some  cases,  carried  to  such  a  degree  as  to 
involve  the  brain  itself.  It  may  be  also  compared  to  the  congestions  which 
accompanv  neuralgic  affections,  phenomena  to  which  I  call  your  attention 
every  day,  and  which  have  been  described  by  Dr.  ISTotta  in  an  excellent 
Memoir.* 

The  opinion  which  I  maintained,  and  which  is  accepted  by  most  practir 
tioners,  is  far  from  being  novel ;  it  was  very  clearly  professed  by  Morgagni 
when  he  wrote  in  his  eighth  letter  "  De  causis  et  sedibus  Morborum : "  "  The 
cause  of  convulsions,  which  consists  in  an  invisible  change  that  has  occurred 
in  the  brain  and  nerves,  cannot  be  detected  by  our  senses  after  death  ;  its 
effects  alone  are  seen,  and  these  vary  according  to  the  violence  and  dura- 
tion of  the  convulsions."  Yet,  gentlemen,  do  not  go  beyond  my  meaning, 
and  believe  that  I  attach  no  importance  to  these  material  lesions.  Although 
thev  occupy  but  a  secondary  place  as  the  effects,  and  not  the  causes,  of  con- 
vulsions, they  should  not  the  less  be  taken  into  consideration.  For,  if  when 
slight,  they  disappear  rapidly  and  spontaneouly  as  soon  as  the  cause  which 
produced  them  ceases  to  act,  they  are  capable,  when  carried  to  a  very  high 
degree,  of  bringing  on  the  most  serious  complications.  When  they  recur 
frequently,  they  may  cause  anatomical  changes,  and  subsequently  incurable 
functional  disorders  ;  if  there  be  no  immediate  danger  of  life,  the  patient  be- 
comes, at  least,  subject  to  incurable  infirmities,  as  we  have  seen  ;  for  instance, 
epileptics  remain  paralyzed  after  convulsive  seizures  ;  a  fortiori,  should  we 
take  into  account  the  extravasations  of  blood  which  result  from  an  attack 
of  eclampsia.     I  shall  revert  to  those  points. 

We  cannot  find  out,  then,  what  the  ancients  called  the  proximate  cause 
of  convulsions,  but  we  know  better  their  predisposing  and  exciting  causes. 

In  our  conferences  on  epilepsy,  I  tried  to  prove  to  you  by  facts  the 
influence  of  hereditary  predisposition  on  convulsive  disorders.  This  ner- 
vous susceptibility  manifests  itself  in  different  generations  either  in  the 
same  or  in  a  different  way.  It  pretty  commonly  happens  that  parents, 
mothers  especially,  who  in  their  infancy  were  subject  to  fits,  give  birth  to 
individuals  who  are  in  their  turn  affected  in  the  same  way. 

One  of  the  most  extraordinary  instances  of  the  kind,  which  I  know  of, 
is  that  related  by  my  old  pupil  and  friend,  Dr.  Duclos  (of  Tours)  in  his 
remarkable  thesis.f     The  case  is  that  of  a  woman,  thirty-four  years  of  age, 

*  Memoire  sur  les  lesions  fonctionnelles  sous  la  de"pendance  des  Nevralgies. 
Archives  Gen.  de  Medeeine,  5e  serie,  tome  iv,  juillet,  septembre,  novembre,  1854. 

f  Etudes  cliniques  pour  servir  a  l'histoire  des  convulsions  de  l'enfance.  Paris, 
1847,  p.  75. 


794  I2TFAKTILE    CONVULSIONS. 

the  sister  of  ten  children,  six  of  whom  died  of  convulsions,  and  who  had 
herself  had  frequent  attacks  of  eclampsia  up  to  the  age  of  seven.  These 
had  left  behind  slight  deviation  of  the  mouth  and  ptosis  of  the  left  upper 
eyelid.  This  woman  had  ten  children,  who  all  had  convulsions;  six  had 
died,  five  in  the  first  two  years,  and  one  when  three  years  old.  Her  young- 
est, whom  she  brought  to  me  at  the  Xecker  Hospital,  was  a  little  girl  six 
months  old.  Three  months  previously  she  had  had  a  first  attack,  which 
had  lasted  about  ten  minutes,  and  which  her  mother  ascribed  to  her  having 
given  the  breast  to  the  child  immediately  after  a  fit  of  passion,  as  the 
convulsions  occurred  on  the  ensuing  day.  Death  took  place,  three  months 
afterwards,  from  cerebro-meningitis. 

Accoucheurs  have  often  remarked  that  infants,  whose  mothers  had  eclamp- 
tic seizures  shortly  before  delivery,  were  liable  to  convulsions  within  a  short 
time  after  birth.  In  some  cases,  death  results  from  the  violence  of  the  fit ; 
in  others,  the  child  gets  well  although  the  paroxysms  have  been  very  fre- 
quent and  have  recurred  at  very  short  intervals.  The  same  authorities 
state  also  that  they  have  seen  infants  at  birth  with  contractions  of  the 
limbs  or  muscles  of  the  neck,  which  were  the  result,  according  to  them,  of 
convulsions  or  of  some  analogous  affection  at  least  from  which  they  had 
suffered  in  utero,  the  mothers  having  had  convulsions  during  pregnancy. 

Independently  of  this  predisposition  transmitted  from  parent  to  offspring, 
there  are  a  series  of  causes  which  predispose  to  convulsions  in  a  singular 
manner,  namely,  all  those  which  teud  to  weaken  the  system.  Hence  con- 
vulsions are  most  frequent  in  children  who  are  insufficiently  fed,  who  have 
lost  a  relatively  large  quantity  of  blood,  whether  from  spontaneous  hemor- 
rhage, or  from  venesection,  or  the  application  of  leeches.  Profuse  diar- 
rhoea, persisting  for  a  long  time,  acts  in  the  same  way.  This  need  not  sur- 
prise, if  this  great  physiological  law  be  kept  in  mind,  namely,  that  in  pro- 
portion as  the  nutritive  and  vegetative  functions  are  feeble  and  languish- 
ing, nervous  phenomena  are  mobile,  exalted,  and  irregular — a  law  which 
has  been  admirably  enunciated  in  this  simple  observation  of  Hippocrates, 
sanguis  moderator  nervorum  ;  if  it  be  especially  remembered  that  the  depen- 
dence of  the  nervous  system  on  the  blood  and  the  nutritive  functions  is 
most  strikingly  marked  in  children. 

I  shall  not  enumerate  to  you  the  long  list,  given  by  authors,  of  the  excit- 
ing causes  of  infantile  convulsions.  I  shall  only  remind  you  that  a  high 
temperature,  sudden  exposure  to  cold,  mental  emotions,  and  local  irritation, 
can  bring  them  on. 

A  few  years  ago,  I  was  asked  to  see,  with  my  friend  and  colleague  Dr. 
Blache,  the  child  of  a  foreign  minister  accredited  to  the  French  government. 
The  child  had  for  some  hours  been  seized  with  paroxysms  of  convulsions, 
for  which  he  had  been  put  in  a  bath.  The  convulsions  did  nut  cease,  when 
Dr.  Blache,  on  removing  the  child's  cap,  saw  a  piece  of  thread  across  his 
head,  and  on  trying  to  take  it  away,  pulled  out  a  long  needle  which  had 
entered  the  brain.  The  convulsions  ceased  immediately,  and  hydrocepha- 
lus set  in  Bhortly  afterwards  and  carried  off  the  patient. 

A  son  of  my  excellent  colleague  Professor  Soubeiran,  having  died  of 
convulsions,  for  which  no  cause  could  be  assigned,  a  post-mortem  examina- 
tion was  made,  when  a  needle  was  found  transfixing  the  liver,  and  to  this 
cause  the  convulsions  were  referred. 

Underwood  relates  a  case  like  my  first  in  his  Treatise  on  Diseases  of 
( Ihildren. 

A  child,  after  incessanl  crying,  had  been  seized  with  convulsions,  which 
could   not  be  clearly  accounted  for  by   the   medical   attendant    until   alter 


INFANTILE    CONVULSIONS.  795 

death.     Ou  removing  the  child's  cap,  a  small  pin  was  found  sticking  into 
the  anterior  fontanelle. 

Bear  these  facts  in  mind,  because  you  may  happen  to  see  convulsions 
cease  when  you  find,  on  undressing  the  little  patient,  that  a  badly-placed 
pin,  or  even  a  painful  constriction  of  the  dress,  was  the  starting-point  of  the 
convulsions. 

Remember,  also,  that  fits  are  often  brought  on  by  the  application  of 
blisters,  of  sinapisms  to  the  limbs  of  children,  with  the  intention  of  com- 
bating nervous  disorders  of  no  gravity.  How  often  have  I  seen  convulsions 
which  terminated  in  death,  supervene  in  children  that  had  been  covered 
over  with  blisters  ;  and  how  often  have  I  seen  medical  men  use  fresh  blisters 
against  the  evil  they  had  themselves  caused,  forgetting  the  nervous  symp- 
toms which  so  frequently  accompany  a  burn  of  the  first  degree. 

The  convulsive  seizures  that  are  so  common  in  some  children,  not  only 
during  the  first  dentition,  but  also,  although  much  more  rarely,  during  the 
second,  are  to  be  ascribed  in  a  great  part  to  the  irritation  caused  by  the 
difficult  evolution  of  the  teeth. 

In  an  etiological  point  of  view,  convulsions  that  ai-e  connected  with  well- 
defined  physiological  conditions,  are  undoubtedly  the  most  interesting  to 
study.  Those  which  are  due  to  an  appreciable  organic  alteration  of  the 
nervous  centres,  such  as  the  convulsions  of  cerebro-meningitis,  need  not 
occupy  our  attention,  and  the  history  of  such  symptomatic  convulsions  forms 
part  of  that  of  the  disease  of  which  they  are  one  of  the  manifestations.  But 
convulsions  which,  from  their  occurring  at  the  onset,  during  the  course  or 
towards  the  close  of  various  diseases,  are  termed  secondary,  and  said  to 
result  from  sympathy,  are  referable  to  eclampsia  properly  so  called,  of  which 
those  diseases  should  be  regarded  as  exciting  causes.  Such  are  the  convul- 
sions which  occur  at  the  outset  of  eruptive  fevers,  of  measles,  and  of  small- 
pox, more  frequently  than  of  scarlatina  ;  at  the  commencement  of  pulmo- 
nary or  intestinal  catarrhal  affections  ;  in  a  word,  of  most  of  the  inflammations 
or  fevers  which  attack  children. 

Apai't  from  these  catarrhal  or  purely  inflammatory  affections,  and  from 
chronic  diarrhoea,  disorders  of  the  alimentary  canal  have  the  greatest  influ- 
ence on  the  production  of  convulsions. 

Indigestion  is  one  of  their  most  frequent  causes,  whether  due  to  excess  in 
the  quantity  of  food,  as  when  the  child  is  given  too  much  milk  which  is 
good  in  all  respects  ;  or  whether  it  is  the  consequence  of  the  use  of  coarse 
food,  which  is  not  adapted  to  the  age,  the  digestive  capabilities,  and  the 
individual  dispositions  of  the  child,  as  when  infants  at  the  breast  are  fed, 
at  too  early  an  age,  on  thick  panadas,  on  haricots,  on  lentils,  or  on  potatoes, 
&c,  as  you  will  too  often  have  occasion  to  see. 

I  wish  to  dwell  very  strongly  on  a  point  to  which  I  have  already  called 
your  attention,  and  to  which  I  cannot  too  often  revert ;  namely,  that,  con- 
trary to  the  generally  accepted  notion,  children  at  the  breast,  who  are 
subject  to  diarrhoea,  are  much  more  frequently  liable  to  convulsions  than 
those  whose  motions  are  habitually  regular,  not  because  diarrhoea  predis- 
poses to  eclampsia  more  particularly,  but  because  persons  whose  bowels  are 
delicate  and  often  disordered,  are  more  than  others  liable  to  indigestion, 
which  is  a  powerful  cause  of  convulsions.  Hence  I  have  for  many  years 
laid  down  a  rule  for  myself,  to  stop  the  diarrhoea  of  children  even  when 
they  are  teething.  Cases  have  been  recorded  of  children  who  had  been 
seized  with  convulsions,  after  taking  the  breast  soon  after  the  mother  had 
felt  a  violent  emotion.  I  saw  at  the  Necker  Hospital,  to  which  I  was 
physician  for  a  long  time,  eclampsia  come  on  in  a  child  whose  nurse  had 
had  a  violent  fit  of  passion  a  moment  before  giving  him  the  breast.     Pro- 


796  INFANTILE    CONVULSIONS. 

fessor  Andral  related  in  his  lectures  still  more  curious  instances,  showing 
that  there  are  singular  idiosyncrasies,  under  the  influence  of  which  the 
milk  of  a  nurse  is  well  digested  by  some  children  and  not  by  others.  "A 
woman  nursed  her  own  child  without  any  ill  effect,  but  another  child  to 
whom  she  gave  the  breast  was  seized  with  convulsions  and  a  third  like- 
wise. "  In  all  such  cases,  the  seizure  comes  on  without  any  other  symptom 
of  indigestion  being  present ;  it  seems  as  if  the  nature  of  the  milk  was  altered 
under  the  influence  of  some  cause  or  other,  and  it  became  a  poison  acting 
on  the  nervous  system. 

I  have  already  called  your  attention  to  the  important  fact,  pointed  out 
for  some  years  past,  of  eclampsia  coming  on  in  children  as  well  as  adults, 
as  a  consequence  of  albuminuria,  whether  it  occurs  in  the  course  of  an 
acute  affection,  as  it  often  does  at  the  close  of  scarlatina,  or  whether  it  be  a 
symptom  of  Bright's  disease. 

In  such  cases,  the  patient  has  generally  had  more  or  less  considerable 
anasarca;  but  you  must  not  think,  as  some  seem  to  admit,  that  anasarca 
is  the  most  favorable  condition  for  the  development  of  convulsions  ;  because, 
on  the  one  hand,  children  who  become  anasarcous  without  passing  albu- 
minous urine  after  an  attack  of  dysentery,  of  obstinate  diarrhoea,  of  measles 
even,  are  rai'ely  seized  with  eclampsia,  whilst  in  albuminuria  without  ana- 
sarca, convulsions  are  of  frequent  occurrence,  and  so  much  so,  that  some 
authors  have  not  hesitated  to  affirm  that,  in  nearly  every  case,  infantile 
convulsions  were  a  symptom  of  albuminuria,  an  opinion  which  to  me  seems 
exaggerated.  Those  authors  have  even  tried  to  diagnose  eclampsia  from 
epilepsy  by  the  presence  of  albumen  in  the  urine  in  convulsions.  I  have 
often  reminded  you  of  Professor  Claude  Bernard's  curious  experiments  on 
the  influence  of  injuries  to  the  fourth  ventricle  on  the  urine.  If,  in  an 
animal,  this  ventricle  be  injured  in  a  certain  spot,  the  urine  is  found  to  con- 
tain sugar  within  a  short  time,  and  to  be  secreted  more  abundantly.  If 
some  other  spot  be  wounded,  mere  polyuria  follows,  and  no  sugar  is  found 
in  the  urine.   An  injury  to  a  third  spot  soon  renders  the  urine  albuminous.* 

Can  it  be  supposed,  then,  that  the  same  venous  modification  which,  in  a 
child  or  in  a  woman,  produces  albuminuria,  causes  a  liability  to  eclampsia  ? 

The  presence  of  worms  in  the  alimentary  canal  has  been  mentioned  by 
all  authors  as  one  of  the  most  common  exciting  causes  of  infantile  convul- 
sions, and  I  have  already  told  you  of  a  case  of  epilepsy  which  was  cured  by 
the  expulsion  of  a  taenia.     Such  cases  are  instances  of  reflex  convulsions. 

Without  attempting  to  review  all  the  causes  of  infantile  convulsions,  I 
will  call  your  attention  to  this  peculiarity;  namely,  that  circumstances 
apparently  themost  insignificant  may  bring  them  on  in  individuals  predis- 
posed to  them ;  that  there  are  children  who  are  convulsed  with  as  much 
facility  as  others  pass  into  a  dreamy  or  delirious  state;  and  that  this  pre- 
disposition is  chiefly  hereditary.  As  \  have  already  told  you  when  speak- 
ing of  epilepsy,  this  nervous  susceptibility  or  excitability  may  in  some  cases 
be  foreseen.  Care,  however,  should  be  taken  not  to  mistake  for  convulsions 
the  rapid  and  hirohnilarij  movements  which  occur,  even  in  the  waking  State, 
in  individuals  whose  nervous  system  is  very  excitable,  when  surprised  by 

an  unexpected  noise,  or  when  under  the  i nil u<  nee  of  sudden  mental  emotion. 

Such  movements  are  convulsive  in  appearance  only,  but  fail  to  present  the 
essential  characters  of  convulsions  properly  so  called. 

Let  us,  then,  sec  what  these  characters  are.  Viewed  ID  ils  simplest  ele- 
ment, a  convulsive  seizure  consists  of  two  successive  and  very  distinct  Btages. 

*  Lccons  do  Physiologic  expenmentale  appliquee  ii  la  B£6decine  faitee  au  College 

do  France. 


INFANTILE    CONVULSIONS.  797 

The  first  .stage  is  one  of  contraction  without  shocks,  consisting  in  a  gradual 
but  rapid  shortening  of  the  muscular  fibres,  shown  by  the  hardness  and  stiff- 
ness of  the  affected  muscle,  which  cannot  be  overcome  in  some  cases.  This 
pt  rim  I  <,/  tonicity  is  soon  followed  by  a  clonic  stage,  characterized  by  the 
occurrence  of  alternating  movements  of  contraction  and  relaxation  inde- 
pendent of  the  will,  which  is  as  powerless  to  suspend  or  moderate  them  as 
it  was  to  excite  them. 

The  tonic  always  precedes  the  clonic  stage,  but  the  duration  and  violence 
of  the  latter  are  by  no  means  proportionate  to  the  duration  and  violence  of 
the  former.  Thus  very  violent  clonic  movements  often  succeed  a  slight 
tonic  contraction,  and  reciprocally  an  excessively  powerful  tonic  contraction 
may  be  succeeded  by  very  moderate  clonic  movements.  Thus  the  length 
of  the  first  stage  is  sometimes  so  short,  and  the  second  stage  comes  on  so 
quickly,  lasting  for  a  more  or  less  prolonged  period,  that  an  observer  who 
is  not  on  his  guard,  or  not  very  attentive,  might  think  that  the  convulsions 
were  clonic  from  the  outset.  In  other  cases,  which  are  not  so  frequent  it 
is  true,  there  are  no  clonic  convulsions,  and  there  is  only  during  the  whole 
time  a  muscular  contraction  more  or  less  energetic  and  jtersisting.  This  is 
what  occurs  in  idiopathic  contractions,  of  which  I  shall  speak  on  some  other 
occasion.  In  eclampsia,  more  especially  in  the  eclampsia  of  children,  of 
which  alone  I  mean  to  treat  to-day,  clonic  convulsions  are  absent  when  death 
occurs  during  the  fit,  and  as  a  consequence  of  the  length  of  the  tonic  contrac- 
tion, from  asphyxia  or  syncope,  by  a  mechanism  which  we  shall  investigate 
by  and  by. 

From  what  I  have  said,  this  remarkable  fact  follows,  that  rigidity  seems  to 
be  an  essential,  obligatory  element  of  all  convulsion.  It  is  never  absent,  and 
can  even  be  alone  present,  whether  it  constitutes  the  convulsion  by  itself, 
as  in  idiopathic  contractions,  or  whether  the  convulsion  is  incomplete,  as 
in  eclampsia,  wdien  the  clonic  stage  is  absent,  whereas  clonic  movements 
never  perhaps  come  on  from  the  first. 

There  is  a  third  stage  which  should  not  be  omitted,  although  it  does  not 
form  part  of  the  convulsive  seizure,  namely,  that  of  collapse,  stupor,  or 
coma.  Whether  it  be  the  consequence  of  cerebral  surprise,  produced  by 
congestion  or  exhaustion  of  the  nervous  excitability,  this  collapse  is  an 
effect,  and  not  the  cause,  of  the  convulsions.  If  in  most  cases  there  sets  in 
after  an  attack  of  eclampsia,  more  or  less  profound,  or  more  or  less  tran- 
sient stupor,  in  some  instances  of  very  infrequent  occurrence,  it  is  true,  there 
is  no  transition  between  the  attack  and  the  return  to  a  normal  state. 

After  this  analysis  of  the  various  phenomena  which  constitute  a  convul- 
sive fit,  I  now  pass  on  to  a  more  general  study  of  infantile  convulsions,  and 
will  attempt  to  describe  them  as  completely  as  possible.  The  subject  is 
one  of  extreme  difficulty,  for  eclampsia  assumes  the  most  varied  forms. 
More  commonly  it  comes  on  like  an  epileptic  fit.  Nothing  foretells  the  in- 
vasion of  the  attack  ;  and,  for  my  part,  I  have  never  observed  the  premoni- 
tory signs  spoken  of  by  Bracket,  and  repeated  after  him  by  others.  The 
state  of  impatience,  of  uneasiness,  of  agitation,  and  malaise  that  is  spoken  of, 
the  light  sleep  or  the  wakefulness,  sometimes,  on  the  contrary,  replaced  by 
languor,  hebetude,  and  somnolence,  are  the  prodromata  of  the  disease,  of 
which  the  convulsions  are  a  primary  manifestation,  and  cannot  be  referred 
to  the  convulsions  themselves. 

The  convulsions  set  in  suddenly.  The  child  utters  a  cry,  loses  conscious- 
ness, becomes  rigid,  and  struggles,  with  a  fixed  chest  and  suspended  res- 
piration ;  the  face,  which  is  pale  at  first,  becomes  red  and  livid ;  the  eyes 
sometimes  fill  wTith  tears,  which  run  over  the  cheeks ;  the  veins  of  the  neck 
project  like  knotted  cords.  The  clonic  stage  then  begins,  characterized  by 
disorderly  and  involuntary  contractions  of  a  great  many  muscles ;   the 


798  INFANTILE    CONVULSIONS. 

limbs  are  alternately  flexed  and  extended  ;  the  fingers  and  toes  are  succes- 
sively bent  and  stretched  out,  separated  from  or  approximated  to  one  an- 
other, but  most  frequently  they  are  in  a  state  of  forcible  flexion  ;  the  thumb 
is  adducted  and  hidden  by  the  fingers.  The  head  is  drawn  backwards  or 
is  bent  forwards ;  sometimes  it  is  pulled  laterally  by  irregular  and  jerking 
rotatory  movements ;  the  muscles  of  the  face  share  in  the  general  convul- 
sions; the  eyes  are  the  seat  of  jerking  movements,  and  roll  in  their  sockets  ; 
they  are  generally  drawn  up  under  the  upper  eyelid  ;  more  rarely  they  are 
pulled  downwards,  and  there  is  strabismus  convergens.  The  labial  com- 
missures are  dragged  upwards  and  outwards,  and  hence  the  distorted  face 
is  sometimes  frightful  to  behold ;  then,  on  each  convulsive  shock,  the  air 
passes  through  the  kind  of  funnel  formed  by  the  corners  of  the  half-opened 
buccal  orifice,  and  makes  a  suction  noise,  accompanied  by  a  flow  of  frothy 
and  sometimes  bloody  saliva.  In  this,  as  iu  an  epileptic  fit,  the  tongue  is 
protruded,  and  may  be  bitten  and  lacerated  by  the  teeth.  As  the  muscles 
of  the  trunk  are  likewise  affected  during  the  tonic  stage,  the  inspiratory 
muscles  are  fixed,  and  the  larynx  itself,  which  is  spasmodically  contracted, 
no  longer  admits  of  the  free  passage  of  air.  The  abdominal  muscles  being 
thrown  into  convulsion,  cause  the  involuntary  expulsion  of  the  urine  and 
feces.  The  clonic  convulsions,  at  first  rapid  and  limited,  become  slower 
and  more  extensive,  and  at  last  a  deep  inspiration,  followed  by  complete 
relaxation,  announces  the  end  of  the  fit.  The  child  then  falls  into  a  state 
of  somnolency  and  stupor. 

These  various  phenomena  take  place  in  much  less  time  than  I  have  been 
in  describing  them,  and  the  fit,  which  is  always  too  long  for  the  frightened 
mother,  lasts  one  or  two  minutes.  When  it  is  completely  over,  and  when, 
after  the  stupor  has  disappeared,  order  is  re-established,  it  is  impossible  to 
see  any  traces  of  what  has  passed,  beyond  that  the  child  shows  signs  of 
fatigue  by  yawning  and  by  a  tendency  to  sleep. 

The  paroxysm  may  consist  of  a  single  fit,  but  this  is  rare.  Generally, 
after  a  more  or  less  prolonged  pause,  a  second  fit  comes  on,  having  the 
same  characters  as  the  first,  lasts  the  same  length  of  time,  and  is,  like  it, 
succeeded  by  coma,  after  which  the  child  recovers  his  normal  condition. 

Like  the  first,  it  comes  on  without  any  appreciable  cause,  but  it  may  be 
brought  on  by  emotion,  by  annoyance,  by  pain,  or  by  movement,  and  may 
recur  every  hour,  every  half  hour,  and  even  at  nearer  intervals. 

An  attack  of  eclampsia  thus  composed  of  several  fits,  may  last  from 
half  a  day  to  one,  two,  or  three  days;  and  there  are  instances  in  which  it 
has  been  prolonged  beyond  that  time,  the  child  being  liable  to  convulsions, 
which,  recurriug  at  more  or  less  short  intervals  in  the  course  of  the  twenty- 
four  hours,  are  continued  over  five,  six,  seven,  and  fifteen  days,  as  in  cases 
reported  by  Dr.  Duclos,*  and  even  over  eighteen  days,  as  in  the  ease  of  a 
child,  five  months  old,  whom  I  saw  at  the  Necker  Hospital. 

During  an  attack  of  hooping-cough,  this  child  had  every  day  one  or  two 
paroxysms,  consisting  of  a  series  of  subintrant  iits  ;  that  is  to  say.  of  tits 
following  one  another  so  quickly  that  one  lit  was  not  yet  over  before  the 
next  one  began;  the  paroxysm  lasted  in  this  way,  without  the  least  inter- 
ruption, for  two,  three,  and  even  four  hours. 1" 

This,  gentlemen,  confirms  what  I  told  you  just  now  as  to  the  variety  of 
forms  assumed  by  infantile  convulsions. 

Generally  intermittent,  separated  by  intervals  of  rest,  during  which  order 
seems  to  be  re-established,  they  are   found,  at    other  times,  as  in  the  above 

ease,  to  succeed  one  another  without  intermission.     A  lit  which  has  lasted 

*  Loc.  cit,  p.  23.  t  lif,  p.  23. 


INFANTILE    CONVULSIONS.  799 

one  or  two  minutes,  is  scarcely  over  -when  it  is  followed  by  .mother,  which 
is,  ill  its  turn,  succeeded  by  from  one  to  twenty  other  fits  ;  so  that  the  little 
patient  merely  passes  from  the  contortions  of  convulsion  into  a  still  more 
awful  torpor;  and  from  want  of  attention,  many  medical  men  consider  this 
state  as  one  of  continued  convulsion. 

A  little  care  is  alone  needed  in  order  to  recognize  a  series  of  paroxysms, 
tlir  violence  of  which  is  generally,  in  such  cases,  less  great  than  that  of 
intermittent  convulsions.  This  condition  resembles  exactly  what  in  epi- 
lepsy I  termed  the  status  epilepticus,  a  condition  of  much  less  frequent  oc- 
currence, however,  in  epilepsy  than  in  eclampsia. 

These  apparently  continuous  convulsions  may  last  a  considerable  length 
of  time,  for  eight  or  ten  hours,  then,  after  a  more  or  less  prolonged  inter- 
val, may  again  assume  a  continuous  form,  and  recur  from  one  to  two  and 
even  to  fifteen  or  seventeen  days  in  succession. 

This  form  of  eclampsia,  therefore,  differs  from  the  one  in  which  the 
attacks  are  markedly  intermittent,  only  as  regards  the  mode  of  recurrence 
of  the  fits. 

There  is,  however,  a  continuous  form,  which  is  pretty  often  met  with 
after  a  violent  epileptiform  seizure.  Just  as  the  jerks  are  expected  to  cease, 
they  return  every  second  or  at  slightly  longer  intervals,  and  this  goes  on 
for  a  quarter  of  an  hour,  for  an  hour,  or  even  for  whole  days.  In  such 
cases,  there  is,  in  reality,  but  a  single  attack  ;  for  although  from  time  to 
time  the  convulsions  seem  to  diminish  in  intensity  to  begin  again  with 
renewed  violence,  there  is  never  a  complete  cessation  of  the  convulsions, 
nor  the  profound  stupor  and  the  general  muscular  relaxation  which  follows 
on  an  ordinary  paroxysm.  In  this  continuous  form  of  eclampsia  there  is  a 
capital  symptom  to  which  I  wish  to  direct  your  attention  at  once.  Whereas 
in  the  first  two  forms,  there  was  loss  of  consciousness,  in  this  form,  on  the 
contrary,  although  the  child  is  convulsed,  he  seems  as  if  he  had  not  entirely 
lost  consciousness,  and  was  not  a  complete  stranger  to  all  that  was  passing 
around  him.  He  expresses  his  wants  or  pain  by  cries ;  he  occasionally 
withdraws  with  a  certain  amount  of  vivacity  his  hand  when  it  is  pinched, 
or  his  foot  wrhen  it  is  tickled,  although  the  very  limb  is  convulsed  which 
still  responds  to  the  commands  of  the  will. 

In  truth  such  convulsions,  which  affect  the  whole  body,  are  not  so  general 
as  they  seem  to  be,  since  there  are  some  muscles  which  still  obey  the  will, 
and  they  must  therefore  be  regarded  as  partial,  strictly  speaking. 

Let  us  now  pass  on  to  more  localized  convulsions.  Partial  convulsions 
present  the  most  marked  differences,  and  their  infinite  diversity  of  form  is 
in  direct  relation  to  their  seat.  It  sometimes  happens  after  an  epileptic 
fit  that  one-half  of  the  body  is  for  several  hours  the  seat  of  spasmodic  clonic 
movements,  which  recur  at  intervals  or  from  one  to  several  seconds.  The 
child  is  yet  perfectly  conscious,  and  the  movements  of  the  opposite  half  of 
the  body  are  executed  with  an  ease  and  a  co-ordination  which  contrast  sin- 
gularly with  the  agitation  of  the  affected  side. 

I  remember  seeing  a  little  boy  of  eleven  months  old  with  the  tubercular 
diathesis,  who,  after  a  violent  attack  of  eclampsia,  recovered  his  senses,  but 
whose  right  arm  and  the  right  half  of  whose  face  were  convulsively  and 
violently  agitated  for  several  hours.  He  knew  his  mother  and  his  nurse ; 
could  drink,  although  with  some  difficulty ;  looked  with  attention  and 
intelligence  at  all  the  objects  around  him,  turned  his  head  quickly  round 
to  look  at  the  persons  who  entered  the  room,  and  sometimes  even,  worried 
by  the  jerks  of  his  right  arm,  tried,  by  holding  it  with  his  left  hand,  to 
stop  the  violence  of  the  convulsive  movements. 

In  other  cases,  instead  of  affecting  in  an  equal  degree  all  the  muscles  on 


800  INFANTILE  CONVULSIONS. 

one  side  of  the  body,  convulsions  affect  unequally  one  muscle  or  another, 
and  often  muscles  which  are  not  supplied  by  the  same  nerve.  Thus  only 
one  muscle  of  the  arm,  the  biceps,  for  instance,  may  be  convulsed,  while 
the  others  are  perfectly  quiet  and  relaxed,  and  one  or  more  fingers  are 
alone  moved.  Occasionally,  although  more  exceptionally,  the  lower  limbs 
are  the  seat  of  these  partial  convulsions. 

They  are  frequently  preceded  and  accompanied  by  the  general  disorders 
which  characterize  an  epileptic  fit,  such  as  a  scream,  loss  of  consciousness, 
and  pallor  of  the  face ;  often,  also,  the  attack  is  followed  by  a  period  of 
stupor  and  cams.  These  phenomena  are  never  more  marked  than  in  the 
cases  when  the  convulsions  are  limited  to  the  trunk,  cases,  which  although 
not  rare,  are  yet  much  less  frequent  than  those  in  which  the  limbs  are 
exclusively  convulsed. 

Partial  convulsions  of  the  trunk  assume,  besides,  two  very  distinct  forms. 
Thev  are  sometimes  incomplete,  and  consist  of  an  exclusively  tonic  con- 
traction of  the  muscles  of  the  vertebral  groove,  which  resembles  a  true 
tetanic  spasm.  The  body  stiffens ;  the  head  is  drawn  backwards  and 
immovably  fixed ;  and  then,  without  there  having  been  any  flexion,  all 
contraction  ceases,  and  the  normal  condition  is  restored.  Sometimes  this 
tonic  stage  is  so  transitory  that  it  seems  to  be  absent,  and  clonic  contrac- 
tions are  alone  seen,  which  make  the  head  rotate  or  bend  forwards  or  back- 
wards, the  convulsions  seeming  to  be  exclusively  limited  to  the  muscles  of 
the  neck.  I  will  here  repeat  an  observation  which  I  have  made  already, 
namely,  that  you  should  not  confound  with  convulsions  certain  move- 
ments which  somewhat  resemble  them,  and  which  recur  in  a  great  many 
children  during  k  febrile  affection.  Such  movements  show  the  excitability 
of  the  little  patient,  and  although  they  are  due  to  an  exaltation  of  the  ner- 
vous system,  are  in  reality  not  convulsive. 

Of  all  partial  convulsions  the  most  frequent  are  unquestionably  those  of 
the  face.  They  sometimes  involve  all.  the  muscles  of  one  half  of  the  face, 
when  the  eyelids,  the  globe  of  the  eye,  the  ala  nasi,  the  cheek,  are  thrown 
into  convulsive  contractions,  the  mouth  is  distorted,  the  lower  jaw  is 
depressed  and  pulled  to  the  affected  side,  and  the  teeth  are  set,  or  there  is 
a  kind  of  chewing  movement  continually  going  on.  In  some  cases  the  con- 
vulsions are  still  more  limited  in  their  area,  involving  either  the  orbicularis 
palpebrarum,  and  causing  rapid  involuntary  winking,  which  lasts  more  or 
less  time,  or  a  few  muscular  bundles  of  the  checks  and  lips,  the  commissure 
of  the  latter  being  then  violently  dragged  upwards  and  outwards,  or  the 
muscles  of  the  ala  nasi,  causing  alternate  dilatation  and  closure  of  the  no— 
tril.  The  muscles  of  the  tongue  are  sometimes  affected,  and  articulation 
being  then  impossible,  there  results  a  kind  of  stammering,  which  is  gener- 
ally transient,  but  sometimes  persistent. 

Convulsions  of  the  muscles  <f  the  eye  arc  the  most  frequent  of  the  partial 
convulsions  of  the  face,  and  I  will  go  so  far  as  to  add  that  they  are  per- 
haps wry  often  overlooked.  Thev  generally  announce  the  invasion  oi  an 
attack  oi  eclampsia,  but  sometimes  also  thev  are  the  only  symptom  of  the 
complaint.    Thev  are,  in  some  cases,  exclusively  tonic;  the  globe  of  the 

eve    i-   drawn    up  and  bidden    under   the  upper  lid,  or    there  is  double  and 

convergent  strabismus;  in  exceptional  cases  the  strabismus  is  divergent 
In  other  instances  one  eye  is  alone  affected,  and  the  other  is  perfectly  mo- 
tionless; the  Strabismus  is  then  almost  always  convergent  It  may  also 
happen  that  the  strabismus  is  convergent  on  one  Bide  and  divergent  on  the 
other.     Usually  the  convulsion-  of  the  muscles  of  the  eve  are  complete; 

that  i.~   to   say,  permanent    contraction    is  succeeded    hy  clonic   movements, 

and  the  globes  of  the  eye  oscillate  continuously,  being  drawn  up  under  the 


INFANTILE    CONVULSIONS.  801 

upper  lid,  and  then  pulled  down  under  the  lower  one,  and  looking  inwards 
towards  the  nose  much  more  frequently  than  outwards. 

With  respect  to  one  point  you  must  he  on  your  guard.  You  will  proba- 
bly be  niori'  than  once  called  upon  to  see  children  said  to  have  been  seized 
with  convulsions,  because  their  eyes  shall  have  been  seen  to  be  drawn  up 
under  the  upper  eyelids  whilst  they  are  asleep,  and  this  essentially  physio- 
logical condition  has  been  mistaken  for  the  consequence  of  convulsions. 
The  eves  are  sometimes  drawn  up  to  such  a  degree  that  on  separating  the 
lids,  the  iris,  and  the  pupil  particularly,  cannot  be  seeu  at  all.  The  pupil 
is  besides  completely  contracted,  whereas  during  convulsions  it  is,  on  the 
contrary,  more  or  less  dilated.  This  physiological  condition  gives  rise  to 
frequent  mistakes,  especially  when  children  have  recently  had  true  convul- 
sive seizures. 

It  is  easy,  gentlemen,  to  recognize  eclampsia  under  the  different  forms 
which  I  have  just  reviewed,  however  elementary  or  partial  it  may  be. 
These  forms  are  perfectly  distinct  and  special,  and  all  medical  men  agree, 
if  not  on  the  nature  of  the  disease,  at  least  on  the  name  which  should  be 
applied  to  it.  The  case  is  always  one  of  convulsions.  But  opinions  have 
differed,  and  still  vary  very  much,  with  regard  to  the  forms' to  which  I  now 
pass  on,  namely,  inward  convulsions,  to  which,  when  slight,  some  authors 
have  applied  the  term  spasms;  and  which,  according  to  the  muscles  that 
are  affected,  give  rise  to  phenomena  which  are  differently  and  sometimes 
singularly  interpreted. 

By  inward  convulsions  are  commonly  meant  partial  convulsions,  more 
particularly  of  the  pharynx,  of  the  larynx,  and  of  the  whole  muscular 
respiratory  apparatus.  The  term  has  certainly  not  a  very  clear  and  pre- 
cise meaning,  but  it  is  good  enough,  provided  its  meaning  be  well  under- 
stood. 

The  most  common  form  of  inward  convulsions  consists  in  the  drawing  up 
and  the  mobility  of  the  globe  of  the  eye,  of  which  I  spoke  just  now ;  in  a 
nearly  complete  loss  of  consciousness,  or  at  the  very  least  in  pretty  profound 
stupor ;  in  extreme  difficulty  or  inability  to  swallow  ;  in  uneven  breathing, 
sometimes  scarcely  perceptible,  sometimes  deep,  broad,  and  blowing,  show- 
ing that  the  diaphragm  and  the  respiratory  muscles  of  the  abdomen  and 
chest  are  more  particularly  involved ;  sometimes  there  is  heard  for  one  or 
several  minutes  a  peculiar  laryngeal  whistling,  which  indicates  an  obstacle 
to  the  entry  and  exit  of  the  air,  a  circumstance  to  which  I  shall  revert 
presently. 

Inward  convulsions  may  coexist  with  general  or  partial  convulsions  of 
the  limbs  and  face  (for  I  have  told  you  that  these  were  usually  accompanied 
by  convulsions  of  the  globes  of  the  eyes),  or  they  may  be  alone  present.  In 
either  case,  again,  they  may  be  complete,  that  is,  tonic  and  clonic,  or  incom- 
plete, and  consequently  consisting  in  tonic  contraction  alone.  If,  in  the 
former  case,  the  patient  be  exposed,  the  convulsions  of  the  diaphragm  and  the 
respiratory  muscles  may  be  seen  to  cause  very  rapid  and  frequent,  though 
not  extensive,  movements  of  the  base  of  the  chest ;  in  the  latter  case,  the 
base  of  the  chest  is  violently  drawn  in  and  remains  immovable.  Clonic 
convulsions,  owing  to  the  frequency  of  their  recurrence  and  the  shallowness 
of  their  movements,  necessarily  produce  profound  perturbation  of  the  re- 
spiratoxy  function,  which  becomes  embarrassed,  and  therefore  of  hreniatosis. 
Again,  the  convulsive  jerks  explain  the  slight  and  peculiar  fits  of  coughing 
which  frequently  accompany  inward  convulsions. 

Tonic  convulsions  suddenly  arrest  and  completely  suspend  the  respiratory 
functions.  Hence  you  can  easily  understand  that  they  cannot  last  for  a 
long  time  continuously,  without  causing  death.  So  that,  whereas  convul- 
vol.  i. — 51 


802  INFANTILE  CONVULSIONS. 

sions  of  the  limbs  and  face  may  extend,  without  any  inconvenience,  over  a 
minute  and  a  half  and  two  minutes ;  tonic  convulsions  of  the  diaphragm 
and  of  the  inspiratory  muscles  must  be  transitory  only,  and  cannot  last  over 
a  minute  without  immediate  danger. 

Inward  convulsions  chiefly  consist,  then,  in  convulsions  of  the  diaphragm 
and  of  the  respiratory  muscles  of  the  abdomen  and  chest;  but  it  happens 
also  that  the  intrinsic  muscles  of  the  larynx  are  convulsed  simultaneously, 
and  this  laryngeal  convulsion  causes  again  disorders  of  respiration,  which 
may,  in  some  cases,  excite  serious  alarm.  A  rickety  child,  subject  to  epi- 
leptiform convulsions,  which,  for  the  last  few  months,  had  recurred  several 
times  a  day  under  the  influence  of  the  least  fit  of  anger,  was  one  day  brought 
to  me  at  the  Necker  Hospital.  He  had  besides,  from  time  to  time,  attacks 
which  his  mother  could  not  describe  clearly,  but  which,  according  to  her 
statement,  were  still  more  grave  than  the  great  seizures.  Several  of  these 
attacks  occurred  in  my  presence.  The  child  suddenly  threw  himself  back- 
wards, his  throat  was  tense,  his  mouth  half-opened,  his  eyes  fixed,  his  arms 
and  legs  moved  by  convulsive  jerks.  Quick  inspiratory  movements  created 
inside  the  chest  a  vacuum,  which  was  immediately  removed  by  the  falling 
in  of  the  ribs ;  air  seemed  not  to  enter  the  larynx,  or,  if  a  little  went  in,  it 
caused  a  sharp  whistling  noise,  somewhat  similar  to  that  which  is  sometimes 
heard  during  the  most  violent  paroxysms  of  croupal  dyspnoea.  During  the 
attack,  the  face,  neck,  and  chest,  and  the  mucous  membrane  of  the  mouth, 
became  more  and  more  livid  in  hue,  until,  as  the  spasm  ceased,  one  or  more 
deep  inspirations  put  an  end  to  this  terrible  scene.  Profound  depression, 
like  what  follows  an  attack  of  eclampsia,  then  ensued.  It  is  these  convul- 
sions which  affect  the  respiratory  apparatus,  and  the  larynx  more  particu- 
larly, that  constitute  the  disease  described  by  Kopp  under  the  name  of 
thymic  asthma,  the  laryngismus  stridulus  of  Hood  and  of  Ley,  and  on  which 
my  colleague,  Dr.  Herard,  has  written  a  good  monograph.* 

Allow  me,  gentlemen,  to  dwell  a  moment  on  this  question,  which  has 
given  rise  to  much  discussion.  You  are  aware  that  this  complaint  has  been 
ascribed  to  an  abnormal  development  of  the  thymus  gland,  but  it  has  been 
conclusively  shown  that  it  is  perfectly  independent  of  it.  First  of  all,  is  it 
necessary  to  state  that  the  thymus  gland,  as  well  as  the  suprarenal  capsules, 
organs  of  transition  which  are  destined  to  atrophy  after  birth,  are,  less  than 
other  organs  in  the  body,  placed  in  conditions  that  give  rise  to  hypertrophy? 
For  more  than  twenty  years  I  was  attached  to  a  hospital  where  a  large 
number  of  very  young  children  was  admitted,  and  I  never  oner  saw  swelling 
of  the  thymus  gland  that  was  capable  of  giving  rise  to  the  slightest  accident. 
Besides,  is  it  conceivable  that  the  thymus  may  grow  to  such  a  size  as  to 
obliterate  the  trachea  to  a  great  degree  without  the  child's  friends  and  the 
medical  attendant  being  warned  by  the  presence  of  habitual  dyspnoea?  And 
if  there  has  never  been  any  dyspnoea,  can  one  understand  by  what  process 
an  organ,  which  contain.-  so  few  bloodvessels, may  in  a  lew  minutes  Become 
a  cause  of  death,  or,  at  least,  of  awfully  serious  accidents?  Now,  it'  the 
hypothesis  he  suggested,  that  the  gland,  on  undergoing  hypertrophy  or 
alteration,  has  involved  the  recurrenl  laryngeal  nerve,  as  in  cases  oi 
tubercular  infiltration  of  the  lymphatic  glands  of  the  neck  and  the  roots  of 
the  bronchi,  how  can  one  believe  that  there  has  been  in)  modification  of  the 

voice  or  of  respiration,  and  that  the  disease  reveal-  itself  Only  by  a  Midden 

attack  of  dyspnoea  ? 

Pathological   anatomy   has   hv   llii-   lime   thrown   sullicient    light   on    this 

contested  point,  and  has  shown  that  if  the  thymus  is  sometimes  abnormally 


*  Da  epttsme  de  la  ^l<>tt<\  [T/iises  tic  Parit),  1847.] 


INFANTILE    CONVULSIONS.  803 

developed,  its  hypertrophy  is  not  necessarily  attended  during  the  child's 
life  with  symptoms  of  the  so-called  thymic  asthma  ;  whereas  in  fatal  cases 
of  inward  convulsions,  like  those  described  under  the  name  of  thymic  asthma, 
the  gland  has  undergone  no  alteration.  The  study  of  the  symptoms  could, 
after  all,  but  lead  to  the  conclusion  that  convulsions  were  alone  in  question, 
for,  on  investigating  the  series  of  the  forms  of  eclampsia,  one  can  easily  rec- 
ognize convulsions  affecting  the  respiratory  apparatus,  the  diaphragm,  and 
more  particularly  the  larynx. 

Who  does  not  see  that  there  need  only  be  a  want  of  harmony  between 
the  spasmodic  movements  of  the  diaphragm  and  those  of  the  muscles  which 
move  the  arytenoid  cartilages,  in  order  to  give  rise  to  the  laryngeal  whis- 
tling and  the  dyspnoea?  In  a  regular  act  of  inspiration,  the  upper  por- 
tion of  the  larynx  opens,  while  the  diaphragm  .is  depressed  and  makes  a 
vacuum  inside  the  chest.  Now,  if  the  diaphragm  be  depressed  too  rapidly, 
and  there  be  at  the  same  time  laryngeal  spasm,  as  happens  in  hooping- 
cough,  inspiration  becomes  almost  impossible,  and  is  accompanied  by  a 
very  loud  whistling. 

In  the  present  instance  we  need  not  have  recourse  to  a  want  of  harmony 
between  the  movements  of  the  diaphragm  and  those  of  the  laryngeal  mus- 
cles ;  we  need  only  suppose  that  the  will  or  instinct  no  longer  pi-esides 
for  a  moment  over  the  movements  of  the  arytenoid  cartilages;  the  muscles 
which  move  these  cartilages,  no  longer  responding  to  a  nervous  impulse, 
are  for  the  time  in  the  same  condition  as  those  of  animals  whose  recurrent 
laryngeal  nerve  has  been  cut. 

What  occurs  deep  in  the  larynx  may  sometimes  take  place  under  the 
observer's  eye.  In  order  to  test  the  truth  of  the  theory  which  I  had 
framed  to  myself  regarding  the  so-called  thymic  asthma,  I  have  on  occasions 
remained  a  long  time  by  the  side  of  a  child  suffering  from  convulsions  of 
the  diaphragm,  without  participation  of  the  larynx,  and  have  brought  on 
at  will  the  phenomena  of  thymic  asthma,  by  closing  for  a  moment  the 
child's  mouth  and  nose. 

When  the  mouth  was  closed,  and  the  nostrils  pressed  slightly,  so  as  to 
occlude  them  for  a  second  only  and  then  to  leave  them  half-opened,  at  the 
moment  when  a  greater  convulsion  of  the  diaphragm  carried  the  air  more 
rapidly  through  the  nasal  fossae,  the  alse  nasi,  yielding  to  the  pressure  of 
the  air,  were  seen  to  press  against  the  septum,  and  so  intercept  the  passage 
of  air,  so  that  immediate  suffocation  resulted.  The  reason  of  this  was,  that 
during  the  convulsions,  the  alse  nasi  did  not  open  during  the  forcible  in- 
spiration, as  they  do  in  a  physiological  and  even  a  pathological  condition* 

I  need  not  remind  you  of  the  distinction  between  thymic  asthma,  and 
the  acute  asthma  of  Millar  :  the  latter  is  stridulous  laryngitis,  in  which  the 
spasm  of  the  larynx  which  characterizes  it  is  due  to  an  inflammation  of 
the  respiratory  tract. 

Thymic  asthma  may  be  preceded  or  accompanied  by  other  symptoms  of 
eclampsia,  but  it  may  also  be  the  only  manifestation  of  the  complaint.  It 
may  set  in  suddenly  in  the  midst  of  apparently  splendid  health,  without 
any  appreciable  cause,  but  it  more  commonly  comes  on  under  the  influence 
of  some  mental  emotion  or  of  a  fright.  I  was  once  consulted  for  a  little  boy, 
who  from  the  beginning  to  the  end  of  his  first  dentition  was  subject  to 
such  seizuress.  He  was  of  a  very  excitable  temperament,  and  the  least  an- 
noyance brought  on  an  attack  :  although  he  is  still  very  excitable,  he  never, 
however,  has  any  such  attacks  now. 

Remember  what  I  told  you  already  in  our  conferences  on  epilepsy,  that 
these  laryngeal  spasms,  and  eclampsia,  in  general,  are,  in  some  cases,  the 
prelude  of  epilepsy,  which,  as  the  individual  grows  older,  manifests  itself 


804  INFANTILE    CONVULSIONS. 

more  clearly.  On  this  account,  therefore,  you  should  be  extremely  re- 
served in  your  prognosis  of  thymic  asthma ;  and  for  a  greater  reason  still, 
namely,  that  the  patient  may  be  carried  off  in  a  fit,  when  it  lasts  beyond 
a  certain  time,  although  when  the  attacks  are  very  short,  they  are  not  grave 
in  themselves.  Indeed,  it  is  very  remarkable  that  eclampsia  in  children 
generally  leave  after  it  no  traces  of  its  passage,  even  though  the  seizures 
have  been  frequent  and  violent,  and  have  recurred  during  five,  eight,  ten 
days,  and  even  more.  The  little  girl,  whom  I  spoke  of  in  the  course 
of  this  lecture,  got  perfectly  well,  and  her  health  did  not  seem  to  have 
suffered  in  the  least  from  the  convulsions  which  had  recurred  during 
eighteen  days. 

In  some  cases,  however,  convulsions  are  followed  by  sequelce,  which  may 
be  temporary,  or  may  be  persistent  and  irremediable.  Thus,  muscles 
which  have  been  particularly  and  most  violently  convulsed,  are  sometimes, 
after  an  attack  of  eclampsia,  the  seat  of  pretty  acute  pain,  resulting  either 
from  laceration  of  their  fibres,  or  effusion  of  blood,  when  the  pain  is  not 
simply  a  consequence  of  the  fatigue  felt  after  exaggerated  muscular  efforts. 

In  other  cases,  more  or  less  incurable  deformities  result  from  attacks  of 
eclampsia.  You  are  aware  that  among  the  theories  propounded  to  explain 
certain  distortions  of  the  neck  in  newborn  infants,  certain  congenital  de- 
formities of  the  limbs,  and  talipes  in  particular,  there  is  one  which  admits 
the  influence  of  convulsions  of  the  foetus  in  utero. 

These  infirmities  may  be  brought  on  after  birth  ;  and  you  know  that 
eclampsia  is  regarded  as  one  of  the  most  frequent  causes  of  squinting  and  of 
stammering.  It  should  be  added,  it  is  true,  that  these  acquired  infirmities 
are  most  frequently  the  result  of  convulsions  that  are  symptomatic  of  an 
appreciable  lesion  of  the  nervous  centres,  and  that  they  are  then  less  due 
to  the  convulsions  themselves  than  to  the  persistent  organic  cause  which 
brought  on  the  fit. 

Sometimes,  again,  eclampsia  is  accompanied  or  followed  by  paralysis.  In 
some  instances,  the  parts  which  were  convulsed  are,  after  the  attack, 
markedly  weak,  and  this  weakness  may  be  carried  to  absolute  loss  of  motor 
power ;  in  other  instances,  the  limbs  on  the  opposite  side  are  paralyzed  ; 
lastly,  the  upper  limb  may  be  convulsed,  while  the  lower  limb  ou  the  cor- 
responding side  is  paralyzed.  The  paralysis  is  generally  transitory,  like 
the  convulsions  which  accompany  it ;  but  it  may  last  more  or  less  per- 
manently after  the  attack.  It  may  be  partial  also,  and,  like  the  convul- 
sions, may  affect  only  one  or  several  muscles.  This  is  especially  the  case 
.with  the  face;  and  these  accidents,  which  occur  either  on  the  same  side 
with  the  convulsions,  or  on  the  opposite  side,  seem  to  give  rise  to  a  certain 
number  of  cases  of  facial  paralysis,  the  origin  of  which  is  vainly  soughl  for 
elsewhere. 

This  secondary  paralysis  partly  explains  some  of  the  deformities  to  which 
I  have  alluded,  and  which  are  in  fact  owing  to  the  permanent  contraction 
of  one  or  several  muscles.  Now,  if  contraction  may  follow  on  convulsions, 
it  is  well  known  also  that  muscles,  which  have  been  long  paralyzed,  arc, 
after  more  or  less  time,  subject  to  it.  Lastly,  idiotcy  very  often  Bnpervenes 
on  infantile  convulsions;   and  it  rarely  happens  thai  in  BUCD  Cases  one  half 

of  the  body  is  not  weaker  than  the  other,  the  paralyzed  -idc  being  less  de- 
veloped than  the  sound  one.  It  is  then  probable  that  the  convulsions  have 
been  accompanied  or  followed  by  deep  lesions  of  the  nervous  centres. 

Although  these  Bequelse  of  convulsions  are  not  very  rare,  on  the  other 
hand,  they  are  not  frequent  in  proportion  to  the  extreme  frequency  of 
eclampsia;  and  I  may  here  repeal  what  I  .-aid  just  now,  namely,  that, 
generally  .-peaking,  this  complaint  i.-  usually  of  no  gravity.     The  fatal 


INFANTILE    CONVULSIONS.  805 

cases,  however,  to  which  I  have  more  than  once  alluded,  and  in  winch  ilmth 
was  an  immediate  conseqw  nee  of  the  attacks,  are  still  too  frequently  mel  with 
for  not  warning  you  of  the  possibility  of  this  awful  termination.  It  is  to 
be  dreaded,  not  only  after  numerous  attacks,  recurring  in  rapid  succession, 
but  even  in  a  first  attack.  Death  then  takes  place,  either  by  asphyxia  I  and 
this  is  the  most  common  mode),  or  by  syncope;  or,  lastly,  by  nervous  exhaus- 
tion. 

Asphyxia  may  be  the  consequence  of  inward  convulsions,  or  of  the  great 
seizures. 

In  the  former  case,  it  is  brought  on  in  two  very  different  ways.  It  may 
be  immediate,  as  when  the  child  dies  choked,  as  if  strangled,  or  as  if  his 
chest  were  violently  and  suddenly  compressed  by  an  iron  hoop.  This 
occurs  in  thymic  asthma,  in  convulsions  of  the  diaphragm,  when  the  tonic 
contractions  persist  for  more  than  a  minute  and  a  half,  or  two  minutes,  at 
the  most,  and  thus  completely  arrest  the  respiratory  movements,  and  sus- 
pend the  function  of  an  apparatus,  the  exercise  of  which  is  immediately 
necessary  for  the  maintenance  of  life. 

A  young  child,  of  whom  I  have  often  spoken  in  this  lecture,  died  in  that 
manner,  and  I  shall  now  relate  in  detail  the  history  of  his  case.: 

He  was  eleven  months  old  when  he  was  admitted  into  the  Necker  Hos- 
pital, to  which  I  was  then  attached,  and  placed  in  cot  No.  11,  St.  Julia 
Ward,  under  my  care.  He  was  suffering  from  chronic  diarrhoea,  which 
improved  under  the  influence  of  small  doses  of  calomel  combined  with 
opium.  In  other  respects  the  child,  who  was  nursed  by  his  own  mother, 
exhibited  no  extraordinary  symptom,  when  he  was  suddenly  seized  one 
night  with  eclampsia,  without  any  premonitory  symptoms.  The  right  arm 
alone  was  convulsed,  and  after  all  slightly  so.  Inspiration,  however,  was 
attended  with  a  kind  of  sob,  somewhat  similar  to  that  of  hooping-cough. 
These  accidents,  which  recurred  at  pretty  short  intervals,  still  persisted  as 
I  was  going  round  the  ward,  and  returned  several  times  in  my  presence, 
each  attack  lasting  less  than  a  minute,  without  producing  any  notable 
dyspnoea.  After  I  had  seen  the  other  patients,  I  returned  to  the  child, 
and  had  him  completely  stripped,  and  held  by  a  nurse,  so  as  to  examine 
him  carefully.  He  was  then  suddenly  seized  with  tonic  convulsions  of  the 
right  arm,  whilst  his  respiration  quickened,  and  wras  attended  with  the  kind 
of  noise  I  mentioned  just  now.  AVithin  eight  or  ten  seconds  his  arms  and 
legs,  and  his  whole  trunk,  became  the  seats  of  tetanic  rigidity,  analogous 
to  that  which  obtains  in  the  first  stage  of  an  epileptic  fit.  His  chest-walls 
were  fixed  and  motionless,  his  diaphragm  did  not  move,  and  breathing  was 
completely  arrested.  I  was  looking  on  with  the  greatest  anxiety,  impa- 
tiently waiting  for  clonic  movements,  or  the  least  muscular  twitching,  when, 
after  less  than  a  minute  of  complete  immobility,  I  saw  the  skin,  which  until 
then  had  retained  its  normal  hue,  turn  livid,  the  face  swell,  and  the  enlarged 
tongue  protrude  out  of  the  mouth,  driving  out  some  froth,  and  the  urine 
flow  copiously.  I  endeavored  to  excite  respiratory  movements  by  squeezing 
and  rubbing  the  chest,  but  my  efforts  failed,  and  the  child  died. 

On  making  a  post-mortem  examination,  I  found  slight  injection  of  the 
pia-mater,  as  well  as  of  the  gray  substance,  and  perhaps  some  slight  soften- 
ing of  the  brain,  a  condition  which  might  be  explained  by  the  high  tem- 
perature of  the  season.  The  most  minute  examination  disclosed  no  lesion. 
The  thymus  gland  was  slightly  larger  than  it  usually  is,  but  was  neither 
indurated  nor  injected,  and  did  not  in  the  least  compress  the  trachea.  The 
lungs  were  merely  engorged  and  full  of  black  blood,  and  the  bronchi  con- 
tained some  froth.  One  of  the  bronchial  glands  was  slightly  swollen  and 
softened. 


806  INFANTILE    CONVULSIONS. 

The  second  mode  in  which  inward  convulsions  bring  on  asphyxia  is  per- 
fectly different.  The  convulsions  are  complete,  but  the  alternate  contrac- 
tion and  relaxation  of  the  respiratory  muscles  succeed  one  another  at  such 
short  intervals,  that  they  do  not  allow  the  chest,  and  consequently  the 
lungs,  to  expand  sufficiently ;  and  from  spasm  of  the  upper  opening  of  the 
larynx  recurring  almost  uninterruptedly,  the  air  can  no  longer  pass  freely 
into  the  larynx,  trachea,  and  bronchi.  The  blood  is  no  longer  regularly 
aerated  ;  because,  on  the  one  hand,  the  respiratory  apparatus  no  longer 
receives  a  sufficient  quantity  of  pure  air,  and,  on  the  other  hand,  it  cannot 
get  rid  of  the  air  which  has  lost  its  oxygen,  and  has  therefore  become  use- 
less for  respiration.  This  function  is  in  consequence  insufficiently  and 
incompletely  performed,  and  asphyxia  supervenes,  as  in  cases  of  organic 
diseases  of  the  larynx,  in  oedematous  laryngitis,  for  example. 

Death  by  the  lungs  may  also  take  place  in  the  great  seizures,  although 
less  immediately  than  in  the  two  preceding  cases.  As  Dr.  Duclos  justly 
remarks,  the  mode  in  which  the  fatal  termination  occurs  is  somewhat  an- 
alogous to  what  happens  so  frequently  after  tracheotomy  when  performed 
in  the  last  stage  of  croup.  It  would  seem  as  if  all  danger  had  been  removed 
after  an  opening  has  been  made  in  the  trachea  through  which  air  may  freely 
pass  on  to  the  lungs.  Yet  asphyxia  continues,  or  at  least  we  can  no  longer 
prevent  the  effects  resulting  from  too  prolonged  disorders  of  hamiatosis — 
effects  which  the  beautiful  experiments  made  by  Dr.  Faure  have  so  clearly 
shown.  The  patient  has  received  a  death-blow,  and  although  the  mechan- 
ical obstacle  which  has  been  the  primary  cause  of  the  asphyxia  is  removed, 
we  are  powerless  in  bringing  on  resuscitation. 

Now,  children  die  in  the  same  manner  after  convulsions  which  have 
recurred  for  several  hours  almost  without  interruption,  and  especially  after 
that  condition  termed  status  convidsivus.  Such  repeated  convulsions  bring 
on  a  considerable  disturbance  of  respiration  and  circulation.  The  face 
gets  congested  and  becomes  of  a  livid  red  hue;  dyspnoea  sets  in  and  goes 
on  increasing  ;  scarcely  is  one  paroxysm  over  before  another  comes  on,  fol- 
lowed by  a  third,  so  that  respiration  and  circulation  have  not  time  to  resume 
their  regular  course.  Hence,  when  the  attack  is  over  and  quiet  has  been 
restored,  even  when  respiration  appears  to  be  regular,  it  is  a  deceptive  calm, 
and  the  patient  dies  within  a  few  hours,  although  there  have  been  no  fresh 
convulsions,  no  marked  dyspnoea,  no  manifestation  of  grave  symptoms. 
He  dies,  if  I  may  say  so,  not  of  asphyxia,  but  of  the  sequela.'  of  asphyxia. 

The  cerebral  congestion,  which  is  an  effect  and  not  a  cause  of  eclampsia, 
may  present  a  certain  amount  of  gravity  when  carried  to  a  very  high  degree. 
But  although  this  accident  has  long  been,  and  is  still  regarded  by  Borne  as 
very  common  and  habitual,  it  occurs,  on  the  contrary,  in  very  exceptional 
cases. 

Death  by  asphyxia  is  the  usual  mode  of  fatal  termination  of  convulsions. 
In  some  cases,  however,  it  must  be  admitted  that  the  individuals  die  by 
syncope,  whether  this  be  explained  by  the  considerable  shock  to  the  nervous 
sy-tein,  or  by  convulsions  of  the  heart  impeding  its  action. 

Nothing  is  so  difficult,  to  my  mind,  gentlemen,  as  to  speak  generally  of 
prognosis  in  infantile  convulsions.     Prognosis  in  such  cases  is  subordinate 

to  a  great  many  circumstances.  From  what  I  have  said,  you  could  Bee  thai 
inward  convulsions  are  much  more  dangerous  than  violent  convulsive  >ei/.- 
ures  almost  exclusively  limited  to  the   limbs.      With  regard  to   the  former, 

there  are  distinctions  to  make  between  incomplete  convulsions  in  which 

there   are    only  tonic    contractions    lasting    beyond    measure,  and    complete 

convulsions  made  up  of  alternate  rigidity, and  relaxation  of  the  muscles. 


INFANTILE    CONVULSIONS.  807 

As  to  the  great  seizures,  they  vary  in  regard  of  intensity,  duration,  and 
more  or  less  frequent  recurrence. 

In  convulsions  which  come  on  at  the  outset,  in  the  course,  or  at  the  close 
of  certain  complaints,  it  is  of  the  highest  importance  to  take  into  account 
the  period  at  which  they  occur,  as  this  influences  prognosis  considerably. 
1  may  here  repeat  what  I  have  told  you  elsewhere.  If  we  analyze  the 
phenomena  of  which  shivering  consists,  we  find  that  it  is,  after  all,  a  con- 
vulsion of  a  small  degree.  Whether  it  be  partial  or  general,  it  is  charac- 
terized by  trembling  and  by  involuntary  movements  of  the  parts  which  it 
affects,  due  to  alternate  contraction  and  relaxation  of  the  muscles.  It  is 
not  extraordinary,  therefore,  that  these  phenomena  should  be  exaggerated 
in  individuals  whose  nervous  system  is  excitable,  as  it  is  in  children,  and 
should  even  pass  into  a  true  attack  of  eclampsia.  Hence,  in  infancy,  espe- 
cially in  cases  of  extreme  nervous  excitability,  the  slightest  fever  is  ushered 
in  by  convulsions,  whether  the  fever  be  due  to  a  mere  gastric  disturbance 
or  to.  some  catarrhal  affection,  an  intestinal  or  a  pulmonary  inflammation, 
or  whether  it  be  one  of  the  prodromata  of  some  continued  fever. 

Such  premonitory  convulsions  are  most  frequent  at  the  outset  of  eruptive 
fevers,  of  measles  in  particular,  and  still  more  frequently  of  small-pox. 
In  fact,  they  are  so  common  in  such  cases,  that  some  authors,  and  Syden- 
ham among  others,  have  laid  it  down  as  an  almost  absolute  law,  that  con- 
vulsions, occurring  in  a  child  who  has  cut  his  first  teeth,  should  make  one 
suspect  the  imminence  of  an  exanthem.  Sydenham,  moreover,  thought 
that  such  convulsions  were  a  favorable  symptom,  showing  that  the  eruptive 
fever  would  be  mild. 

I  am  far  from  agreeing  with  him  on  this  point.  Although  I  admit  that 
convulsions  occurring  at  the  outset  of  measles  and  small-pox  are  nearly 
always  unattended  with  danger,  I  yet  believe,  first,  that  they  give  no  indi- 
cation as  to  the  future  course  of  the  disease,  and  secondly,  that  they  may 
even  prove  (although  in  exceptional  cases)  dangerous  complications,  either 
from  their  violence  and  frequency,  or  from  their  seat ;  but  what  exception- 
ally renders  them  serious,  is  uncalled-for  medical  interference.  How  often 
non-professional  persons,  and  even  medical  men,  have  recourse,  in  cases  of 
infantile  convulsions,  to  treatment  which  is  always  perturbing  and  too 
active.  Leeches  are  applied  behind  the  ears,  in  order  to  remove  conges- 
tion of  the  brain,  which  is  dreaded  above  all  things,  and  the  loss  of  blood, 
contrary  to  the  end  in  view,  brings  the  patient  into  a  condition  which  is 
the  most  favorable  for  the  production  of  nervous  accidents.  Or  baths  are 
had  recourse  to,  cold  affusions,  the  application  of  ice  to  the  head,  which,  if 
the  case  be  one  of  measles,  for  instance,  increase  the  bronchial  inflamma- 
tion which  is  usually  present  in  such  cases,  and  change  into  grave  compli- 
cations these  generally  unimportant  epiphenomena.  Or,  again,  blisters  are 
applied  to  the  limbs,  or  cloths  wrung  out  of  boiling  water  ;  and  the  pain 
caused  by  such  brutal  measures  excites  a  nervous  system,  which  should 
above  all  be  quieted. 

If,  on  the  average,  convulsions  occurring  at  the  outset  of  diseases  be  gen- 
erally unattended  with  risks,  the  same  thing  cannot  be  said  of  convulsions 
which  come  on  during  the  acute  stage  of  a  complaint,  and  a  fortiori,  towards 
its  close.  They  then  indicate  a  fatal  termination.  Whether  the  case  be 
one  of  pulmonary  or  intestinal  inflammation  ;  or  of  measles,  hooping-cough, 
or  small-pox,  convulsions  occurring  in  the  course  or  towards  the  close  of  the 
disease,  point  to  a  danger  arising  from  some  grave  complication  in  the  pa- 
tient's condition.  The  convulsive  seizure  is  then  preceded  by  brain  symp- 
toms similar  to  those  observed  in  typhoid  fever ;  it  recurs  for  two,  three,  or 


808  INFANTILE    CONVULSIONS. 

four  days,  lasting  sometimes  from  a  few  minutes  to  a  few  hours  only,  and 
generally  ushers  in  death. 

Such  accidents  are  to  be  most  dreaded  in  scarlatina.  Even  when  they 
occur  at  the  outset  of  this  exanthematous  fever,  they  have  a  much  more 
serious  import  than  when  they  come  on  at  the  beginning  of  an  attack  of 
measles  or  of  small-pox  ;  but  when  they  happen  in  the  third  stage  of  scarlet 
fever,  they  end  almost  always  fatally.  They  depend,  in  most  cases,  then, 
on  the  presence  of  general  anasarca  and  concomitant  albuminuria  ;  but  they 
manifest  themselves  occasionally  also  independently  of  all  serous  infiltra- 
tion in  the  same  manner  as  jactitation,  delirium,  vomiting,  and  other  ner- 
vous disorders  occur  in  the  course  of  scarlet  fever. 

Prognosis,  in  infantile  convulsions,  depends  on  other  considerations,  which 
a  practitioner  should  be  aware  of,  and  should  take  into  account,  in  addition 
to  the  seat  and  the  course  of  the  convulsions,  and  the  period  at  which  they 
appear  in  the  course  of  various  diseases. 

Clinical  experience  has  made  out  the  fact  that  convulsions  are  less  dan- 
gerous in  proportion  as  they  are  more  easily  excited ;  and  what  Stoll  has 
said  of  children  in  general,  may  be  applied  to  individuals  of  heightened 
nervous  excitability:  "  Convuluo  et  spasmus,  uti  frequentior  in  infant  ibus, 
ita  minus  periculosus  Us  plerumque  est  quam  adultis."  For  there  are  indi- 
viduals, indeed,  who  are  seized  with  convulsions  for  the  least  thing,  and  in 
whom  no  unpleasant  consequences  follow. 

Yet  bear  in  mind  that  this  nervous  excitability  may  be  hereditary,  and 
that  if  in  infancy  it  brings  on  eclampsia,  it  may  subsequently  manifest 
itself  by  producing  very  gravonervous  affections,  such  as  epilepsy.  Recall 
to  mind  the  cases  which  I  related  to  you  when  on  the  subject  of  epilepsy, 
and  remember  especially  that  convulsions  are  accidents  which  expose  med- 
ical men  to  the  most  unpleasant  disappointments.  Even  those  which  come 
on  under  the  most  favorable  circumstances  may  terminate  fatally,  and  when- 
ever, therefore,  you  are  sent  for  to  see  a  child  seized  with  eclampsia,  be  pru- 
dently reserved. 

From  what  I  have  just  said,  it  might  seem  that  a  medical  man  should 
always  interfere,  and  at  any  cost,  in  cases  of  infantile  convulsions.  I  hold 
a  perfectly  contrary  opinion.  I  very  strongly  believe  that  the  less  we  do 
is  in  general  the  best  we  can  do,  and  that  our  treatment  should  be  expectant. 
If  you  question  mothers  whose  children  have  more  than  once  been  seized 
with  eclampsia,  they  will  often  tell  you  that  they  stopped  the  fit  either  by 
putting  salt  into  the  child's  mouth,  or  by  making  him  smell  vinegar  or  dis- 
tilled orange-flower  water,  or  by  throwing  cold  water  in  his  face,  or  by  sonic 
other  method  as  insignificant  as  the  above.  But  because  medical  interfer- 
ence is  rarely  called  for,  it  must  not  be  inferred  that  we  must  stand  with 
folded  arms  in  all  possible  cases.  In  convulsive  seizures  we  should  cer- 
tainly be  on  the  watch,  although  perturbing  measures,  such  as  bleeding, 
leeches,  pretended  revulsives  to  the  skin,  are  always  dangerous  and  almost 
never  useful  :  it  is  essential,  however,  that  the  patient  should  never  be  lost 
sight  of.  If  the  progress,  duration,  and  seat  of  the  convulsions  do  not  in- 
dicate  danger,  certain  measures  should  be  Had  recourse  to  which,  without 

increasing  the  patient's  risks,  console  his  friends,  sustain  their  hopes,  and 
may  irain  for  the  medical  man  the  credit  of  the  cure  Some  of  these  meas- 
ures are,  besides,  unquestionably  useful;  and  antispasmodics  rank  first 
among  them,  sneb  as  ether,  either  alone  or  combined  with  musk  or  bella- 
donna, from  5  to  6  or  8  grains  of  musk,  or  from  Uh  to  |ths  of  ;i  -rain  of 
belladonna. 

When    the  convulsions  keep  recurring,  tlnir  cause  must   he  above  all 


ECLAMPSIA    OF    PREGNANT    AND    PARTURIENT    WOMEN.       809 

sought  for;  and  it  will  be  sufficient  in  many  cases  to  remove  the  cause  in 
order  to  cure  the  convulsions. 

The  timely  administration  of  an  emetic  and  of  a  purgative  enema  has 
been  known  to  stop  convulsions  due  to  embarrassment  of  the  prima  vice; 
in  other  instances  the  fit  has  ceased  on  removing  the  child's  clothes,  when 
a  pin  stuck  in  badly,  or  too  tight  a  bandage,  was  the  exciting  cause  of  the 
seizure. 

But  when  the  cause  of  the  convulsions  escapes  us,  or  when  it  is  beyond 
the  reach  of  our  active  measures,  as  in  eclampsia  due  to  the  pain  of  teeth- 
ing, and  in  certain  symptomatic  convulsions,  there  are  still  powerful  and 
efficacious  therapeutic  measures  which  may  be  used  against  the  convulsions 
when  they  are  prolonged.  Such  are  compression  of  the  carotids  and  chloro- 
form inhalations. 

You  are  aware  how  prudently  chloroform  should  be  used,  how  you  should 
keep  your  finger  on  the  patient's  pulse,  counting  the  number  and  feeling 
the  strength  of  the  pulsations ;  and  by  taking  these  indispensable  precau- 
tions you  may  be  able  to  push  on  the  inhalation  very  far.  In  the  begin- 
ning of  the  year  1860,  I  was  sent  for  to  see  a  child,  five  years  of  age,  the 
son  of  one  of  my  best  friends,  who  had  on  the  previous  day  had  a  very 
slight  attack  of  convulsions.  He  was  afflicted  with  disease  of  the  brain, 
which  had  arrested  his  mental  development.  I  was  sent  for  because  he  had 
been  again  seized  with  convulsions,  which  were  this  time  awfully  violent. 
When  I  saw  him  his  face  was  congested  to  such  a  degree  that  he  looked  as 
if  in  the  last  stage  of  asphyxia.  I  made  him  inhale  some  chloroform  poured 
on  a  handkerchief,  which  I  held  some  distance  from  his  nostrils,  for  a  few 
minutes  at  a  time,  taking  the  precaution  of  constantly  feeling  his  pulse. 
For  six  whole  hours,  from  six  to  twelve  o'clock,  I  thus  administered  chlo- 
roform almost  without  interruption,  and  I  could  not  say  how  much  I  used. 
Thanks  to  this  mode  of  treatment,  the  child,  who  was  at  the  point  of  death, 
recovered,  and  is  at  present  as  well  as  he  was  formerly.  I  have  raised,  and 
still  raise,  my  voice  against  the  application  of  revulsives  to  the  skin,  and  of 
blisters  in  particular,  as  they  have  seemed  to  me  to  do  in  general  more 
harm  than  good.  There  are  cases,  however,  in  which  these  measures  be- 
come necessary,  and  may  be  really  useful,  namely,  cases  of  inward  convul- 
sions which  involve  the  diaphragm  and  the  heart  itself,  are  of  the  tonic 
kind,  and  are  so  prolonged  as  to  bring  on  asphyxia  or  syncope.  In  such 
instances,  a  violent  and  rapid  revulsion  to  the  skin  of  the  chest,  such  as  can 
be  produced  by  ammonia,  may  do  good,  by  exciting  irritation,  which  rouses 
into  action  those  muscles  the  play  of  which  is  indispensable  for  the  acts  of 
respiration  and  circulation. 


LECTURE  XLIV. 

ECLAMPSIA  OF  PREGNANT  AND  PARTURIENT  WOMEN. 

Gentlemen  :  The  details  into  which  I  entered,  in  our  last  conference, 
allow  me  to  be  brief  in  what  I  have  to  tell  you  to-day  of  puerperal  eclampsia, 
apropos  of  a  patient  who  lay  in  bed  No.  28  in  St.  Bernard  Ward.  Were  I 
to  give  you  a  detailed  description  of  this  affection,  I  should  have  to  repeat, 
in  a  great  part,  what  I  said  to  you  about  infantile  convulsions.  This  latter 
description  was  itself  singularly  like  that  of  epilepsy;  for,  as  I  have  more 


810      ECLAMPSIA    OF    PREGNANT    AND    PARTURIENT    WOMEN. 

than  once  told  you,  these  affections  present  the  greatest  analogies  to  one 
another,  if  we  merely  look  at  their  outward  manifestations. 

Recall  to  mind  what  happened  in  the  case  of  the  young  woman  who  was 
in  St.  Bernard  Ward;  and  those  among  you  who  witnessed  her  violent  con- 
vulsive seizures  could  see  how  they  resembled  epileptic  fits. 

These  convulsions  occurred  under  the  following  circumstances :  On  the 
day  previous  to  her  admission,  the  patient  had  been  delivered,  at  three 
o'clock  in  the  morning,  of  her  first  child.  She  had  complained  of  nothing 
peculiar  during  her  pregnancy.  The  midwife  who  was  with  her,  gave  her 
a  full  dose  of  ergot  of  rye  after  delivery,  probably  with  the  idea  of  stopping 
an  abundant  loss  of  blood.  Convulsions  came  on  two  hours  afterwards, 
and  she  was  brought  to  the  hospital  in  the  course  of  the  day. 

My  clinical  assistant,  M.  Moynier,  on  seeing  her  in  the  evening,  decided 
on  bleeding  her  at  the  elbow,  to  the  amount  of  about  27  ounces.  Still,  the 
convulsions  recurred  with  extreme  violence  from  6  to  12  o'clock  p.  M.  They 
had  ceased  when  I  saw  the  patient  on  the  following  morning.  The  lividity 
of  the  face,  -which  had  on  the  previous  day  been  carried  to  a  very  high 
degree,  had  almost  completely  disappeared.  The  tongue  bore  traces  of 
having  been  bitten  in  several  places.     I  prescribed  the  following  mixture : 

R.  Moschi.  1 

Jkxt.  v  alenana?,  J   & 

Aqua?  Mentha?,  ^ij. 

Syrupi  JEtheris,  ")    ? 

*  "      Floris  Aurantii,  /  ^ss-  aa- 

About  11  a.m.,  next  day,  she  had  another  attack,  as  violent  as  the  previous 
ones,  and  followed,  like  them,  by  profound  stupor  and  complete  loss  of  con- 
sciousness. 

The  puerperal  convulsions  had  in  this  case  occurred  at  a  period  when 
they  are  not  generally  common,  namely,  after  delivery.  For,  indeed, 
obstetric  teachers  tell  us  that  eclampsia  is  rare  before  the  sixth  month  of 
pregnancy,  is  less  rare  after  delivery  than  during  pregnancy,  while  it  is 
most  frequent  during  labor. 

In  the  present  case,  I  could  not  make  out  the  exciting  cause  of  the  seizures, 
and  the  only  etiological  condition  to  which  I  could  ascribe  them  was  that 
the  patient  was  a  primipara.  The  influence  of  a  first  pregnancy  on  the  pro- 
duction of  eclampsia  (as  a  predisposing  cause  |  is  a  fact  admitted  by  most 
accoucheurs.  According  to  Cazeaux,  whose  work  is  in  everybody's  hands, 
seven  out  of  eight  cases  of  eclampsia  occur  in  primipara?.  But  although  the 
influence  of  a  first  birth  is  so  considerable,  it  must  not  be  inferred  that  a 
■woman  who  had  passed  through  a  first  pregnancy  and  been  delivered 
safely,  is  forever  secure  against  puerperal  convulsions,  aor  does  the  occur- 
rence of  convulsions  in  a  previous  pregnancy  necessarily  imply  their  recur- 
rence in  succeeding  pregnancies. 

If  you  remember  what  1  told  you  of  epilepsy  and  of  infantile  convul- 
sion-, it  is  unquestionable  that  the  nervous  excitability  which,  in  some 
women,  manifested  itself  during  infancy  by  convulsive  seizures,  and  later 
by  hysterical  symptoms  or  more  less  curious  nervous  disorders,  is  a  pre- 
disposing cause  which  should  engage  the  attention  of  the  physician. 

I  shall  not  review  all  the  exciting  cause-  enumerated  in  text-books,  hut 

there  is  one  to  which  I  am   anxious  to  call   your  attention,  although  it  wa- 

absenl  in  the  case  of  my  patient,—]  mean,  albuminuria. 

I  need  not  discuss  here  whether  the  albuminuria  which  occurs  in  preg- 
nancy he  at  the  outsel  caused  Bolely  by  compression  of  the  kidneys,  of  the 
iliac  vein-,  or  the  trunk  of  the  vena  cava  inferior,  by  the  uterus  ;  whether  it 


ECLAMPSIA    OF    PREGNANT    AND    PARTURIENT    WOMEN.      811 

depends,  as  Braun,  of  Vienna,  believes,  on  this  compression,  and  the  result- 
ing stagnation  of  the  venous  blood,  and  on  the  peculiar  modifications  which 

the  blood  undergoes  during  pregnancy ;  or  whether  it  is  due  to  the  nervous 
disturbance  which  so  often  accompanies  pregnancy. 

It  has  been  sufficiently  proved  by  clinical  observation  that  albuminuria 
occurs  pretty  frequently  during  pregnancy,  especially  in  prim  i  parse,  and  in 
women  who  have  a  malformed  pelvis,  whose  uterus  is  too  high  up  or  is  of 
considerable  size,  either  from  the  presence  of  a  very  large  foetus,  or  of  seve- 
ral foetuses,  or  of  an  excessive  quantity  of  liquor  amnii. 

It  is  sufficiently  proved  also  that  this  albuminuria  has  pretty  frequently 
an  unfavorable  influence  on  the  course  of  pregnancy,  and  on  delivery  and 
its  consequences,  and  lastly,  although  it  has  been  denied  by  some,  that 
there  is  a  relation,  a  coincidence  at  the  very  least,  between  albuminuria 
and  puerperal  convulsions. 

It  should  be  added,  it  is  true,  that  the  coincidence  is  far  from  being 
constant. 

Albuminuria  stands  to  eclampsia  in  the  same  relation  as  it  does  to  ana- 
sarca. Although  anasarca  and  albuminuria  often  coexist  (and  there  is 
then  an  evident  relation  between  them),  the  former  may  be  present  without 
the  least  trace  of  albumen  being  detectable  in  the  urine,  while,  per  contra, 
partial  or  general  dropsy  may  be  completely  absent,  and  yet  there  be 
abundant  albuminuria.  In  the  same  manner,  although  convulsions  recur 
very  frequently  in  women  who  pass  albuminous  urine  (Mr.  Imbert-Gour- 
beyre  has  met  with  it  94  times  out  of  159),*  and  although,  consequently, 
the  presence  of  albuminuria  during  pregnancy  must  make  one  dread  the 
occurrence  of  eclampsia  at  a  more  or  less  distant  period,  it  must  not  be 
forgotten  that,  in  a  great  many  cases,  convulsions  never  occurred,  although 
the  urine  had  for  a  long  time  been  albuminous. 

Lastly,  the  case  of  the  young  woman  which  I  have  related,  and  other 
instances  which  have  come  under  my  observation,  formally  disprove  the 
law  which  has  been  laid  down  by  some,  that  in  all  cases  of  eclampsia 
occurring  in  women,  the  urine  was  invariably  found  to  contain  albumen. 
The  urine  of  that  young  woman  was  examined  on  repeated  occasions,  and 
neither  heat,  nor  nitric  acid,  ever  gave  rise  to  the  least  albuminous  cloudi- 
ness. 

Most  commonly,  if  not  always,  puerperal  convulsions  are  general,  as  they 
were  in  the  case  which  is  still  in  the  hospital.  In  some  rare  instances, 
however,  they  are  partial,  and  the  following  case,  which  came  under  my 
care  at  the  Necker  Hospital,  seems  to  me  to  present  some  analogies  to  this 
partial  form  of  eclampsia. 

A  woman  21  years  of  age,  who  had  six  months  previously  been  delivered, 
at  her  full  term,  of  the  baby  whom  she  was  then  nursing,  was  admitted 
into  St.  Anne  Ward,  and  placed  in  bed  No.  24,  on  January  16th,  1846. 
Her  previous  health  had  been  good,  but  twTo  months  before  delivery,  she 
had  been  seized  with  convulsions,  which  had  come  on  suddenly  during  the 
day,  without  any  appreciable  cause,  and  which,  after  affecting  the  whole 
left  side  of  the  body,  left  behind  them  incomplete  hemiplegia,  that  lasted 
an  hour.     The  patient  was  not  unconscious  during  the  attack. 

She  was  safely  delivered,  but  two  months  subsequently,  and  this  time 
during  the  night,  she  had  another  attack,  which  recurred  three  weeks  later, 
consisted  of  several  fits,  and  lasted  from  half  an  hour  to  an  hour.  The 
seizures  returned  after  this  every  week  at  first,  and  then  every  day.    From 

*  De  l'albuminurie  puerperale  et  de  ses  rapports  avec  l'eclampsie  (Memoires  de 
l'Academie  royale  de  Medecine.     Paris,  1856,  t.  xx). 


812      ECLAMPSIA    OF    PREGNANT    AND    PARTURIENT    WOMEN. 

December  28th  or  30th,  1845,  to  January  16th,  1846,  when  I  saw  her,  the 
attacks  had  returned  nearly  without  intermission,  and  from  that  time,  also, 
the  left  arm  and  leg  had  been  paralyzed.  She  complained  of  having,  in 
the  affected  limbs,  a  sensation  unattended  with  pain,  but  which  she  com- 
pared to  "something  running  over  her  leg;"  the  convulsions  then  began, 
first  in  the  foot,  then  gradually  extending  up  to  the  trunk,  involving  the 
arm  and  even  the  muscles  of  the  face  ;  at  other  times,  they  spread  from 
above  downwards ;  and  at  other  times,  again,  they  were  limited  to  the  face. 

They  consisted  at  first  in  tetanic  rigidity  and  distortion  of  the  affected 
limbs,  almost  immediately  followed  by  convulsive  jerks,  and  the  paroxysm 
terminated  in  relaxation.  Meanwhile,  her  health  was  good;  she  had  a  good 
appetite,  and  I  could  not  find  any  other  symptom  of  local  disease  either  in 
the  brain  or  in  the  thoracic  or  abdominal  organs. 

Perhaps  you  will  think,  gentlemen,  that  the  only  connection  which  these 
seizures  had  with  eclampsia  was  their  having  come  on  for  the  first  time 
during  pregnancy,  and  that  they  did  not  resemble  puerperal  convulsions, 
their  form  reminding  one  rather  of  partial  epilepsy  preceded  by  an  aura. 
T  will  observe  to  you,  however,  that  although  they  were  epileptiform,  these 
attacks  differed  essentially  from  epileptic  fits  in  their  mode  of  invasion  and 
their  course. 

The  patient  remained  in  the  hospital  until  the  following  March.  She 
was  given  strychnine  at  first,  but  narcotics  were  soon  substituted  for  it, 
chiefly  belladonna,  which  was  given  at  once  in  3-grain  doses.  The  con- 
vulsive seizures  gradually  diminished  in  violence  and  frecpuency,  and  ceased 
completely  by  the  24th  of  February.  The  paralysis  lasted  longer ;  from 
the  beginning  of  March,  there  was  only  a  little  numbness  in  the  affected 
parts,  and  when  she  was  discharged  on  March  20th,  she  had  seemed  to  be 
perfectly  cured  for  several  days  previously. 

To  those  who  might  regard  this  case  as  a  kind  of  chorea,  I  will  answer, 
that  St.  Vitus's  dance  presents  neither  this  form  nor  this  course  ;  that  the 
same  may  be  said  of  chorea,  or,  if  you  prefer,  of  hysterical  trembling :  lastly, 
that  if  the  case  cannot  be  absolutely  regarded  as  an  instance  of  partial 
eclampsia,  it  cannot  be  referred  to  a  well-defined  nosological  species,  and 
can,  therefore,  be  mentioned  in  connection  with  convulsions  occurring  in 
pregnant  women. 

But  I  must  return  to  the  case  of  the  woman  in  St.  Bernard  Ward.  After 
her  attacks  of  eclampsia,  the  last  of  which  occurred  on  September  lltb.  she 
remained  for  48  hours  in  a  state  of  profound  coma;  on  the  13th,  during  the 
night,  she  became  delirious,  and  was  so  restless  that  she  had  to  be  confined 
with  a  strait-jacket. 

From  the  16th  to  the  20th  she  was  well,  and  seemed  to  have  calmed  down, 
there  only  remaining  hebetude,  which  had  persisted,  when  on  the  21st, 
during  my  visit,  she  had  an  attack  of  acute  mania.  She  began  calling  out. 
on  a  sudden,  "  My  daughter!  my  daughter!"  with  eves  brighl  with  excite- 
ment, and  asking  for  Iter  child,  who  had  been  taken  away  from  her.  She 
seemed  to  be  unconscious  of  what  she  was  saying  or  doing,  and  still  bad  the 
look  of  hebetude  which  had  never  left  her  Prom  the  beginning.  On  my 
ward  being  cleared  out  in  order  to  be  cleaned,  the  patient  was  removed  into 
another  ward,  under  another  physician's  care,  and  soon  recovered. 

Mania  is  a  pretty  common  result  of  eclampsia,  and  there  are  instances. on 

record  in  which  the  unfortunate  women  have  continued  in  that  state  of 
maniacal  delirium,  and  sometimes  of  more  or  less  complete  dementia. 
Generally,  after  an  attack,  the  intellectual  faculties  are  disordered  for  a 
longer  or  shorter  period  ;  memory  is  particularly  impaired,  and  sometimes 
lost  completely,  and  the  patients  have  no  recollection,  for  several  days,  not 


ECLAMPSIA    OF    PREGNANT    AND    PARTURIENT    WOMEN.      813 

only  of  the  seizure  which  they  have  just  had,  but  also  of  the  circumstances 
which  preceded  it.  The  loss  of  memory  is  sometimes  partial  only,  and 
relates  to  certain  subjects,  such  as  forgetting  the  names  of  certain  persons, 
even  of  those  whom  they  see  most  frequently  and  who  are  dearest  to  them. 

Paralysis  is  one  of  the  most  frequent  of  the  unpleasant  sequelae  of  eclamp- 
sia, and  it  may  be  due  to  an  organic  lesion  of  the  brain,  such  as  hemorrhage 
into  the  meninges  or  the  substance  of  the  brain.  The  same  thing  happens 
here  as  in  epilepsy.  Note  that,  in  both  cases,  the  cerebral  congestion,  which 
is  sometimes  so  intense  as  to  result  in  hemorrhage,  is  no  more  the  cause  of 
the  puerperal  convulsions  than  it  is  that  of  the  epilej)tic  fit;  it  is  an  effect, 
and  nothing  more. 

I  therefore  do  not  include  in  the  treatment  of  eclampsia,  general  or  local 
bleeding,  intended  to  do  away  with  this  pretended  cause  of  puerperal  con- 
vulsions, no  more  than  I  advise  them  in  epilepsy  or  in  the  eclampsia  of 
children. 

Antispasmodics  are,  on  the  contrary,  formally  indicated  in  such  cases, 
and  chloroform  inhalations  rank  first  among  them.  There  are  already  a 
pretty  large  number  of  cases  in  which  chloroform  has  unquestionably  done 
good.  By  its  cautious  use  several  times  in  succession,  violent  attacks  have 
been  known  to  be  completely  arrested,  and  convalescence  to  begin  imme- 
diately. I  shall  mention  in  connection  with  this  point  cases  published  by 
M.  Gros  in  the  Bulletin  General  de  Therapeutique,  for  January,  1849,  which 
you  will  read  with  profit;  and  others,  by  M.  Richet,  in  another  periodical; 
while  Dr.  Campbell  only  recently  communicated  to  me,  among  other  cases 
which  have  come  under  his  personal  observation,  the  marvellous  results 
which  he  had  obtained  by  this  method  of  treatment  in  the  instance  of  a 
child,  the  daughter  of  a  very  high  personage  in  the  state.  I  will  add,  that 
many  eminent  accoucheurs  (among  whom  I  shall  mention  M.  Blot  by  name), 
who  had  long  opposed  the  use  of  chloroform  in  the  treatment  of  eclampsia 
occurring  during  labor,  now  acknowledge,  and  strongly  advocate,  the  use 
of  this  heroic  remedy. 

I  will,  in  conclusion,  remind  you  that  when  eclampsia  comes  on  in  the 
eighth  or  ninth  month  of  pregnancy,  and  has  resisted  all  treatment,  the 
induction  of  premature  labor  is  adopted  by  most  accoucheurs,  a  measure 
recommended  by  Stoltz,  and  approved  of  by  men  of  the  highest  authority, 
among  whom  1  need  only  mention  Professor  Velpeau  and  Dr.  Cazeaux. 
When  eclampsia  occurs  during  labor,  delivery  should  be  hastened,  if  the 
attacks  be  violent,  in  order  to  save  the  mother  and  the  child  from  the 
danger  w7hich  they  incur.  Still,  gentlemen,  although  the  convulsions  cease 
soon  after  delivery  in  the  majority  of  instances,  they  continue  to  recur  with 
renewed  intensity  in  some  cases,  and  quickly  terminate,  fatally. 


814  ON    TETANY. 


LECTURE   XLV. 

ON  TETANY. 

Causes :  the  most  Frequent  are  Nursing  and  the  Puerperal  State ;  Influence  of 
Antecedent  Diarrhoea  ;  Effect  of  Cold. — Description  of  the  Disease :  Three 
Arbitrary  Forms. — Mild  Form :  Local  Manifestations  are  alone  Present, 
and  the  Symptoms  are  very  Slight. — Intermediate  Form :  the  Contractions 
become  General,  and  Sjoread  from  the  Extremities  to  the  Muscles  of  the 
Trunk  and  Face,  while  General  Symptoms  are  Superadded  to  them. — 
Grave  Form:  Violence  of  the  Convulsions. — A  Fatal  Case.- — Prognosis 
generally  not  Grave.  Pathological  Anatomy  very  little  known.  Nature 
of  the  Disease. — Differential  Diagnosis. — Treatment. 

Gentlemen  :  I  shall  devote  this  conference  to  the  clinical  study  of  a 
strange  complaint  of  which  I  have  had  the  opportunity  of  showing  you 
instances  in  my  wards  ;  and  which  has  been  in  turn  called  intermittent 
tetanus,  idiopathic  contraction  and  paralysis,  idiopathic  muscular  spasm,  con- 
traction of  the  extremities,  and,  which  I  myself  called  at  one  time,  rheumatic 
contraction  of  nurses,  but  prefer  calling  now,  for  reasons  which  I  shall 
presently  tell  you,  intermittent  rheumatic  contractions,  and  still  better  tetany. 

This  complaint  is  in  general  of  no  gravity,  although  it  sometimes 
frightens  the  patients  who  suffer  from  it,  and  misleads  medical  men  who  do 
not  recognize  it ;  and  it  is  developed  under  circumstances  which  are  so  fre- 
quently met  with,  and  under  the  influence  of  such  common  causes,  that  it 
must  have  always  existed.  Yet,  whether  it  was  unobserved,  or  rather 
whether  the  phenomena  which  characterize  it  were  confounded  with  other 
forms  of  convulsive  disorders,  there  is  no  description  of  it  to  be  found  in  old 
writers;  and  we  scarcely  find,  scattered  through  their  writings,  a  few  cases 
presenting  some  analogy  to  those  which  we  observe  nowadays.  The  his- 
tory of  tetany  dates,  therefore,  from  our  own  time ;  and,  indeed,  it  is  only 
for  the  last  thirty  years,  and  especially  for  the  last  few  years,  that  attention 
has  been  particularly  directed  to  it. 

In  1831,  a  memoir  was  published  by  Dance,  in  the  Archives  (ienerales 
dc  Medecine,  with  this  title:  "Observations  sur  une  espiVe  de  tetanos 
intermittent"  ("  Observations  on  a  form  of  intermittent  tetanus").  It 
was  the  first  essay  on  flic  subject,  and  was  soon  followed  by  memoirs 
written  by  Tonneie,*  ( !onstant,"|"  Murdoch, J  and  He  la  Berge.§  Since  then 
tetany  had  henceforth  a  place  assigned  to  it  in  text-hooks;  or  at  leasl 
Rilliet  and  Barthez,  in  their  special  treatises  on   Diseases  of  Children,  and 

Monnerel  and  De  la  Berge,  in  the  "  Compendium  of  Practical  Medicine,'' 

*  Mi'iimirc  sur  une  nouvelle  nialadie  convulsive  dea  enfants.  [<J«zeM<  MSdicnle, 
t   iii,  No.  1,  1882.] 

|  "  Observations  et  reflexions  sur  lee  contractures  essentielles."  |  Oa  ette  Midi- 
cate,  p.  80,  1882;  el  Bulletin  '/*■  Therapeutique,  1885.] 

+  "Considerations  sur  les  retractions  musculaires  el  spasmodiqucs."  [Journal 
Hebdomadaire,  t.  viii,  is:;--!,  p.  I17.| 

#  "Note  Mir  certaines  retractions  musculaires  de  courte  duree,"'  &c.  [Journal 
Hebdnmadaire  des  Progria,  &c,  t.  iv,  1686.] 


ON    TETANY.  >  815 

devoted  important  articles  to  it.  In  1843  a  memoir  was  published  in  the 
"Journal  de  Medecine,"  by  Messrs.  Teissier  and  Hermel,  on  Idiopathic 
contraction  and  paralysis  in  adults  ("De  la  contracture  et  de  la  paralysie 
idiopathiques  chez  les  adultes")  ;  and  in  the  following  year,  Dr.  Imbert- 
Gourbeyre,  now  Professor  in  the  Preparatory  Medical  School  at  Clermont- 
Ferrand,  chose  for  the  subject  of  his  inaugural  address,  "  De  la  Contracture 
des  Extremites  "  (Contraction  of  the  Extremities).  Numerous  cases  had 
been  observed,  several  of  which  had  been  published  in  various  medical 
journals  ;  and  I  had  myself  collected  a  pretty  imposing  number  of  them  at 
the  Necker  Hospital  when,  in  1846,  my  friend  Dr.  Delpech,  then  my  clini- 
cal assistant,  now  my  colleague,  and  Assistant  Professor  in  the  Faculty  of 
Medicine,  wrote  a  thesis  on  "  Idiopathic  Muscular  Spasms,"  in  which  he 
summed  up  with  talent  all  that  had  been  done  before,  and  added  other 
cases  to  those  already  known.  Six  years  later,  Dr.  Lucien  Corvisart  took 
up  the  same  subject,  and  proposed  the  name  of  Tetany  as  a  substitute  for 
that  of  Contraction  of  'the  Extremities. 

In  1855,  a  communication  from  Aran  to  the  Medical  Society  of  the 
Paris  Hospitals  gave  rise  to  an  interesting  discussion  on  the  disease  in 
question.  Lastly,  still  more  recently,  Dr.  Rabaud,  house-physician  to  the 
St.  Antoine  Hospital,  published  his  Recherches  sur  l'Histoire  et  les  Causes 
des  Contractures  des  Extremites.  The  author  of  this  monograph,  however 
(which  is  lengthy  and  conscientiously  written),  committed  the  great  fault 
of  confounding  together  all  kinds  of  contraction. 

The  complaint  of  which  I  am  going  to  speak,  constitutes  a  very  distinct 
species.  The  conditions  under  which  it  is  developed,  the  causes  which  seem 
to  bring  it  on,  the  form  which  it  assumes,  and  its  course,  are  all  of  them 
well-defined  characters. 

As  the  first  cases  which  I  saw  at  the  Necker  Hospital  occurred  in  women 
Tvho  had  been  recently  confined  and  who  were  nursing,  I  at  first  thought 
that  the  disease  was  special  to  nurses,  and  I  therefore  called  it  Rheumatic 
Contraction  occurring  in  Nurses ;  but  it  was  not  long  before  I  found  out, 
what  others  had  besides  said  before  me,  namely,  that  nursing  was  not  the 
only  favorable  condition  for  its  development. 

It  must  be  acknowledged,  however,  that  nursing  is,  perhaps,  the  most 
frequent  and  active  cause  of  intermittent  contractions.  I  shall  not  attempt 
to  explain  why  and  how  this  is  so  ;  but  clinical  experience  establishes  the 
fact,  and,  judging  from  what  happens  under  our  own  eyes,  its  influence  is 
unquestionable,  since  in  that  portion  of  St.  Bernard  Ward  which  is  reserved 
for  wet-nurses,  and  contains  twelve  beds  only,  we  have  always  seen  a  greater 
number  of  cases  of  this  complaint  than  in  all  the  other  wards. 

Menstruation,  the  puerperal  state,  and  pregnancy  especially,  have  been 
ascribed  as  causes ;  and  one  may  admit  that  there  is  a  connection  between 
the  phenomena  of  tetany  and  other  nervous  disorders  which  are  so  fre- 
quently met  with  in  those  intermediate  conditions  between  health  and  dis- 
ease; yet  contractions  occur  not  only  in  women  apart  from  such  conditions, 
but  even  in  individuals  of  the  other  sex. 

They  most  commonly  occur  in  young  people,  and  in  the  majority  of  my 
cases,  the  patients'  age  ranged  from  17  to  30.  A  woman,  however,  who 
was  in  bed  No.  20,  in  St.  Bernard  Ward,  was  46  years  old.  She  had  been 
delivered  two  months  previously,  and  the  symptoms  in  her  case  were  rather 
marked.  Instances  of  individuals  thus  affected  are  on  record,  who  were 
52  and  even  60  years  old.  It  is  not  uncommon  to  see  the  complaint  in 
children,  and  even  in  infants  from  1  to  2  years  old  ;  and  you  may  recollect 
seeing  a  very  remarkable  case,  that  of  a  little  girl  21  months  old. 

She  was  the  eighth  child  of  a  woman  asred  30.     Soon  after  birth  she  had 


816  ON    TETANY". 

violent  attacks  of  eclampsia,  and  was  still  subject  to  partial  convulsions, 
consisting  in  spasmodic  trembling  of  the  upper  eyelid  and  the  globe  of  the 
eye ;  sometimes  in  spasm  of  the  glottis,  which  came  on  under  the  influence 
of  emotion  or  of  a  feeling  of  annoyance,  and  was  characterized  by  a  pro- 
longed and  whistling  inspiration.  Contractions  of  the  extremities  (phe- 
nomena of  the  same  nature  as  the  preceding)  were  very  marked  ;  the 
thumb  was  forcibly  adducted,  and  flexed  into  the  palm  of  the  hand  under- 
neath the  fingers,  which  were  pressed  against  one  another.  There  was 
oedema  of  the  feet  and  of  the  upper  limbs  of  the  same  degree.  The  child 
was  of  weakly  constitution,  and  was  suffering  from  membranous  ulcerative 
stomatitis  ;  the  exudations,  which  were  of  a  grayish-white  color,  extended 
over  her  toDgue  ;  and  she  had  also  had,  for  the  last  nine  months,  a  cough, 
which  for  some  time  past  had  assumed  a  convulsive  character. 

The  process  of  teething,  which  so  manifestly  predisposes,  either  directly 
or  indirectly,  to  convulsions,  has  been  regarded  as  exerting  an  influence 
also  on  the  development  of  tetany.  But  it  may  be  Conceived  how  difficult 
it  is  to  appreciate  such  a  cause  as  this,  particularly  as  it  is  nearly  always 
complicated  with  various  pathological  conditions,  on  which  tetany  would 
seem  rather  to  depend. 

Of  these  pathological  conditions,  diarrhoea,  especially  when  abundant 
and  chronic,  is  the  one  which  exerts  the  most  striking  influence.  This 
exciting  cause  had  at  first  completely  escaped  my  attention.  My  friend 
Dr.  Lasegue  was  the  first  who  clearly  pointed  it  out,  and  since  then  it  has 
been  mentioned  by  others,  especially  by  Aran.  Its  influence  is  now  admit- 
ted by  all  practitioners  in  the  majority  of  cases,  and  you  have  been  able 
yourselves,  by  questioning  the  patients,  to  ascertain  that  it  is  almost  con- 
stantly present. 

Yet  in  a  young  man  who  was  in  St.  Agnes  Ward,  contractions  coexisted 
with  obstinate  constipation,  and  disappeared,  on  the  contrary,  when  the' 
bowels  were  freely  acted  on  by  purgatives. 

This  patient  was  stout  and  well  developed,  a  saddler  by  trade,  and  21 
years  of  age;  he  remained  in  hospital  about  five  weeks.  His  complaint 
dated  four  years  back.  His  health  had  been  good  until  then,  and  he  was 
seized  suddenly,  and  for  the  first  time,  while  travelling  by  rail.  Although 
it  was  winter-time,  he  affirmed  that  he  had  not  caught  cold.  He  noticed 
suddenly  that  his  fingers  kept  bent,  and  that  he  could  not  extend  and  use 
them.  This  lasted  for  two  or  three  hours,  and  recurred  every  day  for  three 
months,  his  general  health  being,  after  all,  unaffected.  He  was  treated  by 
bleedings,  but  immediately  after  each  bleeding  the  contractions  were  not 
only  more  violent,  but  became  general  also,  involving  the  muscles  of  the 
limbs,  trunk,  and  face,  to  such  a  degree  that  his  respiration  was  impeded 
and  his  speech  embarrassed.  In  proportion  also  as  the  bleedings  were 
repeated,  the  fits  became  more  violent,  so  much  so,  that  they  were  nev< 
bad  as  after  the  fourth  time  of  bleeding.  Yet,  by  cupping  him  in  twelve 
different  places  along  the  vertebral  column,  a  perfectly  different  result  was 
obtained,  for  the  contractions  disappeared  for  the  period  of  ten  months. 
After  that  time  they  returned,  and  then  recurred  every  year,  coming  on 
every  day  for  two  months,  ami  always  at  the  end  of  winter.  During  the 
summer  previous  to  his  admission  into  the  hospital,  be  bad  two  or  three 
attacks,  transient  only,  and  so  Blight  that  he  was  not  obliged  t<>  give  up  his 
occupation.  His  general  health  was  good  all  the  while;  he  hail  a  j 
appetite;  but  1  wish  t"  draw  your  attention  to  the  fact,  thai  bis  bowels, 
instead  of  being  regular  as  formerly,  were  obstinately  costive.  By  taking 
nearly  two  ounces  of  Epsom-salts,  once  a  week,  he  managed  t<>  unload  his 
bowels,  and  thus  to  remove  his  contraction-  for  a  time;  but  the  costivenees 


ON    TETANY.  817 

returned  as  badly  as  ever,  and  his  bowels  did  not  act  for  four  or  five 
days. 

This  is  too  exceptional  a  case  to  invalidate  in  the  least  the  general  law 
which  may  be  laid  dowu  regarding  the  influence  of  diarrhoea  on  the 
production  of  intermittent  contractions. 

These  may  come  on  also  after  a  severe  illness,  and  in  the  cholera  epidemic 
of  1854,  I  met  with  many  cases  in  individuals  who  had  suffered  from 
cholera.  They  may  occur  after  grave  fevers,  as  typhoid  fever  in  particular, 
as  M.  Demarquay  (quoted  by  M.  Imbert-Gourbeyre)  and  Dr.  Delpech 
have  recorded  instances. 

Perhaps  some  may  ascribe  the  disease  in  such  cases  to  the  intestinal  flux, 
which  is  such  a  predominating  symptom  in  cholera  and  typhoid  fever;  but 
1  will  remind  them  in  answer,  that  contractions  occur  equally,  although 
less  frequently,  in  individuals  who  are  convalescent  from  diseases  in  which 
diarrhoea  is  not  a  usual  symptom,  or,  in  which  it  is  only  a  temporary  epi- 
phenomenon  of  no  great  value ;  and  that  the  muscular  spasms  must  there- 
fore be  more  justly  regarded  as  accidents  of  the  same  nature  as  the  nervous 
phenomena,  the  paralysis,  &c,  which  prolonged  illness  (grave  fevers  espe- 
cially) leave  behind  them,  and  which  result  either  from  a  direct  action  of 
the  morbid  cause  on  the  nervous  centres,  or  from  the  nervous  erethism 
which  coexists  with  general  enfeeblement  of  the  system. 

Besides  the  above  predisposing  causes,  there  are  some  exciting  ones  which 
I  shall  point  out  to  you.  The  influence  of  emotion,  mentioned  by  authors, 
is  very  doubtful,  in  my  opinion,  at  least  as  far  as  the  first  attack  is  con- 
cerned; for  I  admit  that  when  a  person  is  already  subject  to  contractions, 
emotion  may  bring  back  an  attack. 

A  woman,  21  years  old,  who  was  in  bed  No.  11  in  St.  Bernard  Ward, 
and  who  was  seized  with  contractions  in  the  fifth  month  of  her  pregnancy, 
had  more  violent  attacks  when  under  the  influence  of  emotion. 

If  this  kind  of  causes  should  not  be  accepted  without  reserve,  the  same 
does  not  apply  to  cold,  the  influence  of  which  has  been  pointed  out  by  all 
observers,  and  which  uncjuestionably  acts  not  only  as  an  exciting  cause, 
but  is  sufficient  by  itself  to  bring  on  the  disease. 

I  will  relate  a  few  instances  in  point.  A  patient  in  St.  Agnes  Ward 
ascribed  his  complaint  to  his  catching  cold  on  going  out  one  December  day 
too  thinly  clad  for  the  season,  and  he  had  felt  the  cold  all  the  more  keenly, 
that  he  was  in  the  habit  of  working  in  a  very  heated  room. 

Another,  at  No.  23  in  the  same  ward,  haol  spent  the  night  out  of  doors  in 
a  state  of  drunkenness,  and  had  been  founol  the  next  morning  in  the  state 
in  which  he  was  sent  to  the  hospital  from  the  police-station. 

A  woman,  to  whose  case  I  shall  revert  by  and  by,  was  seized  with  con- 
tractions after  having,  during  winter  nights,  fetched  water  from  the  hospital 
yard.  The  cold  had  great  influence  on  her,  because  she  had  been  recently 
confined  prematurely,  was  weakened  by  poverty,  and  by  an  obstinate  diar- 
rhoea which  had  scarcely  left  her. 

Lastly,  when  I  describe  to  you  the  phenomena  which  characterize  con- 
tractions, I  shall  show  you  that  compression  of  the  affected  limb  brings  them 
on  very  rapidly  and  without  fail. 

It  is  no  easy  task  to  draw  a  sketch  of  this  complaint,  and  the  best  de- 
scription cannot  give  you  an  idea  of  what  you  could  not  forget  when  you 
had  once  seen  it.  I  will  still  endeavor  to  give  you  as  accurate  an  idea  of 
it  as  possible,  and  in  order  to  enable  you  to  see  its  principal  features  better, 
I  shall  speak  of  three  distinct  forms  of  the  disease,  although  these  divisions 
are  in  reality  quite  arbitrary. 

vol.  i. — 52 


818  OX    TETANY. 

In  the  first  form,  which  I  will  call  the  mild  form,  there  are  only  local 
manifestations,  and  they  are  as  follows  : 

The  person  has  a  sensation  of  tingling  in  the  hands  and  feet,  and  then 
feels  some  hesitation,  some  impediment  in  the  movements  of  his  fingers  and 
toes,  which  are  not  as  free  as  usual.  Tonic  convulsions  then  set  in,  the 
affected  limbs  become  stiff,  and  the  will  cannot  completely  overcome  this 
stiffness,  although  it  still  struggles  with  it,  and  the  patient  can  still  use, 
within  certain  limits,  the  contracted  muscles,  move  and  even  extend  his 
fingers.  The  involuntary  contraction  increases,  becomes  painful,  and  is 
exactly  like  a  cramp  to  which  the  patient  compares  it  besides. 

In  the  upper  limbs,  the  thumb  is  forcibly  and  violently  addueted ;  the 
fingers  are  pressed  closely  together,  and  semi-flexed  over  the  thumb  in  con- 
sequence of  the  flexion  of  the  metacarpophalangeal  articulation  ;  and  the 
palm  of  the  hand  being  made  hollow  by  the  approximation  of  its  outer  and 
inner  margins,  the  hand  assumes  a  cpnical  shape,  or  better  the  shape  which 
the  accoucheur  gives  to  it  when  introducing  it  into  the  vagina.  This  aspect 
of  the  band,  which  you  will  most  frequently  meet  with,  is  so  peculiar  that 
it  is  oftentimes  sufficient  by  itself  to  characterize  this  kind  of  contraction. 
In  some  cases  the  index-finger  is  more  powerfully  flexed  than  the  other  fin- 
gers, and  is  partially  bent  under  them ;  in  other  cases,  the  flexion  is  more 
general  and  complete.  The  thumb  is  turned  into  the  palm  and  hidden  by 
the  fingers,  which  are  themselves  bent,  and  with  such  force  that  the  nails 
leave  an  imprint  on  the  skin ;  and  they  are  so  squeezed  together,  that  in  a 
case  recorded  by  Dr.  Herard,  sloughs  actually  resulted  from  the  prolonged 
pressure.  The  thumb  alone  may  be  affected,  while  the  fingers  are  scarcely 
contracted ;  but  such  cases  are  rare,  and  it  more  commonly  happens  that 
the  contractions  spread  to  other  parts,  the  wrist  becoming  flexed,  and  the 
hand  turning  forcibly  inwards,  the  patient  having  lost  the  ptower  of  straight- 
ening it. 

In  the  lower  limbs,  the  toes  are  bent  down  towards  the  sole,  and  press 
against  one  another,  while  the  big  toe  turns  in  under  them,  and  the  sole 
becomes  hollowed  out  in  the  same  manner  as  the  hand.  The  dorsum  of  the 
foot  is  strongly  arched,  and  the  heel  pulled  up  by  the  contracted  muscles 
at  the  back  of  the  leg,  while  the  leg  itself  and  the  thigh  are  in  a  state  of 
extension.  The  contractions  may  affect  the  upper  and  lower  limbs  simul- 
taneously, or  alternately;  or  they  may  be  confined  to  one  of  them.  In  ex- 
ceptional cases  the  lower  limbs  are  alone  involved,  while  most  commonly  the 
hands  are  the  parts  that  are  affected.  The  convulsed  muscles  resist  the 
efforts  that  are  made  to  alter  the  position  which  they  make  the  part-  assume; 
and  if  their  resistance  be  overcome,  the  fingers  bend  again  as  soon  as  they 
are  let  free,  or,  in  exceptional  eases,  they  keep  the  last  position  in  which 
they  are  placed,  although  remaining  contracted  all  the  while.  To  the  touch 
the  muscles  feel  more  or  less  bard,  like  tense  and  rigid  ropes;  but  I  have 
never,  for  my  part,  felt  the  fibrillary  contractions  which  have  lien  spoken 
of  by  some.  The  efforts  made  to  overcome  their  resistance  give  the  patient 
pain,  although  some  relief  is  thus  procured  in  certain  cases. 

These  tonic  convulsions  last  uninterruptedly  for  live.  ten.  or  fifteen  min- 
utes, and  sometimes  even  one.  two,  and  three  hours  in  succession  :  tli 
sation  of  formication  then  returns,  and  announces  the  termination  of  tin' 
attack  in  the  same  manner  a-  it  ushered  it  in.  The  affected  parte  become 
movable  again,  until,  after  a  variable  interval  of  rest,  fresh  paroxysms 
recur,  the  series  of  which  constitutes  the  attack,  which  may  be  prolonged 
for  several  days,  and  even  for  one.  two.  and  three  months.  So  long  a-  the 
attack  i-  not  over,  the  paroxysms  may  l.e  reproduced  at  will,  even  though 
the  patient  ha-  been  free  from  them  lor  24,  ■';<'>.   Is.  Tli  hours,  and  more. 


ON    TETANY.  819 

This  is  effected  by  simply  compressing  the  affected  purts,  either  in  the  direc- 
tion of  their  principal  ■ncrtr-trniik*,  or  over  their  bloodvessels,  so  as  to  impede 
the  venous  or  arterial  circulation. 

I  discovered  this  influence  of  pressure  by  chance.  I  was  present  when  a 
woman  suffering  from  contractions  was  being  bled  from  the  arm  at  the 
Necker  Hospital,  and  I  saw  a  paroxysm  return  in  the  hand  on  the  same 
side  when  the  bandage  was  applied  round  the  arm.  I  at  first  thought  that 
it  was  brought  on  by  the  venous  congestion  caused  by  the  pressure  on  the 
vein ;  but  on  trying  to  account  for  the  phenomenon,  I  found  in  other  pa- 
tients that  by  compressing  the  arteries,  the  same  results  were  produced.  I 
have  often  since  repeated  the  experiment,  and  as  the  contractions  cease  as 
soon  as  the  pressure  is  removed,  and  the  patient  is  therefore  not  much 
troubled,  I  have  often  made  it  in  your  presence.  You  saw  then,  that  not 
only  when  the  arterial  or  venous  circulation  was  interrupted,  but  also  when 
the  median  nerve  was  compressed  in  the  arm,  or  the  brachial  plexus  above 
the  clavicle,  the  contractions  came  on,  immediately  preceded  by  the  sensa- 
tion of  formication,  which  is  its  first  symptom.  AYhen  the  femoral  artery 
is  compressed,  as  when  a  ligature  is  applied  round  the  thigh,  or  when  the 
limb  is  firmly  squeezed  between  both  hands,  and  the  sciatic  nerve  thus  com- 
pressed, spasms  of  the  muscles  of  the  lower  extremities  are  brought  on, 
although  with  less  facility.  This  phenomenon,  which  is  already  interesting 
by  itself,  is  not  besides  without  its  practical  utility ;  for  it  furnishes  us  with 
a  means  of  diagnosis,  as  in  no  other  convulsive  disease  are  such  effects  pro- 
duced by  similar  means. 

It  is  an  extraordinary  circumstance  that  cold  (which  has  so  manifest  an 
influence  on  the  development  of  this  complaint)  should  sometimes  stop  the 
contractions  when  applied  to  the  affected  parts.  Thus  it  happens  that,  in  a 
great  many  cases,  patients  suffering  from  contractions  of  the  lower  limbs 
have  only  to  stand  with  naked  feet  on  a  stone  or  tiled  floor  in  order  to 
stop  the  convulsion  almost  instantly,  and  to  regain  the  free  use  of  their 
limbs.  I  have,  in  many  instances,  arrested  paroxysms  of  contraction  in 
the  upper  extremities,  by  making  the  patient  dip  his  arms  and  hands  into 
a  basin  of  cold  water.  The  arrest  is  only  temporary,  it  is  true,  and  the 
contraction  returns  when  the  part  is  no  longer  immersed. 

Intermittent  contractions  are  generally  preceded  and  accompanied  by 
loss  of  muscular  power.  Movements  of  extension  are  not  the  only  ones 
abolished  by  the  convulsive  contraction  of  the  muscles ;  those  of  flexion  are 
equally  so.  The  fingers,  for  instance,  when  half  flexed,  no  longer  obey  the 
will,  and  the  patient  cannot  close  them  further.  This  rigidity  is  sometimes, 
in  grave  cases,  carried  to  a  very  high  degree ;  but  even  when  it  is  slight,  as 
in  mild  cases,  and  is  added  to  the  convulsive  stiffness  of  the  hands,  it  ren- 
ders the  patients  clumsy,  and  prevents  them  from  freely  using  their  hands  ; 
if  they  are  nursing  at  the  time,  they  cannot  attend  to  the  child  in  the  usual 
way,  dress  or  even  hold  him  in  their  arms. 

There  is  anaesthesia  besides,  a-nd  the  sensations  of  formication,  tingling, 
and  numbness  are  referable  to  it.  The  sense  of  touch  is  more  or  less  im- 
paired, so  that  the  patients  lose  the  faculty  of  appreciating  the  size  and 
hardness  of  the  objects  which  they  take  hold  of,  and  which  feel  to  them  as 
if  wrapped  in  some  thick  material.  When  they  walk,  they  have  the  same 
sensation  as  if  they  were  walking  on  a  carpet.  Now  these  alterations  of 
cutaneous  sensibility,  the  integrity  of  which  is  so  necessary  for  the  regularity 
of  muscular  functions,  concur  in  impeding  movements. 

I  have  told  you  already  that  these  contractions  are  generally  attended 
with  pain,  which  is  seated  in  the  affected  muscles,  extends  along  the  course 
of  the  limbs  in  the  direction  of  the  principal  nerves,  and  radiate  sometimes 


820  ON    TETANY. 

to  the  trunk.  This  pain,  the  presence  of  which  by  no  means  excludes 
ansesthesia,  is  often  very  moderate  in  the  mild  form  of  the  complaint ;  and 
as,  on  the  other  hand,  the  convulsive  phenomena  are  often  very  transitory, 
the  result  is  that  the  patient  does  not  complain,  and,  in  some  instances, 
chance  alone  makes  us  discover  their  ailment.  This  was  the  case,  among 
others,  with  a  woman  who  occupied  bed  20  in  St.  Bernard  Ward.  She  was 
admitted  into  the  hospital  for  a  diarrhoea  of  somewhat  old  date  ;  and  if  I 
had  not,  on  going  round  the  ward,  witnessed  myself  an  attack  of  contrac- 
tion in  her  hands,  she  would  never  have  thought  of  complaining  of  an 
ailment  of  which  she  took  no  notice  whatever. 

The  case  is  perfectly  different  in  the  other  two  form's. 

In  that  of  medium  intensity,  the  violence  of  the  pain  and  of  the  spasm 
is  more  marked ;  and  the  local  manifestations  are,  besides,  complicated 
with  general  symptoms,  such  as  febrile  excitement  characterized  by  an  ac- 
celeration of  the  pulse,  malaise,  cephalalgia,  and  loss  of  appetite.  The 
fever,  however,  never  runs  very  high,  and  is  never  accompanied  by  a 
marked  heat  of  skin.  Transient  congestion  happens  in  different  parts  of 
the  body — in  the  limbs,  the  face,  the  eyes,  and  ears ;  sometimes  they  are 
accompanied  by  dizziness,  obnubilatio,  and  tinnitus  aurium. 

This  congestive  process  sometimes  causes  swelling  and  cedematous  pufhness 
of  the  limbs,  which  have  been  mentioned  in  several  cases,  principally  in 
children.  As  to  the  contractions  themselves,  they  are  not  only  stronger 
than  in  the  mild  form,  and  return  more  frequently,  but  they  are  general 
also,  instead  of  being  confined  to  the  extremities,  and  involve  the  muscles 
of  the  trunk  and  face,  and  sometimes  also  those  of  organic  life. 

The  spasms  do  not,  as  a  rule,  involve  simultaneously  the  muscles  of  the 
trunk  and  extremities.  The  upper  extremities  are  generally  the  first  to  be 
affected,  and  while  the  antecedent  numbness  and  formication  descended 
from  the  arm  to  the  hand,  the  convulsions,  following  a  reverse  course, 
begin  in  the  fingers,  and  successively  extend  to  the  wrist  and  elbow.  The 
lower  limbs  are  rarely  seized  before  the  upper.  From  the  extremities,  the 
contractions  spread  to  other  portions  of  the  body,  and  the  short  time  dur- 
ing which  they  last  in  a  given  part,  in  fact,  the  mobility  of  the  complaint, 
is  a  character  of  which  I  shall  make  use  when  I  come  to  speak  of  its  na- 
ture. 

The  abdominal  muscles  may  be  affected,  and,  in  a  case  published  by  Dr. 
Herard,  the  recti  muscles  stood  out  like  two  very  tense  cords.  Instances 
have  also  been  recorded  in  which  the  spasm  has  extended  to  the  bladder, 
and  caused  retention  of  urine.  The  pectorales  majores  and  sterno-cleido- 
mastoidei  have  been  seen  to  contract  violently,  and  it  is  not  uncommon  to 
see  tonic  convulsions  of  the  lace.  The  patient's  aspect  is  then  very  peculiar, 
according  to  the  set  of  muscles  which  arc  affected  ;  when  the  muscles  of  the 
eyeball  arc  convulsed,  strabismus  results,  either  external  or  internal — that 
is, divergent  or  convergent.  At  other  times  the  jaws  are  firmly  clenched,  and 
the  embarrassment  of  speech  may  also  be  due  to  the  tongue  being  involved. 
Deglutition  is  impeded  when  the  pharynx  is  affected,  and  when  the  larynx 
is  involved,  the  series  of  symptoms  of  thymic  asthma  are  produced,  as  in 

the  case  of  the  little  girl  which   I   related   at    the  beginning  of  the    lecture. 

The  laryngeal  spasm,  and  the  contraction  of  the  muscles  of  the  abdomen 
and  chest,  bring  on  more  or  less  marked  dyspnoea,  which  becomes  extreme 
when  the  diaphragm  is  involved. 

The  third  ami  grave  form  of  the  complaint  is  characterized  by  the  pro- 
Longed  duration  of  the  contractions,  their  recurrence  after  short  intervals, 
and  their  greater  intensity.  In  the  month  of  December,  1856,  my  colleague 
and  friend,  Dr.  Lasesue,  was  consulted  aboul  a  patient  who  was  believed 


ON    TETANY.  821 

to  be  epileptic,  at  the  Prefecture  of  Police,  where  he  goes  every  day,  as  he 
is  physician  to  the  department  for  the  insane  there.  The  patient  was  that 
young  man,  18  years  of  age,  whom  you  afterwards  saw  at  No.  13  in  8t. 
Agnes  Ward,  and  to  whose  case  I  have  already  alluded.  He  had  been 
found  in  the  morning  lying  down  in  the  streets,  where  he  had  spent  the 
night  in  a  state  of  drunkenness.  All  his  muscles  seemed  to  be  in  a  state  of 
violent  contraction,  and  he  was  as  stiff  as  a  poker:  he  was  perfectly  con- 
scious, however ;  aud  although  his  spceeh  was  considerably  embarrassed, 
through  his  inability  to  open  his  clenched  jaws,  he  gave  distinct  answers  to 
the  questions  that  were  put  to  him,  and  complained  of  great  pain.  The 
continuance  of  this  general  tonic  convulsion,  and  the  perfect  preservation 
of  the  intellect,  excluded  at  once  all  idea  of  apoplexy;  while  the  character 
of  the  symptoms,  and  especially  of  those  of  the  upper  limbs  (the  hands  being 
in  the  peculiar  attitude  which  I  have  endeavored  to  describe  to  you),  allowed 
Dr.  Lasegue  to  diagnose  the  case  immediately,  so  that  he  had  him  sent  to 
the  Hotel-Dieu.  The  interval  between  the  intermittent  paroxysms  was  very 
short.  All  his  muscles,  those  of  the  trunk  and  of  the  cervical  region,  as 
well  as  those  of  the  limbs,  seemed  to  be  simultaneously  affected,  and,  unable 
to  move  at  all,  the  patient  fell  down  in  a  condition  of  tetanic  rigidity.  The 
contractions  were  very  painful,  and  after  a  short  time  the  breathing  became 
embarrassed,  from  the  tonic  convulsion  of  the  muscles  of  the  chest,  abdo- 
men, and  diaphragm,  the  larynx  itself  not  being  spared.  The  face  became 
red,  and  the  lips  livid;  the  veins  swelled,  and,  during  this  fit  of  awful 
dyspnoea,  attended  with  pulmonary  engorgement,  as  in  epilepsy,  or  better 
as  in  tetanus,  suffocation  was  to  be  dreaded.  Fortunately,  this  state  of 
things  lasted  a  very  short  time  only. 

You  have  more  than  once  witnessed  these  attacks,  when  going  round  with 
me.  They  came  on  suddenly,  ushered  in  by  a  sensation  of  formication,  and 
lasted  several  minutes,  sometimes  for  a  quarter  of  an  hour,  or  even  half  an 
hour.  The  mind  of  the  unfortunate  patient  was  perfectly  clear,  and  he 
could  speak,  although  the  contracted  state  of  the  muscles  of  the  jaws  em- 
barrassed his  speech  considerably;  even  in  spite  of  his  pain  he  was  somewhat 
cheerful. 

When  the  attack  was  over,  he  got  out  of  bed  and  went  on  with  his  occu- 
pation, rendering  slight  services  to  his  companions,  and  acting  as  sick  at- 
tendant. In  the  intervals  between  the  attacks  his  general  health  seemed 
by  no  means  disturbed.  The  attacks,  however,  left  behind  them  lumbar 
pain  and  a  feeling  of  contusion  (in  the  joints  chiefly),  and  a  state  of  weak- 
ness and  prostration  which  lasted  for  some  time.  On  several  occasions  I 
noted  some  fever. 

The  seizures  became  by  degrees  more  rare,  and  after  remaining  a  month 
and  a  half  in  hospital  he  wished  to  go  home.  But  six  weeks  afterwards  he 
was  seized  in  the  same  manner  again,  and  was  readmitted  into  the  Hotel- 
Dieu,  under  the  care  of  my  esteemed  colleague,  Professor  Rostan,  in  whose 
ward  he  died  of  pulmonary  consumption.  The  tubercular  disease  remained 
latent  to  the  last,  and  was  not  revealed  by  stethoscopic  signs;  this  peculi- 
arity was  dwelt  upon  in  the  notes  given  me  of  this  patient's  case;  the  gen- 
eral debility,  cough,  and  habitual  dyspnoea  alone  caused  it  to  be  suspected. 
On  a  post-mortem  examination,  the  lungs  were  found  to  be  infiltrated  with 
tubercles,  and  the  spinal  cord  to  be  slightly  softened  at  its  upper  part. 

I  shall  return  to  this  case  presently,  when  I  tell  you  my  views  of  the 
nature  of  tetany,  and  speak  of  the  relations  between  it  and  the  anatomical 
lesions  which  have  been  found.  I  will  then  tell  you  that  the  convulsive 
seizures  in  this  case  were  by  no  means  due  to  the  tubercles,  of  which  no 
material  manifestation  was  found  in  the  nervous  centres,  and  that  the  soft- 


822  ON    TETANY. 

ening  of  the  cord  should  he  regarded  not  as  the  cause  but  an  effect  of  the 
disease.  I  shall  enter  into  explanations  on  this  point,  which  I  have  besides 
dwelt  upon  in  our  conferences  on  apoplexy  and  on  convulsions. 

I  do  not  admit  the  supposition  that  the  contractions  were  in  this  case 
due  to  the  tubercular  diathesis,  and  this  cannot  be  put  forward  in  the  fol- 
lowing case  observed,  in  M.  Cullerier's  wards,  by  Dr.  Blondeau,  whilst  a 
resident  assistant  at  Lourcine  Hospital. 

Elizabeth  B ,   aged  28,  was   admitted   January  20,  1848,  into  St. 

Mary's  Ward,  Xo.  32.  She  was  in  the  eighth  month  of  pregnancy,  and  was 
suffering  from  syphilis,  with  numerous  ulcerated  mucous  tubercles  in  the 
external  organs  of  generation.  She  had,  besides,  a  very  copious  and  obsti- 
nate diarrhoea.  She  was  in  a  state  of  considerable  weakness  and  maras- 
mus, and  on  February  13  she  was  delivered  of  a  stillborn  child.  Two  slight 
contractions  of  the  uterus,  which  were  scarcely  perceived,  were  sufficient  to 
expel  the  foetus.  The  diarrhoea  ceased  at  last,  on  the  administration  of 
nitrate  of  silver  injections.  It  was  completely  arrested  five  days  after  de- 
livery ;  the  appetite  became  good  again,  all  the  digestive  functions  regular, 
and  a  marked  improvement  of  the  general  condition  of  the  patient  was  ob- 
served from  day  to  clay.  She  had  even  regained  her  strength  and  a  certain 
amount  of  flesh,  when  she  was  seized,  on  February  27,  with  symptoms  which 
terminated  fatally. 

She  complained  in  the  morning  of  some  swelling  of  the  feet,  and  ex- 
pressed a  fear  that  she  might  be  again  paralyzed,  as  she  had  been  on  a  former 
occasion.  She  added,  however,  that  she  felt  well,  and  indeed,  apart  from 
this  slight  swelling  of  the  lower  limbs,  nothing  was  found  which  called  at- 
tention. On  the  following  night  she  had  a  violent  pain  in  the  head,  and 
the  next  morning  she  was  seized  with  tetany. 

Her  hands  and  feet  were  violently  convulsed,  and  her  fingers  and  toes 
semiflexed,  in  the  attitude  which  I  need  not  again  describe.  The  muscles 
were  so  contracted  that  all  efforts  to  overcome  their  resistance  proved  use- 
Less.  The  muscles  of  the  face  were  involved,  the  jaws  were  convulsively 
clenched,  and  speech  was  embarrassed.  The  patient,  however,  still  answered 
the  questions  that  were  put  to  her,  and  her  intellect  was  perfect ;  as  the 
nroscles  of  the  neck  and  chest  shared  in  this  general  convulsion,  respiration 
wa<  impeded,  and  the  face  red  and  congested. 

It  was  then  ascertained  that  the  patient  since  her  delivery,  and  even 
when  her  diarrhoea  had  scarcely  stopped,  had  on  several  occasions  got  out 
of  bed  during  the  night,  and  fetched  water  from  the  fountain  in  the  hospi- 
tal yard.  On  the  night  of  February  27  >he  again  committed  the  same 
imprudence,  and  it  was  after  this  that  the  symptoms,  which  were  already 
imminent  the  preceding  day,  manifested  themselves  with  awful  violence. 

She  looked  on  the  point  of  choking,  and  cerebral  congestion  was  also  t" 
he  dreaded.  She  was  immediately  bled  from  the  arm,  but  four  hours  after- 
wards Dr.  Blondeau  wa- miii  tor;  the  contractions  had  diminished  in  tin1 
limbs,  but  the  symptoms  had  become  worse'  in  regard  to  respiration.     The 

muscles  of  the  neck   and  face   were  more   violently  contracted    than  in    the 

morning;  the  livid  face,  the  fixed  eyes,  the  anxious  breathing  (which  hail 
already  become  stertorous),  the  uncountable  pulse,  pointed   to  asphyxia 

carried  to  the  highesl  degree,  and  to  imminent  death  ;  and  yet,  in  the  midst 
of  this   storm,   the    patient    seemed    to    retain    her   consciousness.        Twelve 

leeches  were  ordered  to  he  applied  behind  the  ears,  hut  two  or  three  had 

scarcely  taken  before  the  patient  died. 

( )n  making  a  post-mortem  examination,  all  the  viscera  were  examined 
with  the  greatesl  care,  and  no  other  appreciable  material  lesion  wa-  found 


ON    TETANY.  823 

than  traoes  of  congestion  in  the  meninges,  the  veins  of  which  contained  a 
little  more  dark  blood  than  usual. 

This  is  the  only  instance,  gentlemen,  in  which  I  have  known  idiopathic 
contractions  terminate  in  death,  for  the  young  man  whom  you  saw  in  one 
ot  my  wards,  and  who  subsequently  died  under  Dr.  Rostan's  care,  died  of 
tubercular  consumption  and  not  of  his  convulsive  affection. 

Notwithstanding  the  fatal  case  which  I  have  just  related  to  you,  the 
prognosis  of  tetany  is  not  grave.  Even  in  its  most  severe  forms,  when  the 
symptoms  have  sometimes  become  apparently  serious,  and  have  excited 
fears  that  death  might  occur,  I  have  never  seen  a  single  patient  die,  and  I 
have  by  this  time  seen  a  very  considerable  number  of  such  cases. 

After  the  complaint  has  lasted  a  variable  period,  from  several  days  to 
one,  two,  or  three  months,  the  patient  gets  well,  even  when  he  has  not  un- 
dergone treatment ;  and  the  attacks,  which  leave  behind  only  lumbago  and 
transient  weakness,  do  not  seem  to  affect  the  system  deeply,  or  to  impair 
the  general  health. 

Pathological  anatomy  has  necessarily  done  very  little  in  this  complaint ; 
but,  from  a  mere  review  of  the  symptoms,  it  is  impossible  to  admit  that 
such  mobile  and  transitory  phenomena  can  be  due  to  the  existence  of  se- 
rious organic  lesions.  Those  which  some  authors,  Dr.  Imbert-Gourbeyre 
among  others,  have  regarded  as  the  causes  of  idiopathic  contractions,  be- 
longed to  the  diseases  of  which  the  individuals  died,  and  in  the  course  of 
which  the  convulsions  had  developed  themselves.  Some  degree  of  cerebral 
congestion  was,  it  is  true,  found  in  the  woman  who  died  under  Mr.  Cul- 
lerier's  care;  but  it  was  an  effect  not  the  cause  of  the  convulsions,  or  rather 
of  the  asphyxia,  which  had  brought  on  death.  In  the  case  of  the  young  man 
who  had  been  in  my  wards,  the  softening  of  the  spinal  cord  was  itself  a 
secondary  change  analogous  to  those  met  with  in  convulsive  diseases — 
facts  to  which  I  have  sufficiently  called  your  attention  in  connection  with 
epilepsy. 

Intermittent  contractions  have,  therefore,  been  justly  classed  with  neu- 
roses, and  regarded  as  a  convulsive  neurosis,  like  epilepsy,  eclampsia,  and 
hysteria,  although  we  know  less  of  their  nature.  Yet  the  conditions  which 
are  favorable  for  their  development,  the  evident  influence  of  cold  on  their 
production,  the  suddenness  with  which  the  symptoms  that  characterize  them 
come  on,  the  mobile  and  flying  character  of  these,  the  intermission  between 
the  attacks,  induce  me  to  believe  that  they  are  of  a  rheumatic  nature.  In 
support  of  this  view,  in  which  they  concur,  several  medical  men  have 
pointed  out  the  coincident  existence  of  rheumatism,  and  have  insisted,  as  I 
have  done  myself,  on  the  presence  of  a  buffy  coat  on  the  blood  drawn  in 
such  cases.  This  last  argument,  however,  is  perhaps  of  less  value  than  we 
have  ascribed  to  it. 

I  shall  not  dwell  on  the  differential  diagnosis  between  tetany  and  other 
forms  of  contractions,  because,  from  what  you  have  seen  yourselves  and 
what  I  have  told  you,  it  seems  to  me  difficult  to  confound  this  complaint 
with  any  other.  In  the  grave  form  alone,  and  the  form  of  medium  inten- 
sity, one  may  be  for  a  moment  in  doubt,  because  he  may,  at  first  sight,  think 
that  the  case  is  one  of  idiopathic  tetanus.  But  while  in  this  latter  affection, 
the  convulsions,  whether  they  be  regularly  tonic  or  mixed  up  with  clonic 
convulsions  which  preceded  them,  begin  first  in  the  muscles  of  the  jaws, 
those  of  the  face  (producing  trismus),  and  those  of  the  trunk,  and  only  by 
degrees  extend  to  the  extremities  simultaneously,  rheumatic  contractions 
run  an  opposite  course.  It  rarely  happens,  moreover,  that  the  muscles  of 
the  extremities  and  those  of  the  rest  of  the  body  are  affected  at  the  same 


824  ON    TETANY. 

time  ;  lastly,  the  circumstance  that  it  may  be  provoked  by  compressing  the 
limbs  is  an  important  character,  pathognomonic  of  the  complaint. 

I  shall  not  speak  of  the  differential  diagnosis  between  tetany  and  con- 
tractions depending  on  cerebral  or  spinal  diseases,  the  analogies  between 
these  being  only  very  remote.  Besides,  symptomatic  contractions  are 
generally  limited  to  a  certain  number  of  muscles  exclusively,  and  are  pre- 
ceded or  accompanied  by  a  group  of  phenomena, — such  as  disorders  of  the 
intellect,  impairment  of  sensibility,  pei-sistent  paralysis,  and  febrile  symp- 
toms,— which  essentially  differ  from  what  we  observe  in  tetany,  in  which 
local  manifestations,  having  themselves  very  special  characters,  are  every- 
thing. 

If  you  recall  to  mind  what  I  told  you  of  epilepsy,  either  in  its  convulsive 
or  its  partial  form,  you  will  understand  why  I  do  not  dwell  on  the  diagnosis 
between  it  and  tetany,  for,  to  my  mind,  it  is  attended  with  no  difficulty. 
The  retention  of  the  intellectual  faculties  in  cases  of  general  contractions, 
carried  to  the  highest  degree,  is  of  itself  sufficient  to  enable  one  at  first 
sight  to  recognize  them  from  an  epileptic  fit,  and  doubt  is  possible  in  such 
cases  only. 

Now  what  should  the  treatment  of  tetany  be? 

Bloodletting  seemed  to  me  from  the  beginning  to  be  formally  indicated, 
with  the  view  of  combating  the  congestion,  which  considerably  alarmed  me 
in  the  first  cases  which  came  under  my  notice.  Although  my  premises 
were  wrong,  I  was  thus  led  to  apply  a  method  of  treatment  which  even  now 
renders  me  the  greatest  services.  Chiefly  when  the  patient  is  of  a  vigorous 
constitution,  and  when  there  is  very  marked  febrile  reaction,  I  have  recourse 
to  bleeding  from  the  arm,  and  to  cupping  of  the  spine.  Whatever  be  the 
mode  of  action  of  this  plan  of  treatment,  its  good  results  cannot  be  called  in 
question,  and  I  cannot  be  suspected  when  I  advocate  it,  for  you  are  aware 
that  there  are  few  men  who  are  as  chary  of  bleeding  as  I  am.  When  I 
afterwards  thought  that  this  neurosis  was  of  a  rheumatic  nature,  I  admin- 
istered quinine,  which  is  acknowledged  by  most  practitioners  to  be  efficacious 
in  the  treatment  of  rheumatism.  Although  I  obtained  some  really  good 
results  from  it,  they  were  not,  however,  to  be  compared  with  those  of  blood- 
letting. 

But  there  are  cases  in  which  bleeding  is  not  admissible,  and  treatment 
must  then  consist  chiefly  in  the  administration  of  quinine.  Thus,  when  the 
patient  suffering  from  idiopathic  contractions  is  of  a  weakly  constitution,  or 
has  been  debilitated  by  a  chronic  diarrhoea  (as  was  the  case  in  the  woman 
whoniyou  saw  at  No.  20  in  St.  Bernard  Ward,  and  who  nursed  twins,  of 
whom  she  had  been  delivered  only  a  month  before),  bleeding  would  be 
productive  of  fatal  consequences,  so  that  the  intercurrent  accidents  should 
be  combated,  the  exhausting  discharge  arrested  by  all  means,  and.  as  soon 
as  the  stomach  can  bear  it,  quinine  is  to  he  given. 

Opium  and  belladonna,  in  small  doses,  are  useful  adjuncts  of  bloodletting 
or  of  quinine. 

In  the  grave  form  of  the  disease,  and  in  violent  paroxysms,  as  those  of 
the  woman  in  Lourcine  Hospital,  chloroform  inhalations  I  practiced  with  all 
the  prudence  demanded  by  such  a  potent  drug  and  by  peculiar  idiosyn- 
crasies) are  indicated,  as  in  convulsions  in  general.  The  young  man  who 
was  in  St.  A.gnes  Ward  begged  for  them  himself  during  his  lit-,  so  greal 
wire  his  hopes  of  obtaining  relief  from  it  ;  and  however  temporarily  it  might 
he,  vet  chloroform  never  tailed  to  relieve  him.  Lastly,  gentlemen,  you  will 
find  in  the  Bulletin  Therapeutique  for  March,  I860,  a  case  reported  by  my 
regretted  friend,  Dr.  Aran,  of  idiopathic  contractions  of  the  extremities 

cured  hy  local  aj)j>licaUon€  of  chloroform  to  the  contracted  muscles,  simulla- 


ON    CHOREA.  825 

neously  with  its  internal  administration,  in  doses  of  four  or  five  mini  ins 
every  hour,  in  acacia  mixture. 

Aran  appends  to  his  case  certain  remarks  which  should  be  borne  in 
mind.  It  should  not  be  forgotten,  lie  says,  that  chloroform  irritates  the 
skin  very  much  ;  and,  consequently,  too  large  a  quantity  of  the  fluid  should 
not  be  used  in  persons  with  a  fine  and  delicate  skin.  A  piece  of  fine  linen 
impregnated  with  chloroform  is  alone  required,  and  it  is  not  even  necessary 
that  the  whole  piece  be  moistened,  but  only  the  part  which  is  in  contact 
with  the  contracted  muscles.  He  also  suggests  that  in  women  with  a  very 
fine  and  delicate  skin,  some  advantages  might  be  gained  by  using  chloro- 
form mixed  with  an  equal  or  double  the  quantity  of  oil  of  sweet  almonds, 
or  of  camphorated  chamomile  oil.  At  all  events,  the  piece  of  linen  should 
be  kept  in  situ  by  means  of  a  few  turns  of  a  bandage,  so  as  to  make  sure 
that  the  affected  parts  are  in  contact  with  the  chloroform. 


LECTUEE  XL VI. 

ON  CHOREA. 

Gentlemen  :  Those  among  you  who  have  for  some  years  continuously 
attended  my  clinical  lectures  have  seen,  in  our  male  and  female  wards, 
patients  suffering  from  convulsive  affections,  characterized,  all  of  them,  by 
muscular  agitation,  more  or  less  disorderly  and  strange  movements  and  con- 
tortions, and  to  which  the  generic  term  chorea  (from  the  Greek  word 
yopz'.a,  a  dance)  might  perfectly  be  applied. 

Quite  recently  we  had  three  women,  at  the  same  time,  in  St.  Bernard 
Ward  (one,  21  years  old,  at  No.  2;  another,  a  young  girl,  16  years  of  age, 
at  No.  30;  and"a  third,  aged  19,  at  No.  31a),  who  were  all  suffering  from 
the  same  complaint,  which  had,  however,  set  in  under  very  different  cir- 
cumstances ;  while  these  very  same  symptoms  were  present  in  a  young 
man,  19  years  old,  lying  in  bed  No.  4.  St,  Agnes  Ward.  You  were,  at 
first  sight,  struck  with  the  look  of  hebetude  and  imbecility  of  this  young 
man.  He  was  constantly  making  grimaces,  grinned  for  the  least  thing,  and 
answered  badly  the  questions  put  to  him,  seeming  scarcely  to  understand 
them.  The  impairment  of  his  intellectual  faculties  was,  however,  much 
more  apparent  than  real ;  for  it  was  the  constant  convulsive  agitation  of 
the  muscles  of  his  face  which  gave  him  that  imbecile  look,  and  the  grim- 
acing and  grinning  aspect  which  immediately  attracted  your  attention. 
He  kept  also  making  disorderly  movements,  strange  contortions,  which 
were  most  marked  in  the  extremities,  chiefly  in  the  arms. 

At  Nos.  8  and  9  in  the  same  ward  you  could  see  two  men — one  aged  51, 
a  hatter,  in  whose  trade  the  acid  nitrate  of  mercury  is  used  for  milling  the 
felt  of  which  hats  are  made  ;  the  other  a  house-painter,  who  affirmed  that 
he  had  never  had  painter's  colic  or  any  other  symptom  of  lead-poisoning, 
but  who  confessed  that  he  was  in  the  habit  of  drinking  brandy  every 
morning  fasting,  in  quantity  not  sufficient  to  make  him  drunk,  but,  accord- 
ing to  his  own  expression,  sufficient  to  excite  him.  Both  these  men  were 
affected  with  general  trembling  of  the  upper  and  lower  limbs,  which  was 
so  great  in  the  case  of  the  patient  at  No.  9  that  he  could  not  stand,  even 
by  holding  on  to  his  bedpost ;  he  could  scarcely  eat,  from  the  difficulty  he 


826  ON    CHOREA. 

had  in  carrying  his  food  to  his  mouth,  and  he  spoke  with  the  greatest  dif- 
ficulty, from  his  tongue  itself  being  involved  in  the  disease. 

Again,  in  bed  No.  6,  St.  Bernard  Ward,  there  was  a  girl  13?  years  old, 
who  was  likewise  affected  with  a  convulsive  agitation,  which  had  manifested 
itself  subsequently  to  accidents,  of  which  she  gave  the  following  account. 
She  enjoyed  good  health  ;  she  had  menstruated,  for  the  first  time,  eighteen 
months  previously  ;  and  there  had  been  no  irregularity  of  this  function, 
which  had  been  at  once  established  properly.  She  had  never  had  hysteri- 
cal fits,  although  she  laughed  and  cried  without  a  real  reason,  was  fright- 
ened about  nothing,  and  presented  all  the  characters  of  a  nervous  mobile 
temperament.  About  sixteen  months  before  the  complaint  set  in  for  which 
she  came  into  hospital,  she  had  had  typhoid  fever  of  six  weeks'  duration, 
which  had  left  behind  it  constant  headache,  to  which  she  had  not  been 
previously  subject.  Five  weeks  before  her  admission  she  went  to  work  as 
usual,  but  during  the  course  of  the  day  she  was  seized  with  convulsive 
movements  of  the  arms  and  legs,  which  were  after  all  rather  moderate,  for 
she  went  on  with  her  work.  The  movements  became  more  violent  the  next 
day,  and  were  accompanied  by  other  phenomena.  She  had,  without  cause, 
paroxysms  of  wild  joy,  which  did  not  calm  down  even  on  her  visiting  her 
sick  mother,  and  although  she  was  deeply  moved  ;  on  the  contrary,  her 
demonstrations  of  joy  became  more  and  more  wild  in  the  course  of  the  day. 
She  went  to  work  again  the  next  day,  and  kept  on  working  as  usual,  in 
spite  of  the  constant  agitation  of  her  arms  and  hands;  but  about  11  o'clock 
in  the  morning  more  serious  symptoms  manifested  themselves.  She  turned 
suddenly  pale,  and  nearly  lost  consciousness.  As  this  state  lasted,  she  was 
taken  home ;  she  then  complained  of  shivering,  and  a  general  sensation  of 
cold,  which  made  her  shake  all  over  and  her  teeth  chatter.  She  had  a 
complete  syncope  at  4  p.m.,  soon  followed  by  convulsions  violent  enough  to 
require  a  strait-waistcoat  to  restrain  her.  This  attack  lasted  an  hour  and 
a  half,  during  which  time  she  was  delirious,  alternately  siugiug  and  crying 
out  fiercely,  and  frightening  all  the  people  in  the  house.  Her  face  was 
red  and  swollen,  and  she  looked  haggard.  She  was  then  brought  to  the 
Hotel-Dieu,  where  the  attack  quickly  subsided  spontaneously,  leaving  after 
it  the  convulsive  agitation  of  the  muscles  which  we  saw. 

As  the  patient  lay  on  her  bed,  these  convulsions  consisted  in  alternate 
movements  of  flexion  and  extension,  recurring  continuously,  and  always  in 
the  same  direction.  If  she  were  asked  to  take  hold  of  an  object  shown  to 
her,  even  when  of  small  size  (as  a  piu,  for  instance),  she  contrived  to  do 
it,  moving  her  hand  towards  it  in  jerks,  but  without  difficulty,  and  in  a 
straight  line.  She  never  dropped  the  pin  when  she  had  once  seized  it  : 
and  although  she  continued  to  shake,  she  could  fix  it  in  her  dress.  She 
could  feed  herself  also,  and  easily  guided  the  spoon  from  her  plate  to  her 
mouth;  whilst  the  man  at  No.  9  in  St.  Agnes  Ward  could  not  do  this,  nor 
the  young  man  at  No.  4,  nor  the  three  patients  at  '2,  .'10,  and  31a  in  Si. 
Bernard  Ward. 

The  first  thing  which  unquestionably  struck  you,  gentlemen,  in  all  these 
cases,  was  the  presence  of  choreic  movements  ;  hut  before  inquiring  into 
Other  elements  of  diagnosis,  apart  from  this  common  character,  a  moment's 

attention  already  enabled  you  to  catch  such  distinct  differences  in  the  mus- 
cular agitation  and  the  involuntary  movements  which  characterized  it,  that 

you  could  not  only  recognize  well-defined  species  belonging  to  the  genus, 

Inn  were  also  led  to  conclude  that  some  of  the  species  belonged  to  very  dif- 
ferent pathological  genera. 

Thus,  while  the  young  women  lying  respectively  in  beds  2,  :'■<>,  and  •".!  \. 
in  St.  Bernard  Ward,  ami  the  young  man  in  lied    I,  St.  A.gnes  Ward,  were 


I 


f 


ON    CHOREA.  827 

affected  with  that  kind  of  chorea  which,  since  Sydenham,  has  been  called 
St.  Vitus's  dance,  the  young  girl  at  No.  6,  in  the  female  ward,  suffered  from 
an  hysterical  choreiform  affection  ;  the  two  men  at  8  and  9  in  St.  Agnes 
Ward  had,  the  one  alcoholic  chorea,  and  the  other  mercurial  chorea — or, 
if  you  like,  trembling,  a  term  applied  to  those  species  of  chorea  in  nosolog- 
ical tables. 

I  have  been  accused  of  changing  the  meaning  of  the  word  chorea,  admit- 
ted by  every  one,  it  is  said,  to  designate  what  I  call,  after  Sydenham,  St. 
Vitus's  dance,  and  of  thus  confounding  with  chorea,  properly  so  called,  vari- 
ous choreic  affections,  such  as  tarentismus,  hysterical  dansomania,  hysterical 
chorea,  and  trembling,  which  nobody  ever  thought  of  mixing  up  together. 
My  answer  is,  that  I  am  not  the  only  one  who  has  taken  in  its  widest 
acceptation  au  essentially  generic  term.  As  to  the  confusion  which  is  laid 
to  my  charge,  I  will  endeavor  to  put  you  on  your  guard  against  it  (pre- 
cisely because  I  too  often  see  medical  men  commit  that  error),  if  not  by 
describing  to  you  all  the  species  of  chorea,  some  of  which  besides,  such  as 
the  epidemic  choreomania  of  the  Middle  Ages,  and  tarentismus,  are  almost 
unknown  now,  but  by  passing  some  of  them  at  least  in  review,  and  especi- 
ally by  speaking  to  you  of  St.  Vitus's  dance,  to  as  great  a  length  as  the 
nature  of  this  course  admits,  and  by  pointing  out  the  characters  which 
distinguish  it  from  other  choreiform  affections. 


St.  Vitus's  Dance — Chorea  Sancti  Viti,  Sydenham. 

Reason  why  the  term  St.  Vitus's  Dance  appears  to  me  better  than  that  of  Chorea. 
— Predisposing  Causes :  Age,  Sex,  Hereditary  Influence. — Pathological 
Conditions :  Chlorosis,  Tubercular,  and  Strumous  Diathesis,  Rheuma- 
tism.— Exciting  Causes:  Emotions,  Fright. — Description  of  the  Disease. — 
Antecedent  Phenomena. —  Convulsive  Phenomena. — Their  Specific  Char- 
acter.— Paralysis. — Disorders  of  Sensibility. — Impairment  of  the  Intel- 
lectual Faculties. — The  Complaint  is  usually  Curable. — Its  Mean  Dura- 
tion.— It  may  terminate  in  Death,  and  how.. — Pathological  Anatomy 
throws  no  light  on  it. — Influence  of  Intercurrent  Febrile  Diseases  on  the 
course  of  the  Complaint. — Relapses  and  Recurrences :  their  Duration  is 
less  than  that  of  the  Previous  Attacks. — Treatment:  Cold  and  Warm 
Baths,  Sulphur  Baths,  Gymnastics. — Internal  Remedies :  Tartar  Emetic, 
Strychnine,  Opium  in  large  doses  in  grave  cases,  Hygienic  Measures. 

Gentlemen  :  It  is  beyond  question,  especially  since  the  beautiful  his- 
torical researches  made  on  this  point  by  Messrs.  G.  See  and  Roth,*  and 
some  others,  that  the  name  St.  Vitus's  dance  was  at  first  given  to  a  singu- 
lar disease,  very  different  from  the  one  which  we  now  know,  and  which 
was  epidemic  in  several  German  villages  at  the  end  of  the  fourteenth  and 
the  beginning  of  the  fifteenth  century.  This  name  was  applied  to  it  because 
individuals  suffering  from  this  choreomania — a  regular  ecstatic  frenzy, 
to  which  that  of  the  convulsionists  at  St.  Medard  has  been  compared — 
went  on  a  pilgrimage  to  St.  Vitus's  Chapel,  at  Dresselhausen,  in  the  dis- 
trict of  Ulm,  in  Suabia,  as  the  Saint  was  said  to  have  the  power  of  curing 
them,  just  as  in  our  own  time  other  saints  are  said,  in  popular  legends,  to 
possess  an  analogous  power  in  other  complaints.  Whatever  its  origin,  the 
name  St.  Vitus's  dance,  perverted  from  its  original  meaning,  was  given  by 

*  Germain  See,  "  De  la  Choree"  (Mem.  de  l'Aead.  de  Med.  1850,  t.  xv,  p.  373). 
Roth,  "  Histoire  de  la  Musculation  irresistible"  (Paris,  1850). 


828  ON    CHOREA. 

Sydenham,  who  did  not  pique  himself  on  being  an  erudite,  to  the  com- 
plaints of  which  I  am  now  speaking ;  and  from  having  been  adopted  by 
the  authors  of  the  eighteenth  century,  it  is  now  understood  by  every  one. 

It  has  been  adopted  in  your  very  text-books,  and  there  given  as  synony- 
mous of  chorea,  a  generic  term  which  Bouteille  proposed,  in  1810,  to  sub- 
stitute for  it ;  while  it  has  taken  such  firm  root  in  medical  language,  that 
all  efforts  made  to  restore  its  first  meaning  to  it  have  failed. 

If  this  is  to  be  regretted,  in  an  historical  point  of  view,  science  and  prac- 
tice, I  must  hasten  to  add,  do  not  lose  much  by  Sydenham's  mistake  in  eru- 
dition ;  for  it  is  to  this  great  physician  that  we  are  indebted  for  the  first 
truly  scientific  description  of  the  symptoms  of  the  complaint.  For  ray  part, 
now  that  everybody  understands  what  is  meant  by  St.  Vitus's  dance,  this 
name  appears  to  me  the  best — better  than  that  of  chorea,  which,  in  its  gen- 
eric acceptation,  includes  many  things  and  specifies  none,  while  the  former 
term  applies  to  one  complaint  alone  and  to  the  whole  of  it,  as  the  rule  is  in 
sound  logic.  It  has  the  immense  advantage  of  designating  the  disease  in 
question  better  than  could  be  done  by  any  other  name  constructed  accord- 
ing to  the  principles  of  the  most  correct  nosology :  whatever  be  the  ideas 
entertained  of  the  nature  of  the  disease,  this  name  prejudges  nothing,  and 
all  theories  can  conveniently  adapt  themselves  to  it.  The  same  thing  hap- 
pens in  the  case  of  this  word  as  in  that  of  all  those  words  which  mean  noth- 
ing in  themselves  but  have  been  adopted  by  custom :  they  are  the  best, 
because  they  include  a  complete  definition,  and  convey  to  the  mind  a  com- 
plete idea  of  the  object  meant.  So  it  is  with  the  terms  coqiieluche  (hooping- 
cough)  and  verole  (pox),  for  instance,  which,  in  spite  and  perhaps  on  account 
of  their  strange  etymology,  have  become  part  of  ordinary  as  well  as  of  med- 
ical language,  and  which  could  not  be  replaced  by  any  other  term  borrowed 
from  a  nomenclature  having  high  pretensions  to  scientific  accuracy. 

I  now  pass  on  to  the  study  of  St.  Vitus's  dance. 

Although  a  certain  number  of  cases  of  this  complaint  may  be  every  year 
seen  in  my  wards  where  patients  over  16  years  old  are  alone  admitted,  such 
cases  are  rare  when  compared  with  those  that  are  met  with  in  children's 
hospitals;  and  I  shall  only  tell  you  what  you  know  already,  when  1  say, 
that  St.  Vitus's  dance  is  a  complaint  occurring  in  childhood  and  jyubi  rty,  and 
generally  from  6  to  15  years  of  age.  It  is  only  exceptionally  that  it  affects 
children  before  they  have  changed  their  first  teeth,  and  it  is  much  more 
common  to  see  it  in  individuals  who  have  attained  the  age  of  puberty,  up 
to  25  years.  There  are  even  instances  of  chorea  on  record  attacking  older 
persons;  and  M.  ( '<.  See  lias  seen  it  in  a  woman  36  years  old.  in  another  44 
years  of  age,  and  in  a  man  aged  59.  Jeffreys  saw  it  in  a  patient  <><•  years 
old,  and  Powel  and  Maton  in  another  7<i  years  old,  while  Bouteille  saw  a 
man  aged  7'_'  who  was  afflicted  with  it  ;  and  lastly,  only  recently  Dr.  Henri 
Roger  has  recorded  a  ease  of  chorea  occurring  in  a  lady  83  years  of  age. 

This  last  case  is  so  interesting,  on  account  of  its  singularity,  that  I  must 
beg  permission  to  read  il  to  you  in  lull  : 

"  Mrs. ,  83  years  old,  lias  as  strong  a  constitution  and  as  dear  a  mind 

a-  may  be  expected  at  her  advanced  age.     Apart  from  some  weakness  in 

the  [egs  and  palpitation-  of  the  heart,  of  which  she  lias  complained  for  aboul 

the  last  ten  years,  unaccompanied  by  murmur  and  by  marked  precordial 
dulness,  and  without  a  history  of  antecedent  acute  articular  rheumatism, 

except  also  a  rather  obstinate  constipation,  and  some  vague  rheumatic  pains 
in  the  loins  and  the  limbs,  her   health  i-  at   present  a-   satisfactory  a-  possi- 

ble.     I  musl  mention,  however,  that  eight  years  ago,  I  attended  Mrs. 

for  an  attack  of  pleurisy  with  effusion  on  the  right  side;  and  two  year-  ago 


I 


ON    CHOREA.  829 

for  sciatica,  which  was  of  moderate  intensity  and  duration ;  and  last  year 
for  cerebral  congestion,  which  disappeared  after  a  few  days. 

"On  the  loth  of  May  last,  I   was  sent  for  to  see  Mrs. and  easily 

recognized  chorea.  For  three  or  four  days  previously  only,  she  had  felt, 
without  any  appreciable  cause,  any  intense  emotion,  or  other  premonitory 
symptoms,  some  uncertainty  and  exaggeration  in  the  movements  of  her 
right  arm  and  leg.  These  two  limbs,  when  I  saw  her,  were  the  seats  of 
other  marked  movements  ;  the  arm  was,  at  very  short  intervals,  moved 
suddenly  and  with  a  jerk  ;  when,  in  ohedience  to  the  patient's  will,  it  was 
drawn  forwards,  it  was  soon  pulled  backwards  or  dragged  more  forwards 
by  involuntary  contractions;  its  movements  were  strange,  irregular,  and 
badly  co-ordinated.  The  same  thing  occurred  with  the  leg,  which,  although 
it  lay  on  the  bed,  was  drawn  up  by  a  sudden  contraction,  in  such  a  man- 
ner that  the  foot  was  thrust  at  haphazard  in  various  directions. 

"  "When  asked  to  do  so,  the  patient  could,  by  an  effort  of  the  will,  stop 
these  movements,  but  they  began  again  almost  immediately.  Their  uncer- 
tainty and  irregularity  increased  still  more  when  the  patient  was  up.  She 
could  scarcely  keep  on  her  legs,  and  was  compelled  to  sit  down  instantly. 
With  some  care,  and  with  time,  she  managed  to  feed  herself.  The  face  was 
only  slightly  distorted,  from  the  muscles  of  the  face  being  less  frecpuently 
and  less  violently  contracted  than  those  of  the  limbs.  Speech  was  nearly 
natural,  and  was  interrupted  at  rare  intervals  only. 

"  The  muscles  of  the  walls  of  the  chest  and  abdomen  were  not  the  seats 
of  special  contractions.  The  senses  were  not  markedly  affected.  The  pa- 
tient complained  of  a  sense  of  fatigue  all  over,  owing  to  the  exaggerated 

motility.    General  sensibility  was  neither  diminished  nor  exalted  ;  Mrs. 

was  iowspirited,  or  rather  had  grown  inpatient,  on  account  chiefly  of  her 
sleeplessness,  although  she  had  some  sleep,  during  which  the  chorea  ceased. 
The  animal  functions  (digestion,  circulation,  urinary  secretion)  were  nor- 
mally performed.  These  details  sufficiently  prove  the  existence  of  idio- 
pathic chorea :  the  disease,  let  it  be  added,  was  at  first  moderately  intense, 
but  increased  in  violence  after  three  or  four  days.  The  movements  became 
more  incessant  and  more  violent,  were  almost  more  marked  in  the  arm  and 
leg,  and  exclusively  limited  to  the  right  side.  The  patient  could  not  feed 
herself,  and  was  not  able  to  walk,  while  the  chorea  persisted  during  nearly 
the  whole  night,  and  prevented  sleep.  The  disease  continued  in  this  degree 
until  June  1,  that  is  to  say,  for  about  a  fortnight.  From  that  date  it 
decreased  by  degrees,  and  on  June  15,  namely,  after  five  weeks,  the  patient 
got  perfectly  well.  During  the  whole  time  there  was  no  impairment  of  the 
general  health,  and  there  was  no  concomitant  phenomenon  deserving  of 
notice,  except  the  coexistence  of  neuralgic  pain  along  the  course  of  the 
arm,  on  a  level  with  the  insertion  of  the  deltoid  and  about  the  elbow  (with- 
out swelling  or  redness  of  the  parts,  and  without  fever). 

"The  treatment  was  simple.  It  consisted  in  the  internal  administration 
of  oxide  of  zinc  and  of  powdered  belladonna,  in  gradually  increasing  doses 
of  from  5  to  15  grains  of  the  former,  and  from  1  to  2  grains  of  the  latter. 
Local  applications  of  chloroform  diluted  with  water  (1  part  to  30)  were  used, 
and  calmed  the  pain  in  the  arm,  which  was  the  seat  of  the  choreic  move- 
ments, and  the  limbs  were  rubbed  and  kneaded,  especially  the  leg,  which 
was  not  painful." 

An  analogous  case  is  reported  in  Graves's  "  Clinical  Lectures."  The 
chorea  was  very  violent,  and  the  patient  was  a  Dublin  chemist,  70  years 
of  age. 

Dr.  Henri  Roger  justly  remarks  that  his  patient  was  really  suffering 
from  St.  Vitus's  dance.     "  The  complete  integrity  of  the  functions  of  the 


830  ON    CHOREA. 

nervous  system  before  the  setting-in  of  the  convulsive  affection,  the  ab- 
sence of  all  antecedent  or  subsequent  cerebro-spinal  disease,  the  unequivocal 
form  of  the  symptoms  (which  were  choreic  and  not  choreiform),  the  dura- 
tion of  the  neurosis,  which  was  almost  the  usual  one  in  such  cases,  and  its 
favorable  termination,"  amply  justify  the  diagnosis. 

These  rare  instances  of  St.  Vitus's  dance  affecting  individuals  after 
puberty  have  almost  exclusively  occurred  in  women.  Sex,  therefore,  plays 
in  such  cases  a  very  important  part  as  a  predisposing  cause ;  and  this  in- 
fluence of  the  female  sex  is  very  remarkable  at  the  periods  of  life  in  which 
chorea  most  generally  manifests  itself,  for  statistics  show  that  the  proportion 
between  girls  and  boys  is  as  3  to  1.  This  proportion  is  still  higher  after 
puberty,  and  it  may  be  stated  that  St.  Vitus's  dance  occurs  exceptionably 
in  males  after  the  age  of  15,  while  a  pretty  good  number  of  cases  of  the 
disease  in  females  might  be  cited.  While  on  this  point  I  must  call  your 
attention,  gentlemen,  to  the  fact  that  articular  rheumatism  attacks  males 
more  frequently  than  females,  and  that  this  tends  to  detract  from  the  value 
of  the  opinion  which  holds  that  St.  Vitus's  dance  is  an  expression  of  the 
rheumatic  diathesis. 

I  need  not  mention,  as  some  authors  have  done,  that  the  nervous  tem- 
perament more  than  any  other  predisposes  to  this  neurosis.  Dr.  G.  See  has 
done  away  with  this  commonplace  remark,  as  well  as  with  the  influence  of 
the  patient's  constitution. 

The  same  cannot  be  said  of  hereditary  predisposition,  which  is  unquestion- 
able; and  even  if  judicious  statistics  had  not  proved  it,  it  might  have  been 
asked  why  St.  Vitus's  dance  should  not  be  subjected  to  the  same  law  as  all 
nervous  diseases  in  which  hereditary  predisposition  holds  such  an  important 
place. 

On  inquiring  into  the  family  history  of  individuals  affected  with  chorea, 
you  will  find  that  either  their  direct  or  collateral  ancestors  (of  the  latter, 
according  to  some,  but  for  what  reason  I  know  not,  no  account  should  be 
taken)  have  suffered  from  various  neuroses,  such  as  hysteria,  epilepsy,  or 
eclampsia ;  or  you  will  ascertain  the  existence  of  certain  diathetic  manifes- 
tations, and  in  particular  of  the  tubercular  diathesis.  And  here,  again,  we 
have  to  deal  with  the  question  of  the  mutual  transformation  of  diatheses,  a 
great  question  of  general  pathology,  to  which  I  have  already  alluded  sev- 
eral times. 

Several  pathological  conditions  have  been  regarded  as  predisposing 
causes  of  chorea,  but  their  influence  for  the  most  part  is  far  from  being 
proved.  I  do  not  stop  to  speak  of  the  metastases  of  eczematous  diseases — 
of  the  itch,  of  febrile  eruptions,  and  of  the  metastases  sequential  to  the  sup- 
pression of  habitual  discharges — which  have  been  too  often  erroneously 
enumerated  among  the  etiological  conditions  of  diseases  the  real  cause  of 
which  escapes  us;  nor  shall  I  say  anything  of  gastro-intestinal  disorders 
and  of  intestinal  worms,  which  stand  to  chorea  in  a  very  doubtful  relation 
of  cause  and  effect,  however  marked  their  influence  may  lie  on  the  develop- 
ment of  eclampsia.  I  will  add  that  the  impairment  of  the  digestive  func- 
tions— which,  as  I  shall  tell  you  presently,  is  a  very  common  complica- 
tion of  St.  Vitus's  danc( — is  a  consequence  of  the  perturbation  of  the  whole 
nervous  system  arising  from  the  disease  itself,  and  should  not  he  regarded 
as  its  starting-point.  Ii  is  unquestionable  that  St.  Vitus's  dance  has  often 
a  marked  influence  on  the  development  of  chlorosis.  It  is  equally  unques- 
tionable that  a  huge  number,  the  largest  number  even,  of  choreic  women 
Were  previously  chlorotic,  and  that  they  get  well  when  they  are  cured  of 
chlorosis  by  the  measures  indicated  in  such  cases.  It  is  evident  that  chlo- 
rosis is  very  often  a  concomitant   condition,  at  the  very  least,  which  should 


ON    CHOREA.  831 

be  taken  into  account  in  the  treatment  of  St.  Vitus's  dance.  I  will  go  fur- 
ther: chlorosis,  like  all  causes  capable  of  weakening  the  organism  and  of 
producing  erethism  of  the  nervous  system,  plays  an  important  part  in  the 
etiology  of  this  singular  neurosis.  In  pregnancy,  which  may  be  regarded  as 
a  favorable  condition  for  the  production  of  this  nervous  complaint,  the 
latter  should  be  ascribed  to  the  chlorosis  which  so  frequently  accompanies 
pregnancy.  No  one  denies  this  indirect  influence  of  pregnancy  on  the  pro- 
duction of  St.  Vitus's  dance.  Dr.  G.  See  has  collected  sixteen  instances 
of  the  disease  occurring  in  women  from  19  to  20  years  of  age,  and  my  col- 
league, Dr.  Horteloup,  has  seen  one  case  in  a  young  woman  aged  16. 

I  told  you  a  moment  ago,  gentlemen,  apropos  of  hereditary  predisposition, 
that  St.  Vitus's  dance  could  be  the  manifestation  of  certain  diatheses  which 
had  shown  themselves  in  the  direct  or  collateral  ancestors  of  the  patient, 
in  their  usual  form.  I  would  not  go  so  far  as  to  say,  with  J.  Frank  and 
Dr.  G.  See,  that  the  tubercular  or  strumous  diathesis  plays  an  important 
part  in  the  production  of  chorea,  although  a  large  proportion  of  choreic 
patients  are  also  tubercular.  The  proportion  which  exists  between  other 
chronic  diseases  and  tubercles  should  be  first  established. 

But  of  all  these  predisposing  pathological  states,  rheumatism  is  assuredly 
the  most  marked  and  the  least  questionable.  The  relation  of  rheumatism  to 
St.  Vitus's  dance  had  been  partially  seen  by  Stoll,  by  Copland,  by  Bouteille, 
by  Abercrombie,  Begbie,  Bright,  Gabb,  and  Richard  ;  while  others,  again, 
had  pointed  out  the  coexistence  of  pericarditis  and  endocarditis  with  chorea. 
Dr.  Botrel  went  further  in  1850,  when  he  chose  for  the  subject  of  his  thesis, 
"  Of  Chorea  considered  as  a  Rheumatic  Affection,"  and  propounded  the  opin- 
ion, professed  before  him  by  Dr.  Hughes,  that  the  former  complaint  was  only 
a  special  manifestation  of  the  latter.  But  in  his  remarkable  memoir  on 
"Chorea  and  the  Nervous  Affections,"  &c,  which,  in  1851,  gained  a  prize  at 
the  Academy  of  Medicine,  Dr.  G.  See  has  brought  out  this  fact  so  prom- 
inently, that  the  greater  portion  of  this  discovery  really  belongs  to  him. 

The  interesting  researches  made  by  Dr.  See,  who  is  physician  to  the 
Hopital  des  Enfants,  led  him  to  the  conclusion  that  in  nearly  every  case  of 
St.  Vitus's  dance,  rheumatic  pain  had  at  least  been  complained  of.  Dr. 
See  has  not,  however,  guarded  himself  from  exaggeration,  and  has  con- 
founded under  the  same  head,  Rheumatic  Affections,  simple  lumbago  and 
muscular  pain,  which  so  frequently  accompany  the  invasion  of  chorea. 

This  law,  however,  when  made  less  exclusive,  is  an  acquired  fact  in 
science,  and  there  is  no  practitioner  nowadays  who  has  not  been  able  to 
verify  it.  On  several  occasions,  I  showed  you  how  it  applied  to  cases  that 
we  saw  together — among  others  to  the  case  of  a  poor  young  woman  in  St. 
Bernard  Ward,  who  was  carried  off  by  a  most  violent  attack  of  chorea, 
which  manifested  itself  ten  or  fifteen  days  after  the  setting-in  of  acute  artic- 
ular rheumatism. 

About  the  same  period  I  was  asked  by  my  colleague  and  friend  Legroux 
to  see  with  him  the  daughter  of  a  tailor  in  the  Rue  Richelieu,  who  was 
suffering  from  an  attack  of  acute  and  general  articular  rheumatism.  We 
found  endocarditis  also ;  and  the  pain  persisting  ten  or  fifteen  days  after 
the  outset  of  the  rheumatic  fever,  St.  Vitus's  dance  set  in.  It  was  moder- 
ate at  first,  but  soon  became  complicated  with  awful  muscular  disorders, 
delirium,  and  lastly  comatose  symptoms ;  the  girl  died  on  the  seventeenth 
day. 

Dr.  E.  Moynier  published,  in  the  thesis  which  he  wrote  for  his  doctor's 
degree  in  1855,  the  following  case,  which  I  had  communicated  to  him.  A 
girl,  10^  years  old,  has  a  first  attack  of  chorea,  after  which  she  becomes 
hemiplegic.     At  the  age  of  14  she  has  rheumatic  fever,  and  subsequently 


832  OX    CHOREA. 

a  second  but  slight  attack  of  St.  Vitus's  dance.  Her  brother,  when  13 
years  old,  had  had  rheumatic  fever,  and  two  months  afterwards  had  been 
seized  with  the  same  convulsive  affection  as  his  sister.  Their  father  had 
on  five  several  occasions  suffered  from  articular  rheumatism,  but  never 
from  chorea. 

A  boy,  5!  years  old,  is  seized  on  January  1,  1859,  with  articular  rheu- 
matism, which  lasts  a  month.  On  the  1st  of  February  following  he  had 
St.  Vitus's  dance,  which  was  still  present  on  March  7,  when  I  saw  him, 
and  I  recognized  endocarditis,  characterized  by  a  rough  cardiac  murmur. 

I  could  add  a  good  many  more  cases  which  have  come  under  my  own 
observation,  and  some  of  which  are  quite  recent ;  for  I  never  allow  the 
opportunity  to  pass  now,  of  inquiring  into  the  law  of  coincidence,  to  which 
the  labors  of  Drs.  Hughes,  Botrel,  and  G.  See  have  called  my  attention 
particularly.  Profiting  by  their  researches,  I  have  in  many  cases  been 
able  to  foretell  that  children  suffering  from  rheumatism  would  become 
affected  with  chorea.  On  the  other  hand,  I  have  been  able  to  predict  that 
choreic  children  who  were  brought  to  me  would,  sooner  or  later,  have  rheu- 
matism. Yet  you  will  rarely  see  it  precede  rheumatism,  while  it  often 
follows  it,  in  the  proportion  of  one-third  of  the  cases. 

This  proportion,  which  is  nearly  the  one  given  by  Dr.  G.  See,  may,  per- 
haps, seem  exaggerated,  if  cases  of  purely  articular  rheumatism  be  alone 
reckoned ;  but  the  great  pathological  law  laid  down  by  my  eminent  col- 
league at  the  Charite  Hospital,  Dr.  Bouillaud,  namely,  the  law  of  coinci- 
dence between  cardiac  affection  and  rheumatism,  comes  here  to  our  help. 
For,  if  vou  do  not  find  articular  rheumatism  in  a  pretty  large  number  of 
choreic  patients,  you  will  find  the  signs  of  old  endocarditis,  a  manifestation 
of  rheumatism  which  spared  the  joints,  but  existed  nevertheless,  and 
affected  the  organism  deeply.  Allow  me  to  relate  to  you  a  case  which  you 
saw  with  me. 

A  girl,  14  vears  old,  who  had  never  menstruated,  was  admitted  iuto  the 
clinical  wards  on  January  9,  1861,  for  St.  Vitus's  dance,  affecting  chiefly 
the  left  side.  She  had  been  ill  for  twelve  days,  and  gave  us  very  incom- 
plete information  as  to  her  previous  history.  I  found  out,  however,  that 
when  a  child  she  had  had  choreic  movements  and  articular  pains.  Her 
face  wore  a  very  marked  expression  of  hebetude ;  she  could  scarcely  speak, 
and  her  lips  moved  in  a  singular  manner.  When  she  tried  to  speak,  she 
protruded  her  tongue  out  of  her  mouth  in  jerks  :  and  when  she  drank,  she 
swallowed  the  liquid  spasmodically.  She  could  scarcely  walk;  her  left 
arm  and  hand  and  her  left  leg  were  shaken  in  a  disorderly  manner;  she 
wus  obliged  to  keep  in  bed,  and  could  not  iced  herself.  Sensation  was 
diminished  on  the  left  side,  both  in  the  lace  and  limbs.  There  was  m>  in- 
testinal disorder;  respiration  and  circulation  were  normal;  but  over  the 
cardiac  region,  especially  at  the  apex,  there  was  heard  a  soft  systolic  blow- 
ing murmur,  which  did  not  extend  into  the  bloodvessels. 

On  .January  16  she-  had   on   the   limb.-  velvety  eminences,  like   thoe 
urticaria;  on   tin-   17th   she   had    lever,  characterized   by  a    frequent    pulse 
and  heat  of  skin.    She  complained  of  rheumatic  pain  in  several  joints,  ami 

there  was  marked   effusion  into  the  right  knee.      The  cardiac  blowing  mur- 
mur was  more  distinctly  heard  and  more  prolonged. 
For  .-even  days,  several  articulation-  were  attacked  with  rheumatism, 

which    left    them  to  return  again   after  a    time,  and    meanwhile  the  choreic 

movements  nearly  disappeared.     On  January  25  the  aspect  of  stupor  was 

Very  marked  ;   the  expression  of  the  face  never  varied,  and  the  pupils  were 

dilated.  The  child  lay  on  her  back,  scarcely  complaining  of  pain  in  the 
joint-,  and  -he  hail  convergent  strabismus.     There  was,  however,  marked 


ON    CHOREA.  833 

diminution  of  the  pulse  and  of  the  respiratory  movements.  Since  January 
20  the  digitalis  had  been  stopped,  which  had  been  administered  for  several 
days,  without  producing  any  perceptible  modification  of  the  heart's  pulsa- 
tions, which  until  then  had  been  frequent,  and  been  felt  over  a  broad  area, 
as  they  usually  are  in  rheumatism.  The  frontal  headache,  the  strabismus, 
stupor,  diminution  of  the  movements  of  the  heart  and  of  respiration,  the 
nearly  complete  cessation  of  the  pain  in  the  joints,  were  sufficient  indica- 
tions that  rheumatism  had  attacked  the  brain  ;  yet  the  cerebral  macula 
only  became  manifest  on  January  26,  but  very  conspicuously.  There  was 
constipation  also.  The  brain-symptoms  persisted  during  fourteen  days,  the 
pulsations  of  the  heart  had  become  less  and  less  frequent  (48  per  minute), 
and  the  breathing  was  slow,  sometimes  interrupted  for  a  few  seconds. 
Four  ounces  of  coffee  a  day  had  at  first  been  given,  and  subsequently 
calomel,  in  divided  doses.  On  February  4,  that  is,  fourteen  or  fifteen  days 
after  the  onset  of  the  cerebral  rheumatism,  all  the  brain-symptoms  im- 
proved ;  there  was  less  stupor,  the  intellect  was  clearer,  the  strabismus  less 
marked,  the  pupils  less  dilated,  and  the  patient  answered  questions  readily, 
while  she  had  not  been  able  to  do  this  for  several  days.  The  pulse  became 
more  frequent,  and  the  respiration  more  regular ;  the  face  no  longer  had 
the  same  bluish  tint,  and  the  cerebral  macula  was  less  developed,  and 
lasted  a  shorter  time.  From  that  time  the  improvement  increased  every 
day,  markedly  and  continuously,  and  all  the  brain-symptoms  disappeared 
soon,  and  pain  was  no  longer  complained  of  in  the  joints.  As  the  appetite 
had  returned,  nourishment  could  be  given.  The  girl  was  fairly  conva- 
lescent, although  her  face  still  wore  a  singular  expression ;  and  although 
she  had  no  choreic  convulsions,  her  voluntary  movements  were  still  slightly 
uncertain.     The  cure  was  afterwards  complete. 

In  this  case,  gentlemen,  St.  Vitus's  dance  opened  the  scene;  acute  articu- 
lar rheumatism  soon  followed,  preceded  by  cardiac  symptoms,  and  then 
there  supervened  a  grave  complication,  cerebral  rheumatism.  Rheumatism 
attacks  children  more  frequently  than  is  believed.  Independently  of  the 
causes  which  produce  it  in  adults,  and  to  which  children  are  equally  liable, 
there  is  one  cause  to  which  they  are  more  exposed  than  others,  namely, 
scarlatina.  When  I  come  to  speak  of  this  exanthematous  fever,  I  shall 
dwell  fully  on  the  coincidence  of  rheumatism  and  scarlatina ;  and  I  will 
tell  you  that  it  is  pretty  common  (less  so  in  children,  however,  than  in 
adults,  in  whom  this  occurs  in  one-third  of  the  cases)  to  see  rheumatic 
affections  set  in  during  the  acute  stage  of  the  eruptive  fever ;  but  as  the 
rheumatism  does  not  give  rise  to  the  general  symptoms  which  xisually  char- 
acterize it,  as  the  patients  complain  little  of  it,  and  as  it  is  most  frequently 
confined  to  three  or  four  joints  (chiefly  the  wrists),  it  is  often  overlooked. 
Yet  by  carefully  questioning  the  patients,  by  examining  their  joints  with 
attention,  and  slightly  compressing  them,  pain  is  found  to  exist  in  the  joints 
from  the  third  to  the  eighth  day  of  the  disease,  sometimes  later.  Thus  is 
explained  the  production  of  endocarditis  and  pericarditis,  complications 
which  manifest  themselves  when  scarlatina  is  declining,  pericarditis  some- 
what more  rarely  than  endocarditis. 

Deep  emotion,  from  any  cause,  and  most  particularly  fright,  is  a  determin- 
ing cause  of  St.  Vitus's  dance.  The  young  girl,  16  years  old,  who  lay  in 
bed  30,  St.  Bernard  Ward,  afforded  an  instance  of  this.  Her  previous 
health  had  always  been  good  ;  she  had  never  had  rheumatic  pains  (and 
careful  auscultation  detected  no  sign  of  cardiac  disease),  and  her  complaint 
dated  a  fortnight  back.  A  man  caught  hold  of  her  one  evening  as  she  was 
going  downstairs  without  a  light,  and  she  was  so  frightened  that  she  had  a 
nervous  fit,  and  from  that  moment  became  affected  with  St.  Vitus's  dance. 
vol.  i. — 53 


834  ON    CHOREA. 

The  disease  was  developed  to  a  pretty  high  degree,  and  her  ease  could  be 
regarded  as  typical. 

Several  among  you  may  recollect  another  girl,  aged  17,  who  was  sent  into 
my  ward  by  Professor  Jobert,  in  December,  1860.  She  had  an  artificial 
anus  in  the  umbilical  regiou,  which  had  rendered  a  surgical  operation 
necessary.  She  had  always  been  very  nervous,  and  had  a  strange  temper ; 
and  she  was  so  alarmed  by  the  operation,  that  she  was  immediately  seized 
with  St.  Vitus's  dance,  which  was  very  grave,  was  attended  with  delirium, 
and  got  well  by  slow  degrees  also. 

The  invasion  of  St.  Vitus's  dance  is  rarely  sudden  as  it  was  in  these  two 
instances ;  in  the  immense  majority  of  cases  there  are  premonitory  phe- 
nomena, which  often  escape  notice,  and  thus  induce  the  belief  that  the 
choreic  movements  developed  themselves  at  once. 

These  prodromata  consist  in  impairment  of  the  intellectual  faculties.  The 
child's  temper  changes ;  the  joyousness  habitual  to  its  age  is  replaced  by 
uuusual  sadness  and  morosity,  and  he  becomes  capricious  and  agitated ;  he 
sheds  tears  copiously  for  the  least  thing ;  he  is  irritable ;  his  natural 
timidity  grows  worse;  he  seeks  solitude,  and  keeps  away  from  his  play- 
fellows. He  becomes  at  the  same  time  incapable  of  fixing  his  attention 
long;  his  aptitude  for  work  diminishes;  his  memory  is  less  retentive;  and 
this  enfeeblement  of  the  iutellect,  which  does  not  escape  the  attention  of 
mothers  (who,  however,  are  always  ready  to  exaggerate  their  children's 
qualities),  increases  still  more  in  proportion  as  the  disease  progresses.  I 
will  presently  revert  to  this  important  point. 

Generally,  also,  the  patient  complains  of  malaise,  of  headache,  of  vague 
pains  in  the  limbs,  and  of  precordial  anxiety.  The  digestive  functions 
lose  their  accustomed  regularity  ;  the  appetite  diminishes,  digestion  becomes 
more  difficult,  and  there  is  constipation.  The  convulsive  agitation  is 
already  announced  by  a  wish  to  move  constantly  from  place  to  place,  and 
by  uneasiness  in  the  limbs ;  this  agitation  becomes  more  and  more  marked, 
and,  lastly,  the  choreic  convulsions  manifest  themselves. 

The  symptoms  of  the  confirmed  disease  show  themselves  sometimes  in  the 
upper,  at  other  times  in  the  lower  extremities,  and  at  others  again  in  both 
at  the  same  time.  In  some  cases  the  face  gets  distorted  first,  but  more 
frequently  the  upper  limbs  are  the  first  to  be  affected,  and  it  is  of  very  rare 
occurrence  indeed  that  the  disease  is  general  from  the  outset. 

As  a  rule,  I  repeat,  chorea  begins  in  one  side  and  attacks  the  other  side 
by  degrees,  involving  the  trunk  and  face  also.  In  some  very  rare  cases  it 
is  localized  during  the  whole  course  of  the  disease,  and  we  had  in  St.  Bernard 
Ward  an  instance  of  this  hemickorea.  The  right  side  was  affected  in  that 
case,  while  most  commonly  unilateral  chorea  is  on  the  left  side.  Even 
when  general,  chorea  always  presents  something  <>t'a  unilateral  character — 
that  is,  the  convulsive  movements  an-  more  marked  on  one  side  than  on 
the  other,  more  particularly  mi  the  left.  This  may  take  place  alternately 
also;  for  instance,  the  agitation  may  cease  on  the  side  which  was  most 
affected,  and  may  become  more  violent  on  the  other. 

Chorea  which  is  /><irii>i/  at  the  beginning  may  remain  so  throughout,  or 
after  becoming  general  it  may  afterwards  affect  a  few  muscles  only.  Such 
cases  are  rare,  however,  and  a  greal  many  of  those  which  have  been  re- 
ported as  such  were  not  instances  of  St.  vitus's  dance,  bul  of  tic,  a  Bpecies 

of  chorea  which  should  not   he  mistaken  tor  it. 

It',  at  the  outset,  the  Symptoms  which  characterize  this  complaint  are 
sufficiently  Blight  not  to   attract  the  atteiiti. f  the  child's  friends,  and   if 

they  then  consul  merely  in  a  want  of  precision  of  the  voluntary  movent 

or  in  a  sort  of  carphology,  or  in  -one-  more  or  less  t  ransient  contortion-   of 


ON    CHOREA.  835 

the  trunk  and  face;  when  the  disease  is  fully  developed,  it  can  no  longer 
be  mistaken,  and  the  most  minute  description  cannot  give  an  accurate  idea 
of  its  strange  and  varied  aspect. 

One  is  struck  at  first  sight  with  the  singularity,  the  uncertainty,  and 
irregularity  of  the  child's  movements.  He  cannot  remain  a  single  moment 
at  rest.  He  has  a  difficulty  in  remaining  in  the  standing  posture,  for  his 
legs  bend  under  him,  and  then  straighten  themselves  in  an  instant ;  his 
gait  is  peculiar,  and  he  runs  rather  than  walks.  If  he  tries  to  take  a  step 
forward,  he  raises  his  foot  higher  than  he  desires,  thrusts  it  right  and  left; 
and  scarcely  has  this  foot  touched  the  ground  again,  than  the  other  gets  off 
at  once  and  moves  in  a  similar  manner.  His  walk  consists  in  constant 
leaping — in  a  sort  of  ill-cadenced  dance,  which  assumes  a  more  grotesque 
character,  painful  to  witness,  from  the  irregular  movements  of  the  upper 
limbs,  the  contortions  of  the  trunk  and  head,  which,  according  to  Dr.  Ruiz's 
comparison,  make  the  poor  choreic  patient  resemble  one  of  those  puppets 
that  are  moved  by  strings.  When  the  symptoms  are  very  severe,  the  stand- 
ing posture  and  progression  are  perfectly  impossible,  and  the  patient  is 
compelled  to  remain  in  bed  under  pain  of  falling  down  without  being  able 
to  get  up  again. 

The  upper  limbs  move  likewise  in  different  directions.  They  pass,  with 
excessive  rapidity,  from  a  state  of  flexion  into  one  of  extension,  from  prona- 
tion into  supination,  and  these  various  movements  succeed  one  another 
without  regularity.  The  patient  succeeds  in  reaching  a  determined  spot 
with  his  hand  only  after  many  efforts.  If  he  tries,  for  instance,  to  carry  it 
to  his  head,  he  raises  his  arm  up,  after  many  false  moves,  striking  his  face 
and  forehead  while  doing  so,  and  he  is  unable  to  retain  that  position  long. 
When  he  tries  to  take  hold  of  any  object  presented  to  him,  he  thrusts  his 
hand  forward  as  if  his  arm  moved  by  means  of  a  spring,  then  withdraws  it 
with  the  same  suddenness,  without  reaching  his  aim  or  going  beyond  it, 
and  attaining  it  at  last  after  numerous  attempts ;  even  when  he  gets  at 
what  he  desires,  it  often  is  by  upsetting  it,  and  throwing  it  away  from  him. 
After  seizing  it  he  is  on  the  point  of  dropping  it  suddenly ;  and  when  he 
has  got  hold  of  it  at  last,  if  it  be  a  glass,  for  instance,  and  he  tries  to  drink, 
he  only  succeeds  with  great  difficulty ;  and  before  he  does  so,  as  Sydenham 
says,  he  makes  a  thousand  and  one  contortions,  moves  his  glass  right  and 
left,  until,  on  its  meeting  his  lips  by  chance,  he  gulps  down  the  liquid ;  or, 
again,  he  holds  the  glass  between  his  teeth,  and  lets  it  go  only  after  empty- 
ing it.  You  may  conceive,  gentlemen,  how  difficult  it  is  to  nourish  a 
patient  in  such  cases,  and  why  they  have  to  be  fed  by  others. 

The  face  wears  a  singularly  imbecile  look  from  the  convulsions  of  its 
muscles,  which  give  rise  to  grimaces  of  the  most  varied  kind.  The  eye- 
brow's, the  skin  of  the  forehead,  the  alse  nasi  contract  and  relax;  while  the 
eyelids  are  alternately  raised  and  lowered,  the  lips  pulled  in  various  di- 
rections, the  mouth  opens  and  closes  unceasingly,  and  the  eyes  roll  con- 
vulsively in  the  orbit. 

As  the  muscles  of  the  tongue  are  involved  as  well  as  the  rest,  speech  is 
often  hesitating,  or  the  patient  actually  stammers,  and  can  be  understood 
with  difficulty.  Articulation  is  all  the  more  embarrassed  that  the  muscles 
of  the  larynx  are  themselves  involved  in  some  cases,  and  the  sound  of  the 
voice  being  then  altered,  the  patient  utters  a  kind  of  bark. 

Strange  sounds  are  occasionally  produced  through  the  voice  coming  out 
in  inspiration  instead  of  expiration.  While  the  patient  expires  in  the  act 
of  speaking,  the  inspiratory  muscles  suddenly  contract  convulsively,  and 
cause  the  air  to  rush  into  the  larynx ;  so  that,  from  this  kind  of  antagonism 


836  ON    CHOREA. 

between  the  mind  that  wills  the  speech  and  the  inspiratory  muscles,  the 
voice  undergoes  a  strauge  alteration. 

Lastly,  the  pharynx  and  other  muscles  of  organic  life  may  be  affected  ; 
deglutition  is  then  impaired,  while,  owing  to  the  relaxation  of  the  sphincters 
of  the  rectum  and  bladder,  the  urine  and  fseces  are  passed  involuntarily. 
Such  cases,  however,  are  somewhat  rare. 

Choreic  convulsions,  therefore,  attack  the  muscles  of  the  life  of  relation 
almost  exclusively ;  and  although  the  movements  are  involuntary,  like  all 
convulsions,  the  will  still  possesses  a  certain  influence  over  them.  The  want 
of  co-ordination  seems  to  result  from  the  fact  that  some  of  the  contractions 
are  involuntary,  and  others  voluntary,  but  the  latter  are  not  in  sufficient 
number  to  neutralize  the  former.     I  will  explain  myself. 

When  the  will  commands  freely — as,  for  instance,  when  it  orders  the  arm 
to  rise,  or  the  leg  to  move  forwards,  the  muscles  which  ai'e  charged  with 
the  execution  of  these  movements  do  so  with  perfect  regularity ;  they  act 
with  co-ordination,  and  in  a  perfectly  harmonious  order.  ISTo\v,  while  this 
harmony  persists  still  in  hysterical  chorea,  and  in  the  various  kinds  of 
trembling,  in  which  the  will  is  incapable  of  preventing  the  convulsions  and 
yet  commands  combined  movements,  it  does  not  obtain  in  St.  Vitus's  dance. 
In  this  complaint,  on  the  contrary,  it  seems  that  the  will  is  powerful  enough 
to  call  the  muscles  into  action,  but  is  unable  to  direct  or  moderate  them 
by  means  of  the  antagonistic  muscles  when  the  impulse  has  once  been 
given ;  it  seems  that,  instead  of  obeying  then  a  single  will,  each  muscle 
contracts  at  its  own  pleasure,  or  obeys  different  wills.  This  is  an  important 
fact,  which  is  observed  in  St.  Vitus's  dance,  and  sometimes  also  in  locomotor 
ataxy,  as  I  have  already  told  you. 

There  is  another  phenomenon  which  is  likewise  special  to  this  kind  of 
chorea,  namely,  paralysis,  which  is  almost  always  present.  The  limbs  which 
are  most  affected  with  choreic  movements  are  the  seat  of  the  paralysis  ; 
the  arm,  for  instance,  which  is  the  most  convulsed,  is  the  one  also  in  which 
muscular  strength  is  most  diminished.  The  child  often  complains  that  this 
arm  is  heavier  than  the  other.  The  leg  which  is  most  convulsed  is  also  the 
one  which  bears  the  weight  of  the  body  least,  and  which  is  dragged  the 
most  when  the  child  walks.  This  coexistence  of  a  greater  degree  of  con- 
vulsive agitation  and  of  a  diminution  of  muscular  strength,  is  all  the  more 
inexplicable  that  the  paralysis  is  as  mobile  as  the  choreic  affection  with 
which  it  is  connected.  Thus  when  the  chorea  is  more  marked  in  one  half 
of  the  body,  the  paralysis  is  also  marked  on  that  side  ;  but  if  the  convul- 
sions become  more  violent  on  the  opposite  side,  that  side  will  in  its  turn 
be  paralyzed. 

This  paralysis  disappears  almost  always  simultaneously  with  the  chorea, 
but  it  may  in  some  cases  persist  after  it,  and  be  complicated  with  atrophy 
of  the  paralyzed  muscles,  constituting  then  a  more  or  less  durable  infirmity. 
In  some  still  rarer  instances,  paralysis  I  I  do  not  mean  a  mere  diminution 
of  muscular  strength,  hut  true  paralysis)  precedes  the  manifestation  of  con- 
vulsive phenomena. 

A  girl,  18  years  old,  was  brought  to  Paris  by  her  mother,  who  was 
alarmed  at  seeing  her  seized  with  righl  hemiplegia.  Professor  Amlral  and 
I  were  asked  to  see  her,  and  we  made  out  thai,  besides  a  marked  diminu- 
tion of  muscular  strength,  there  was  also  a  very  appreciable  diminution  of 
cutaneous  sensibility  on  the  righl  side.  On  carefully  examining  the  pa- 
tient, however,  we  noticed  that  her  right  foot  was  constantly  adducted  and 
abducted  iii  turn,  that  her  hand  was  also  perpetually  agitated,  her  fingers 
bending  and  then  straightening  themselves  out.     Moreover,  the  patient 

kept  her  head  inclined  on  her  chest,  and    her  face  wore   a   singular  expres- 


ON    CHOREA.  837 

sion  of  sadness  and  of  fear.  We  immediately  thought  of  St.  Vitus's  dance, 
and  asked  the  mother  whether  these  movements  had  existed  for  a  long 
time,  but  they  had  not  yet  attracted  her  notice.  The  characteristic  symp- 
toms which  soon  afterwards  manifested  themselves  proved  the  accuracy  of 
our  diagnosis. 

The  diminution  of  sensibility  which  we  found  in  this  case  exists  in  most 
instances,  for  disorders  of  sensibility  are  nearly  constant  in  St.  Vitus's  dance. 
I  have  already  spoken  to  you  of  the  vague  pains  which  the  patient  feels 
in  his  limbs,  and  which,  after  announcing  the  invasion  of  the  disease,  per- 
sist when  it  is  fully  developed.  To  them  are  then  superadded  a  sensation 
of  formication,  of  tingling,  and  more  or  less  marked  anaesthesia,  which  is 
always  greater  on  the  most  convulsed  side.  You  saw  me  prick  and  pinch  the 
young  woman  in  bed  31a,  in  St.  Bernard  Ward,  and  thus  recognize  this 
perversion  of  tactile  sensibility.  This  patient  also  told  us  that  she  could 
not  see  very  well  with  her  right  eye,  and  that  this  weakness  of  sight  had 
set  in  since  the  first  attack  of  the  same  complaint,  which  she  had  had  a 
year  before,  and  that  it  had  never  improved.  This  impairment  of  sight, 
which  is  probably  due  to  paralysis  of  the  retina,  has  been  pointed  out  by 
several  authors ;  Dr.  G.  See  records  an  instance  of  it  which  fell  under  his 
own  observation,  but  he  justly  adds  that  this  accident  is  excessively  rare. 

The  convulsions,  and  the  motor  and  sensory  paralysis,  are  not  the  only 
indications  of  the  perturbation  of  the  nervous  system.  With  very  rare 
exceptions  there  is  in  every  case  a  more  or  less  marked  impairment  of  the 
intellectual  facidties.  This  consists  in  a  deeper  modification  than  the  timidity 
and  the  change  in  the  moral  disposition  of  the  patient  which  I  have  men- 
tioned already.  I  do  not  mean,  gentlemen,  that  a  person  who  is  afflicted 
with  St.  Vitus's  dance  becomes  demented  or  an  imbecile  ;  but  although  he 
looks  stupid,  owing  to  the  singular  mobility  of  his  features,  and  the  im- 
pediment in  his  speech  (which  circumstance  may  certainly  mislead,  and 
induce  the  belief  that  the  intellectual  impairment  is  greater  than  it  really 
is),  yet  it  is  unquestionable  that  his  intellect  is  below  par.  If  he  happens  to 
be  at  school,  the  change  which  has  taken  place  in  him  is  found  out  by  his 
losing  his  place  in  the  class.  In  some  exceptional  cases  there  have  been 
signs  of  real  insanity,  and  you  saw  an  instance  of  this  in  the  young  woman 
of  whom  I  have  already  spoken,  and  who  became  choreic  after  an  operation 
performed  by  M.  Jobert. 

This  intellectual  disturbance  is  as  transitory  as  the  disease  itself.  There 
are  instances  on  record,  however  (rare  though  they  be),  of  children  who 
never  again  showed  the  same  degree  of  intelligence  as  before  they  became 
affected  with  St.  Vitus's  dance;  and  cases  have  been  even  related  in  which 
deep  changes  had  been  left  behind — namely,  a  certain  degree  of  hebetude, 
and  even  of  mental  alienation. 

It  more  frequently  happens  that  nervous  excitability  and  an  exaggerated 
sensitiveness  persist  in  some  cases. 

These  disorders  of  innervation  manifest  themselves  also  in  the  organic 
functions,  and  to  them  are  due  the  precordial  anxiety  and  the  palpitations 
of  the  heart  complained  of  by  the  patient.  The  latter  are  accompanied  by 
a  soft  blowing  murmur,  which  is  heard  over  the  base  of  the  heart,  along 
the  vessels  of  the  neck.  It  is  an  ansemic  murmur,  which  should  not  be  con- 
founded with  the  rough  bruit  that  characterizes  rheumatic  endocarditis,  and 
it  is  owing  to  chlorosis,  which  often  complicates  if  it  does  not  precede  chorea, 
and  may  be  regarded  as  an  effect  of  the  influence  of  this  disease  on  nutri- 
tion. The  chlorosis  is,  besides,  characterized  by  the  discoloration  of  the 
integuments,  by  vertigo,  headache,  neuralgic  pain,  singing  in  the  ears — 


838  ON    CHOREA. 

sometimes  by  swelling  of  the  face,  and  in  girls  by  dysmenorrhoea  and  even 
amenorrhoea. 

The  disorders  of  the  digestive  functions,  which  showed  themselves  from 
the  beginning,  either  continue,  or  reappear  and  produce  gastralgia.  There 
comes  a  time  when  the  appetite,  at  first  capricious,  is  lost  entirely,  when 
digestion  is  painful,  and  there  is  actual  overloading  of  the  stomach*.  Con- 
stipation is  also  habitually  present,  as  Sydenham  pointed  out  long  ago. 

Emotion  increases  the  violence  of  the  convulsions,  and  you  should  bear 
this  in  mind,  lest  you  be  mistaken  as  to  the  real  gravity  of  a  case,  on  seeing 
for  the  first  time  a  patient  who  is  not  used  to  you. 

It  is  a  remarkable  circumstance,  which  happens  in  every  case,  that  these 
convulsive  movements,  however  disorderly,  violent,  and  persistent  they 
may  be  when  the  patient  is  awake,  cease  completely  during  sleep,  and  the 
patient  looks  as  quiet  as  in  health.  In  grave  cases,  however,  he  is  restless, 
his  sleep  is  of  short  duration  only,  and  interrupted  by  bad  dreams.  In  still 
more  severe  cases,  the  excessive  agitation  of  the  nervous  system  produces 
insomnia,  which  in  its  turn,  acting  as  a  cause  of  greater  excitability,  gives 
the  unfortunate  patient  no  rest  at  all.  Brain-symptoms  then  set  in — delir- 
ium, coma — and  the  patient  gets  into  a  state  of  exhaustion  which  tends  to 
a  fatal  termination.  When  I  come  to  speak  of  treatment,  I  shall  tell  you 
how  to  combat  this  dangerous  complication,  which,  if  not  opposed  in  time, 
becomes  so  severe  as  to  be  soon  beyond  remedy ;  and  I  shall  tell  you  also 
that,  although  they  be  of  real  and  unquestionable  utility,  these  measures 
are  no  longer  useful,  and  should  be  replaced  by  others  as  soon  as  the  dis- 
ease resumes  its  regular  course. 

Although  St.  Vitus's  dance  usually  terminates  favorably,  and  gets  well 
after  having  lasted  from  one  to  several  months,  it  may  not  only  leave  behind 
it,  as  I  have  told  you,  excessive  nervous  irritability,  partial  paralysis,  and 
intellectual  debility,  but  it  may  also  cause  death.  Although  such  cases  are 
rare,  they  are  but  too  frequent  still ;  and  I  told  you  of  two  instances — one 
that  of  a  young  woman  in  St.  Bernard  Ward,  and  the  other  of  a  girl  at- 
tended by  Dr.  Legroux  and  myself.  I  have  myself  met  with  five  or  six 
cases  of  the  kind  in.  the  course  of  my  practice,  and  M.  Moynier  has  related 
several  similar  instances  of  the  kind  in  his  thesis. 

Death  may  take  place  from  the  extreme  agitation ;  it  may  be  due  to  ner- 
vous exhaustion,  or  to  cerebral  rheumatism  (as  in  cases  which  I  shall  relate 
to  you),  or  it  may  be  the  result  of  no  less  formidable  accidents.  The  patient 
may  die  of  a  fever  similar  to  that  which  kills  persons  who  have  been  burnt 
over  a  large  surface,  and  the  analogy  is  the  more  striking  that  this  fever 
ari-< ■>  from  more  or  less  numerous  and  extensive  wounds,  which  are  pro- 
duced in  the  following  manner. 

I  told  you  that  choreic  patients  were  sometimes  unable  to  stand,  and 
were  compelled  to  remain  in  bed.  Their  agitation  is  then  so  excessive  thai 
they  arc  kept  in  bed  with  the  greatest  difficulty.     Their  movements  are  so 

disorderly  and  violent  that  they  knock  themselves  against    the  w 1  or 

ironwork  of  the  bedstead,  bruise  themselves  severely  ;  and  these  bruises, 
getting  inflamed,  become  the  Btarting-points  of  purulent  infiltrations  and  of 
phlegmonous  erysipelas.  Or,  again,  they  rub  off"  their  skin,  which  they 
literally  wear  out  by  constantly  robbing  againsl  the  bedclothes,  which  they 
tear  to  pieces.  Horrible  wounds  are  thus  produced,  which,  deepening  by 
degrees,  reach  the  bony  prominences  of  the  heels,  the  malleoli,  elbows,  spine, 
and  scapula'.  You  may  conceive  the  consequences  which  must  follow  the 
pain  and  abundanl  suppuration  to  which  these  wounds  give  rise. 

Such  wounds  are  the  more  easily  produced  thai  the  same  thing  happens 
in  St.  Vitus's  dance  as  in  grave  fevers — in  all  diseases,  in  fact,  which 


ON    CHOREA.  839 

deeply  affect  the  nervous  system,  and  in  which  there  is  a  marked  tendency 
to  suppuration  and  ulceration. 

The  following  case,  which  was  communicated  to  me  by  a  country  prac- 
titioner, is  an  important  one,  as  bearing  on  this  point: 

A  young  girl,  whose  mother  was  healthy,  but  whose  father  had  been 
subject  to  eczematous  eruptions,  and  who  was  of  delicate  health  herself, 
and  had  had,  in  the  preceding  year,  eczema  of  the  head,  neck,  and  shoulder, 
became  choreic.  The  disease  grew  so  violent  in  a  few  days  that  she  was 
unable  to  feed  herself.  Strychnine  was  given,  in  gradually  increasing 
doses  (up  to  li  grain)  in  the  course  of  the  twenty-four  hours ;  it  did  not 
produce  tetanic  rigidity,  and  quieted  the  symptoms  markedly,  so  that  the 
patient  was  soon  able  to  drink  by  herself,  with  scarcely  any  difficulty. 
The  tip  of  the  right  thumb,  however,  became  affected  with  a  whitlow, 
which  got  well  rapidly  ;  but  two  days  after  the  wound  had  healed,  although 
the  convulsions  had  notably  improved,  the  child  was  seized  with  high  fever 
and  diarrhoea.  Diffuse  phlegmonous  inflammation  of  the  hand  soon  showed 
itself,  which  in  less  than  twenty-four  hours  involved  the  back  of  the  wrist 
and  forearm,  so  that  several  incisions  had  to  be  made.  From  the  outset 
the  greatest  precautions  had  been  taken,  in  order  to  prevent  the  excoria- 
tions which  the  agitation  made  one  dread.  The  patient  was  placed  on  a 
mattress  laid  on  the  floor,  and  constant  watch  was  kept  over  her.  Later, 
when  the  convulsions  became  more  violent,  her  limbs  were  wrapped  in 
small  cushions,  and  then  a  strait-jacket  put  on.  The  phlegmonous  in- 
flammation of  the  upper  limb  seemed  to  be  proceeding  towards  a  favorable 
termination  ;  the  suppuration  was  less  ;  the  walls  of  the  suppurating  cavity 
had  a  tendency  to  adhere  together  ;  the  fever  had  ceased,  and  the  convul- 
sive movements  continued  to  improve,  when  fever  and  diarrhoea  returned 
with  greater  severity.  Phlegmonous  inflammation  attacked  the  lower  limb 
also,  and  within  two  days  it  affected  the  right  leg  and  thigh,  and  this  time 
it  resisted  all  treatment.  Unhealthy  pus  was  secreted,  the  skin  became 
loose  over  an  extensive  surface,  the  wound  ulcerated,  the  soft  parts  Were 
destroyed,  and  the  tendons  exposed.  Numbers  of  bullae,  filled  with  a  cloudy 
and  purulent  serosity,  developed  themselves  on  the  neck,  trunk,  and  limbs, 
especially  on  the  arms — some  of  the  diameter  of  a  lentil,  and  others  of  a 
larger  size ;  ulcers  formed  on  the  lips  and  tongue  and  in  the  pharynx  even. 
The  fever  became  more  violent,  typhoid  symptoms  set  in,  and  the  patient 
died  about  three  weeks  after  the  manifestation  of  the  first  phlegmonous  in- 
flammation. 

In  this  case,  as  the  practitioner  who  attended  it  remarked,  death  was 
the  consequence  of  the  nervous  exhaustion,  brought  on  by  excessive  jacti- 
tation and  exaggerated  by  sleeplessness  ;  for  the  poor  child  had  scarcely 
four  hours'  sleep,  and  even  then  of  interrupted  sleep,  in  the  course  of  the 
twenty-four  hours.  The  exhaustion  was  increased  by  the  malnutrition  of 
the  patient,  who  could  not  feed  herself,  and,  lastly,  by  the  abundant  suppu- 
ration of  the  phlegmonous  erysipelas  from  which  she  suffered,  and  the 
starting-point  of  which,  like  that  of  the  bulla?,  was  the  adynamia  which 
was  consequent  on  this  nervous  exhaustion. 

Death  comes  on,  sometimes,  as  a  result  of  cardiac  rheumatic  complica- 
tions, as  in  the  following  case,  which  was  in  one  of  my  wards  : 

A  young  woman,  twenty-four  years  of  age,  was  admitted  into  St.  Bernard 
Ward  on  February  3,  1861.  She  told  us,  and  her  mother  confirmed  her 
statement,  that  on  January  1,  she  had  had,  with  her  sister-in-law  and  her 
husband,  a  rather  sharp  quarrel,  which  had  excited  her  considerably ;  soon 
after  this,  it  was  noticed  that  she  was  more  irritable  than  usual.  On 
January  15  she  had  not  perfect  command  over  the  movements  of  her  right 


840  ON    CHOREA. 

hand,  and  had  some  difficulty  in  sewing  and  ironing.  To  this  disorder  of 
motility,  which  rapidly  increased  in  the  right  arm,  there  was  superadded 
a  certain  degree  of  agitation  when  she  walked.  She  still  continued,  how- 
ever, to  attend  to  her  household,  and  to  nurse  her  last  child,  who  was  five 
months  old.  In  the. last  days  of  January  the  movements  of  the  right  side 
of  the  body  were  more  disorderly,  and  became  notably  more  so  every  day. 
On  her  admission  her  right  hand  and  arm  were  most  affected,  and  were 
constantly  moved  in  jerks  ;  her  gait  Avas  unsteady,  and  she  rested  instinc- 
tively against  the  wall  or  against  her  bed  when  she  stood  up.  Sensibility 
was  found  normal  wherever  it  was  tested,  and  the  patient's  mind  was  clear  ; 
the  choreic  movements  of  the  muscles  of  her  face,  and  especially  of  her 
lips  imparted  to  her  physiognomy  a  rather  strange  look.  Her  manner  of 
speaking  was  markedly  hurried,  and  her  thoughts,  although  very  clear, 
were  extremely  versatile.  Thus,  when  it  was  proposed  to  take  away  her 
child,  who  ran  the  risk  of  being  dropped  from  her  arms,  she  began  to  cry  ; 
then  comforted  herself,  asking  that  her  friends  should  have  the  child,  and 
a  moment  after  requesting  that  he  should  be  left  with  her.  For  several 
months  past  she  had  only  slept  or  even  dozed  for  four  or  five  hours  every 
night,  complaining  of  numbness  in  the  limbs,  which  disappeared  only  when 
she  shifted  herself,  or  when  she  got  up  and  walked  about.  She  had  never 
had  rheumatic  pain,  and  no  blowing  murmur  was  heard  over  the  heart. 
Her  previous  health  had  been  good  until  January  1.  Her  muscular 
strength,  when  tested  with  the  dynamometer,  gave  twelve  pounds  for  the 
right  hand,  and  nine  pounds  for  the  left. 

For  the  first  two  days  after  her  admission  into  the  Hotel-Dieu,  she  took 
two  spoonfuls  of  the  syrupus  strychnia?.  As  her  agitation  persisted,  I  then 
gave  her  syrup  of  opium,  repeated  every  hour,  in  order  to  procure  sleep  ; 
and  although  the  dose  of  extract  of  opium  amounted  on  the  first  day  to  11 
grains,  she  only  had  four  hours'  uninterrupted  sleep.  On  the  following 
days,  the  quantity  of  opium  was  gradually  increased,  but  without  benefit. 
The  agitation  was  still  extreme  on  February  9  ;  the  patient  kept  shrieking, 
and  rolling  through  the  ward  in  search  of  fresh  air;  her  mind  was  not  af- 
fected, for  she  gave  clear  answers  to  questions  put  to  her.  But  her  agita- 
tion, the  curt  and  jerked  manner  in  which  she  spoke,  her  singular  aspect, 
the  constant  movements  of  the  muscles  of  her  face,  and  continued  want  of 
sleep  for  three  days,  indicated  great  cerebral  excitability.  The  quantity  of 
opium  was  again  increased  on  February  9;  laudanum  was  added  to  the 
syrup,  so  that  from  9  a.m.  to  6  p.m.  she  took  every  hour  2  grains  of  extract 
of  opium  ;  this  dose  was  slightly  diminished  in  the  evening.  She  fell  asleep 
at  12  P.M.,  after  having  thus  taken  from  15  to  17  grains  of  opium.  The 
next  morning  her  breathing  was  calm,  her  pulse  was  very  regular,  and 
had  a  certain  degree  of  strength  (120  to  130)  ;  her  pupils  were  contracted, 
and  she  was  in  a  deep  sleep,  from  which  I  did  not  attempt  t<>  rouse  her. 
About  half  past  twelve,  however,  her  respiration  suddenly  became  embar- 
rassed, and  there  was  some  tracheal  rhonchus ;  the  breathing  suddenly  be- 
came  inappreciable,  and  the  patient,  who  looked  as  if  asleep,  died  without 
agony  and  without  fresh  convulsions. 

A  post-mortem  examination  was  made  on  Tuesday,  February  21,  forty- 
four  hours  after  death.      There   was   no    notable   change   in    the   brain   and 

spinal  cord.  There  was  merely  Blight  injection  of  the  cerebral  meuinges, 
without  a  large  amount  of  serosity  in  the  ventricles.  The  cortical  ami 
centra]  white  ami  gray  matter  were  of  normal  color  ami  consistency.  The 
pia-mater  could  he  stripped  oil'  without  lacerating  the  cerebral  Bubstance, 
ami  there  were  no  opaline  -pot-  in  the  interlobar  fissures.  The  lungs  pre- 
sented only  a  few  cicatrices  at  the  apex,  and  were  not  engorged.    The  heart 


ON    CHOREA.  841 

was  in  its  normal  position,  and  of  normal  size  and  color.  The  right  cham- 
ber of  the  organ  and  the  pulmonary  artery  contained  no  fibrinous  clots  oor 
blood-concretions,  and  the  orifices  were  free  and  healthy.  The  endocardium 
was  of  pinker  hue  than  normal  in  the  right  and  left  chambers.  The  aortic 
orifice  was  free,  and  the  sigmoid  valves  healthy.  The  mitral  orifice  was  of 
normal  dimensions,  but  the  mitral  valve  was  covered,  on  its  free  edge  and  on 
its  auricular  surface,  with  small  polypoid  concretions,  of  pink  and  yellowish 
color,  agglomerated,  mulberry-like,  very  adherent,  semi-transparent,  and 
resisting  pressure.  Under  the  microscope  (600  cliam.  Nachet)  they  were 
seen  to  consist  of  amorphous  granulations  and  rudimentary  fibrilke  of  con- 
nective tissue.  There  was  valvular  endocarditis,  and  yet  there  had  been 
no  blowing  murmur  during  life,  for  we  had  only  heard  a  dry  valvular  click. 
The  abdominal  organs  presented  nothing  worth  noting.  There  were  nu- 
merous ecchymoses  on  the  arms  and  legs,  and  incipient  sloughing  over  the 
sacrum. 

As  in  the  case  of  other  neuroses,  pathological  anatomy  teaches  us  scarcely 
anything  as  to  the  material  alterations  of  the  nervous  centres  in  St.  Vitus's 
dance.  If  you  consult  various  authors,  you  will  find  contradictory  facts 
and  opinions.  One  looks  upon  inflammation  or  induration  of  the  tubercula 
quadrigemina  as  the  characteristic  lesion  of  the  disease  ;  another  regards  as 
such  induration  or  hypertrophy  of  the  brain  or  of  the  spinal  cord,  or  a 
more  or  less  extensive  softening  of  the  cerebro-spinal  centres ;  a  third  be- 
lieves in  calcareous  concretions  of  the  brain,  a  fourth  in  cysts  of  the  pineal 
gland,  or  osteoids  of  the  vertebral  canal,  and  I  know  not  what  else.  But 
does  not  this  very  diversity  of  the  lesions  found  after  death  prove  that  there 
is  no  relation  between  them  and  the  dynamic  phenomena,  even  if  it  had 
not  been  ascertained  that  in  most  cases  no  appreciable  anatomical  change 
can  be  detected  in  the  nerve-centres  ?  For  my  own  part,  in  the  rare  in- 
stances in  which  I  have  examined  the  bodies  of  individuals  who  had  died  of 
St.  Vitus's  dance,  after  presenting  the  most  violent  symptoms  of  the  disease, 
I  never  met  with  any  lesion,  I  do  not  mean  which  could  account  for  death 
(for  in  all  diseases  whatever,  in  which  there  is  an  evident  relation  between 
certain  symptoms  and  certain  organic  lesions,  the  latter  are  far  from  al- 
ways accounting  for  the  cessation  of  life,  especially  in  cerebral  affections), 
but  which  seemed  to  me  to  be  in  accordance  with  the  convulsive  phenom- 
ena of  chorea. 

Because  tubercles  were  found  in  the  brain  in  some  instances,  no  one  can 
infer  that  this  pathological  condition  is  a  characteristic  lesion  of  St.  Vitus's 
dance,  and  even  in  such  cases  it  may  be  questioned  whether  there  was  any 
correlation  between  the  tuberculization  of  the  brain  and  the  chorea.  I  do 
not,  of  course,  allude  to  cases  in  which  there  were  merely  choreiform  symp- 
toms, for  such  are  no  more  instances  of  chorea  than  epileptiform  seizures 
are  of  true  epilepsy,  and  the  symptoms  are  evidently  dependent,  more  or 
less  directly,  on  the  appreciable  organic  alteration.  In  cases  of  genuine 
chorea,  the  question  arises,  whether  there  was  not  merely  a  coincidence 
between  this  neurosis  and  the  organic  lesion  in  the  brain,  and  whether  they 
were  not  both  manifestations  of  a  diathesis  and  nothing  more?  This  view 
of  the  question  is  very  plausible,  or  admits  at  the  very  least  of  discussion, 
when  it  is  remembered  that  St.  Vitus's  dance  may  show  itself  in  phthisical 
individuals,  in  whose  nervous  centres  no  tubercular  deposit  is  found  after 
death,  although  such  deposit  may  be  seen  in  other  parts — in  the  peri- 
toneum, for  instance,  as  in  a  case  of  Dr.  Eufz,  or  in  the  lungs,  as  in  a  pa- 
tient under  my  care  at  the  Necker  Hospital.  It  is  not,  therefore,  this  or 
that  lesion  which  caused  the  development  of  the  convulsive  affection  ;  but  it 
is  the  diathesis  itself,  which  not  only  revealed  itself  during  life  by  special 


842  ON    CHOREA. 

symptoms,  and  after  death  by  peculiar  anatomical  characters,  but  which 
expressed  itself  also  by  the  production  of  St.  Vitus's  dance,  as  it  does  in 
other  cases  by  the  development  of  other  neuroses. 

As  to  the  rheumatic  organic  lesions  of  the  heart  and  of  serous  membranes, 
they  are  a  material  proof  of  the  relations  which  exist  between  rheumatism 
and  St.  Vitus's  dance,  but  they  have  never  been  regarded  as  characterizing 
the  disease. 

I  wish  now  to  call  your  attention  to  the  influence  which  Intercurrent 
Febrile  Diseases  possess  on  St.  Vitus's  dance,  and,  vice  versa,  the  latter  on  the 
former.  Dr.  G.  See  is  the  one  who  has  studied  this  point  the  most.  "While 
chorea  but  slightly  modifies  intercurrent  diseases,  the  latter,  febrile  affec- 
tions in  particular,  have  unquestionably  an  influence  on  the  course  of  ner- 
vous phenomena  in  general,  which  has  been  clearly  indicated  in  the  works 
of  the  ancients.  '  It  is  better,'  said  Hippocrates,  '  that  fever  should  set  in 
subsequently  to  spasms  than  spasms  after  fever.'  In  another  passage  he 
speaks  in  clearer  terms,  saying  '  that  spasms  may  be  arrested  by  acute 
fever' — an  axiom  which  is  fertile  in  applications,  but  which  has  been  re- 
jected by  many,  because  it  implies  important  restrictions,  which  have  not 
been  taken  into  account,  and  have  therefore  raised  doubts  as  to  the  truth 
of  the  statement.  For  if  there  be  instances  of  chorea  on  record  which  was 
arrested  by  an  exanthematous  fever,  and  afterwards  recurred  for  a  time,  only 
disappearing  at  last  rapidly  with  or  without  treatment,  thus  conclusively 
showing  the  iufluence  of  the  fever  on  the  course  of  the  chorea,  there  are 
other  cases  also  which  clearly  indicate  that  the  axiom  of  Hippocrates  may 
be  completely  at  fault.  Thus  Dr.  Rufz  rejects  it,  and  relates  two  cases  of 
chorea  complicated  with  measles,  one  of  which  continued  until  death  with- 
out becoming  modified. 

"The  only  way  to  interpret  these  difficulties,  and  to  conciliate  opinions 
that  are  so  opposed  to  each  other,  is  to  appeal  to  clinical  observation,  and 
submit  the  facts  to  a  rigorous  analysis.  Now,  of  128  cases  which  we  col- 
lected, and  in  70  of  which  febrile  complications  existed,  rheumatic  fever 
was  present  25  times,  and  exanthematous  fevers  17  times — namely,  scarla- 
tina, 10  times  ;  measles,  3  times  ;  idiopathic,  ephemeral,  or  catarrhal  fevers, 
12  times;  and  inflammations,  16  times  (pneumonia,  7,  angina,  3,  phleg- 
monous inflammation,  4  times,  and  diphtheria  twice). 

"These  various  diseases,  which  have  but  one  symptom,  fever,  in  common, 
exert  a  similar  influence  on  the  nervous  phenomena.  When  these  are  on 
the  point  of  disappearing,  they  are  suddenly  arrested  by  the  fever,  but  this 
is  exceptional  only.  When  they  are  not  declining,  the  fever  first  produces 
a  general  excitation,  attended  with  evident  exasperation  of  the  choreic  move- 
ments, which  latter  continue  as  long  as  the  premonitory  and  invasion  stages, 
and  the  period  of  increase  of  the  disease  last  (from  twenty-four  to  thirty-sis 
hours  in  the  case  of  ephemeral  fevers,  and  from  two  to  seven  days  in  continued 
fevers  and  in  inflammations);  then,  as  soon  as  the  fever  has  reached  its 
point  of  maximum  intensity,  the  choreic  jactitation  begins  to  calm  down  ; 
and  from  the  time  when  the  reaction  ceases,  although  the  pulse  is  more  fre- 
quent, and  the  heat  of  the  skin  still  greater  than  in  health,  the  spasmodic 
movements  diminish,  and  lastly  disappear  for  good — yielding  to  the  efforts 
of  nature  alone,  and  the  more  easily  that  the  neurosis  has  been  of  longer 
duration.  Lastly,  in  a  case  of  chorea  which  has  just  set  in,  or  which  i-  on 
the  increase,  the  only  favorable  change  is  that  which  takes  place  in  the  in- 
terval of  time  which  elapses  from  the  invasion  of  the  fever;  hence,  it'  the 
fever  lasts  fur  a  short  period  only,  ami  does  not  allow  time  for  the  improve- 
ment of  the  nervous  symptoms,  the  latter  persist  until  the  patient's  strength 
is  exhausted;   and  when  his  genera]  condition  is  such  that  his  life  is  en- 


ON    CHOREA.  843 

dangcred,  the  gesticulations  recur  until  death.  In  nine  cases  which  ended 
fatally,  the  muscular  agitation  continued  in  this  manner  until  death,  run- 
ning fatally,  as  it  were,  a  parallel  course  to  the  phases  of  the  intercurrent 
disease.     All  these  circumstances  seem  formally  to  contradict  the  principle 

enunciated  by  Hippocrates ;  for  although  it  expresses  a  real  and  certain 
truth,  the  statement  is  only  accurate  if  the  precise  moment  when  the  crisis 
takes  place  be  taken  into  account.  The  disappearance  of  the  nervous  phe- 
nomena does  not  occur  at  the  outset  of  the  fever,  but  generally  after  the 
remission  of  the  febrile  symptoms,  and  on  the  express  condition  that  the 
nervous  state  be  on  the  decline;  so  that  whenever  fever  is  lighted  up  in  a 
patient  who  has  been  suffering  from  chorea  for  five  or  six  weeks  previously, 
the  convulsive  movements  will  cease  :  spasmos  febris  aecedens  solvit.  Most 
of  these  remarks  are  applicable  to  the  various  kinds  of  chorea." 

I  told  you,  gentlemen,  that  after  lasting  a  variable  time,  St.  Vitus's 
dance  in  most  cases  got  well ;  the  improvement  is  nearly  uniform  in  its 
course,  the  convulsions  disappearing  in  the  lower  limbs  before  they  do  so  in 
the  upper  extremities.  Their  violence  goes  on  decreasing,  and  there  comes 
a  time  wdien  they  only  manifest  themselves  when  the  movement  -which  is 
performed  requires  a  certain  degree  of  energy  or  a  good  deal  of  precision. 
The  face,  however,  still  retains  for  some  time  a  grinning  expression,  and 
the  intellect  remains  weak.  At  last  all  these  symptoms  disappear,  and  the 
patient  recovers  his  normal  condition. 

It  is  not  uncommon,  however,  that  the  cure  is  temporary  only ;  after  a 
variable  period  of  time,  a  few  weeks  perhaps,  the  agitation  returns,  and 
there  is  a  relapse.  In  other  cases,  several  months,  one,  two,  or  three  years, 
elapse  before  a  recurrence  of  the  disease  takes  place. 

It  is  worthy  of  notice,  that  the  duration  of  the  complaint  in  relapses  and 
recurrences  is  generally  shorter  than  in  the  first  attack.  This  law  of  de- 
crease is  far  from  being  absolute,  however,  for  the  reverse  obtains  in  some 
cases.  Thus  Dr.  Moynier  saw  a  child,  ten  years  old,  whose  first  attack  of 
chorea  lasted  two  months,  while  a  second  attack  lasted  two  months  and  a 
half,  and  a  third  and  last  three  months.  In  another  case  the  first  attack 
lasted  two  months,  the  second  three,  and  the  third  five  months.  But  as  the 
law  of  decrease  applies  to  the  generality  of  cases,  you  should  be  aw7are  of  it, 
and  you  should  take  it  into  account  in  order  to  appreciate  the  value  of  the 
treatment  which  has  been  had  recourse  to.  From  not  paying  sufficient  at- 
tention to  the  natural  course  of  the  disease,  and  from  not  taking  into  con- 
sideration that  after  having  gone  through  its  different  stages,  and  lasted  a 
determinate  period  of  time,  St.  Vitus's  dance  generally  got  well  spontane- 
ously, cures  which  were  entirely  due  to  nature  have  been  ascribed  either  to 
methods  of  treatment  based  on  more  or  less  erroneous  theories,  or  to  em- 
pirical remedies.  Although  this  is  the  case  in  a  great  many  and  perhaps 
in  most  cases,  in  some,  however,  medical  interference  may  be  of  use,  by  di- 
minishing the  violence  of  the  symptoms,  and  shortening  a  little  (sometimes 
very  markedly)  their  duration.  It  may  be  especially  of  use  against  certain 
complications,  which,  if  left  to  themselves,  may  lead  to  the  most  fatal  con- 
sequences. 

NowT,  gentlemen,  what  are  the  therapeutical  measures  of  which  we  can 
dispose  in  the  treatment  of  St.  Vitus's  dance  f 

I  will  spare  you  the  tedious  enumeratien  of  a  great  many  remedies  which 
have  been  recommended,  based  on  certain  theoretical  views  Avhich  are  per- 
fectly erroneous;  nor  will  I  say  anything  of  those  pretended  specifics  wdiich 
have  been  invented  by  superstition,  or  by  coarse  empiricism,  and  which  are- 
nowadays  justly  forgotten.  I  will  only  speak  of  those  methods  of  treatment 
the  efficacy  of  which  is  recognized,  which  slightly  disturb  the  natural  phe- 


844  OX    CHOREA. 

nomena  of  the  disease,  and  make  the  patient  run  the  least  amount  of  risks, 
and  which  have  been  adopted  by  the  generality  of  good  practitioners. 

The  water-cure,  vauuted  first  by  Dumangin,  formerly  physician  to  the 
Charite  Hospital,  by  Bayle,  and  afterwards  by  Jadelot,  of  the  Children's 
Hospital,  consists  in  the  administration  of  baths,  or  the  use  of  cold  lotiom, 
with  water  of  10°  or  15°  Cent.  The  baths  or  the  lotions  are  repeated  two 
or  three  times  a  day,  for  one  or  two  minutes  each  time;  and  the  child  is 
quickly  wiped  and  dressed,  and  should  immediately  afterwards  take  as 
much  exercise  as  possible.  This  treatment  acts  both  through  the  sedative 
and  tonic  properties  of  cold,  and  through  the  momentary  perturbation  of 
the  nervous  system  which  it  occasions.  It  moderates  the  intensity  of  the 
disease,  even  though  it  does  not  arrest  it,  or  sensibly  shorten  its  duration ; 
and  from  its  favorable  influence  on  the  whole  system,  it  places  the  patient 
in  a  good  condition  for  going  through  the  attack. 

River  and  sea-bathing  are  other  forms  of  the  same  method  of  treatment, 
and  I  recollect  seeing,  at  an  establishment  of  mineral  baths,  an  arrangement 
intended  to  imitate  what  is  known  under  the  name  of  wave-bathing.  The 
patient  was  placed  on  a  kind  of  swing,  so  arranged  that  when  it  oscillated 
he  went  very  rapidly  through  the  most  superficial  layer  of  the  water  in  the 
tank  over  which  he  was  balanced. 

Cold  baths  have,  however,  unquestionable  disadvantages.  Children,  on 
the  one  hand,  take  them  with  a  certain  reluctance,  and  on  the  other  hand, 
even  when  they  are  administered  with  the  greatest  precautions,  they  may 
bring  on  rheumatism,  which  was  only  threatening,  or  intensify  it  if  it  be 
already  present ;  in  the  latter  case,  therefore,  they  should  be  abstained  from. 

On  this  account,  cold  baths  were  replaced  at  the  Children's  Hospital  by 
baths  at  from  15°  to  18°  Cent.  (59°  to  65°  Fahr.),  and  I  have  myself  ad- 
vised that  the  child  should  be  merely  dipped  two  or  three  times  into  water 
at  first  of  24°  Cent,  (about  75°  Fahr.),  but  the  temperature  of  which  was 
to  be  gradually  lowered  every  day. 

Baudelocque  was  the  first  to  propose  sulphur-baths,  and  to  lay  down  roles 
for  their  administration  and  their  indications;  their  efficacy  is  sufficiently 
marked  to  make  most  trustworthy  practitioners  (my  colleague,  Dr.  Blache, 
among  others)  adopt  them  as  their  chief  remedial  measure.  They  should 
be  prepared  with  from  half  an  ounce  to  an  ounce  of  sulphuret  of  potassium 
dissolved  in  100  litres  of  water,  at  a  temperature  of  from  30°  to  31°  Cent. 
(about  86°  Fahr.  |,  and  should  be  taken  for  an  hour  at  the  most.  It  is 
essential  that  they  should  be  repeated  with  great  regularity  every  day.  In 
cases  of  threatening  rheumatism  these  baths  are  contraindicated. 

Besides,  gentlemen,  the  great  medical  law,  on  which  I  every  day  insisl 
so  much  (for  it  finds  its  application  every  moment  i — namely,  the  influence 
of  medical  constitutions  on  the  results  of  treatment — also  applies  to  chorea. 
Thus,  Baudelocque  and  his  cull,  agin-,  M.  Bouneau,  found  themselves  com- 
pelled, in  a  period  of  from  eight  to  ten  years,  to  vary  their  treatment  of 
chorea:  al  first  the  disease  was  quickly  cured  by  cold  water,  but  a  few 
years  later  sulphur-baths  had  to  1>«'  administered;  while  these  latter  again 
proved  of  no  Bervice  after  a  time,  and  had  to  be  replaced  by  preparations 
of  iron. 

Among  the  various  methods  of  treatment  of  chorea,  gymruuti 
certainly  hold-  a  pretty  important  rank  ;  and  Dr.  Blache  has  of  late  made 
an  interesting  communication  on  this  subject  to  the  Academy  of  Medicine,11 

*  '*  M&noires  de  l'Academie  de  M6decine"  (Paris,  1855),  t.   \i\.  p 
also  a  learned  report  by  M.   Bouvier  ("Bulletin  de  l'Acad6mie  de  Mfidecine,"  t. 

xx.  p. 


ON    CIIOREA.  845 

in  which  he  has  given  the  results  of  his  long  experience.  The  idea  is  not 
novel,  although  it  has  been  recently  brought  forward  again;  for  Dr.  Louvet- 
Lamarre  (of  St.  Germain-en-Laye)  published  a  case,*  in  1827,  tending  to 
show  the  utility  of  gymnastic  execises.  The  kind  of  exercise  which  he  par- 
ticularly recommended  was  that  of  skipping  with  the  rope. 

I  have  many  a  time  heard  Recamier  speak  in  terms  of  praise  of  the  good 
results  which  he  had  obtained  from  what  he  called  prescribed  and  regulated 
gymnastic  exercise,  and  which  consisted  in  performing  movements  in 
measured  time.  He  thus  told  choreic  children  to  follow  drummers  when 
beating  to  quarters,  and  recommended  their  friends  to  make  them  beat 
time  several  times  in  the  day.  I  have  often  availed  myself  of  this  idea  of 
Recamier,  and  have  advised  choreic  individuals  to  execute  rhythmical 
movements,  guided  themselves  by  a  metronome,  or  by  the  pendulum  of  one 
of  those  village-clocks  called  cuckoos,  keeping  time  to  their  oscillation.  In 
the  beginning  partial  movements  are  executed  as  directed,  then  combined 
movements,  at  first  quickly  (for  they  are  more  easily  performed  thus),  and 
then  more  slowly.  I  have  by  this  means  succeeded  in  modifying  not  the 
symptoms  of  St.  Vitus's  dance  alone,  but  of  other  kinds  of  chorea,  also  and 
in  particular  of  the  forms  of  tic,  which  I  shall  speak  of  presently. 

It  would  seem  as  if,  in  this  method  of  treatment,  a  strange  will  replaced, 
after  a  time,  the  patient's  will,  which  was  unable  to  co-ordinate  the  move- 
ments which  itself  commanded. 

The  principle  according  to  which  the  gymnasiarch  deals  with  the  indi- 
viduals who  are  intrusted  to  his  care,  is  exactly  similar  to  the  one  which  I 
have  just  described.  He  makes  them  go  through  certain  movements,  which 
he  first  performs  himself  before  them  ;  and  in  order  to  insure  their  being 
done  harmoniously,  he  makes  them  repeat  with  him  cadenced  songs.  He 
begins  with  simple  movements,  such  as  the  acts  of  stretching  out  and 
bending  the  arms,  flexing  and  extending  the  knees,  and  striking  the  ground 
with  the  foot  in  cadence ;  and  when  the  children  succeed  in  executing 
these  movements  with  regularity,  he  tries  to  make  them  walk  in  step,  slowly 
or  quickly,  and  next  he  makes  them  run.  Lastly  he  makes  them  swing  or 
raise  themselves  by  their  arms,  going  by  that  means  through  manoeuvres 
which  are  gradually  more  complicated.  These  exercises  are  repeated  every 
day,  and  are  not  kept  up  for  more  than  half  an  hour,  so  as  to  be  within 
fatigue.  There  are  certainly  great  difficulties  to  overcome  in  the  beginning, 
but  in  a  short  time,  and  from  the  first  attempts,  a  certain  regularity  of  the 
movements  is  obtained  for  a  few  moments,  and  this  improvement  becomes 
more  and  more  marked. 

But  regulated  gymnastic  exercise  cannot  always  be  managed,  and  may 
then  be  replaced  by  movements  regulated  by  means  of  a  metronome  or  of  a 
pendulum,  by  exercises  such  as  dancing,  skipping  with  a  rope,  &c,  although 
the  latter  are  not  followed  by  the  same  beneficial  results.  It  is  especially 
towards  the  close  Of  the  disease  that  such  results  are  obtained,  so  that  gym- 
nastic exercises  are  only  accessory  in  the  treatment  of  St.  Vitus's  dance, 
and  I  have  more  faith,  therefore,  in  the  internal  administration  of  remedies. 

Of  these  remedies,  some  act  on  the  general  condition  of  the  system,  which 
complicate  the  chorea,  and  influence  it  more  or  less.  First  among  these 
are  tonics  and  preparations  of  iron,  when  the  disease  is  due  to  chlorosis, 
which  not  only  accompanies  but  often  precedes  it. 

On  the  same  ground,  again,  arsenic  has  been  prescribed,  from  its  possess- 
ing, as  you  are  aware,  the  property  of  causing  general  excitation,  and  espe- 
cially increased  vigor  of  the  lower  extremities.     Dr.  Rayer,  who  has  given 

*  "Nouvelle  bibliotheque  medicate, "  t.  xvii,  p.  408. 


846  ON    CHOREA. 

it  in  cases  of  old  and  obstinate  chorea,  which  had  resisted  the  usual  methods 
of  treatment,  has  thus  been  able  to  improve  and  even  to  cure  them  com- 
pletely. 

Yet,  gentlemen,  although  other  instances  in  which  this  treatment  was 
successfully  employed  have  been  recorded  by  Thomas  Martin  ( who  first 
used  arsenic),  by  Gregory,  by  Latter,  and  more  recently  by  Babington,  by 
Hughes,  and  by  Begbie,  this  drug  has  been  laid  aside  by  these  very  men 
who  were  the  first  to  advocate  it,  either  on  account  of  its  difficult  adminis- 
tration, and  the  prudence  required,  or  because  the  success  attending  it  was 
really  questionable.  Yet,  let  me  add  at  once,  arsenic  is  administered  with 
greater  facility  than  iodine,  and  especially  than  strychnine,  of  which  I  shall 
presently  speak. 

Iodine  and  iodide  of  potassium  have  been  likewise  vaunted,  and  are  indi- 
cated when  the  object  is  to  modify  a  strumous  diathesis  and  a  predominating 
lymphatic  temperament. 

Other  modes  of  treatment  act  directly  on  the  nervous  system.  One  of 
these  is  pre-eminently  a  sedative  plan,  which  is  said  to  have  been  formerly 
used  with  benefit  by  Rasori,  and  without  doubt  by  Laennec,  in  1822,  and 
which  has  been  revived  within  the  last  few  years,  after  having  been  for- 
gotten for  a  long  time :  I  mean  the  treatment  by  tartar  emetic  in  large 
doses. 

My  learned  confrere  M.  Bouley,  in  1857,  adopted  this  treatment  with 
some  modifications ;  and  about  the  same  time  my  regretted  colleague,  Dr. 
Gillette,  tried  it  at  the  Children's  Hospital.  The  results  of  his  trials  were 
published  in  the  following  year  (1858)  by  Dr.  E.  Bonfils,  in  an  excellent 
thesis,  which  I  advise  you  to  read.  After  the  modifications  of  this  plan 
which  Gillette  suggested,  and  the  good  results  which  he  obtained,  it  may 
be  said  that  the  use  of  tartar  emetic  in  large  doses  became  of  very  great 
importance  in  the  treatment  of  chorea. 

Gillette  advised  that  it  should  be  administered  according  to  the  follow- 
ing rules,  which  Dr.  Henri  Roger  followed  rigorously,  in  the  cases  which 
he  communicated  to  the  Medical  Society  of  Hospitals,  and  which  were 
published  in  the  "Union  Medicale  "  for  June  and  July,  1858. 

The  whole  treatment  generally  comprises  several  series,  each  of  which  is 
of  three  days,  and  is  separated  from  the  next  by  an  interval  of  from  three 
to  five  days.  On  the  first  day,  tartar  emetic  is  given  in  doses  of  from  4  to 
5  grains  in  the  twenty-four  hours.  This  quantity  is  doubled  en  the  second 
ami  trebled  on  the  third  day;  after  this  the  patient  is  allowed  to  rest  for 
three  or  five  days. 

If  a  second  series  be  necessary,  that  is,  if  the  chorea  persist  to  the  same 
degree,  or  if  the  convulsive  movements  have  merely  diminished  in  violence, 
tartar  (luetic  is  again  administered  for  another  period  of  three  days, 
beginning  with  the  same  dose  as  on  the  first  day  of  the  firs!  series,  plus  an 
additional  grain. 

W,  after  another  interval  of  rest  of  1'our  or  five  days,  the  disease  is  no1 
cured,  or  only  incompletely  so,  tin-  medicine  is  given  tor  a  third  time,  accord- 
ing  to  the  Mime  rules ;  thai  is,  the  dose  given  on  the  firsl  day  of  the  third 
series  will  he  the  same  as  that  administered  on  the  firsl  day  of  the  second 
series,  |>ln.-  an  additional  grain.  So  that  if  the  dose  given  on  the  firsl  day 
of  the  firsl  series  he  4  grains,  that  on  the  firsl  day  of  the  second  Beries  will 
he  5  grain8,  and  on  the  first  day  of  the  third  Beries  6  -rain-,  and  "ii  the  third 
day  of  the  third  serii  -  L8  grains. 

i  hail  recourse  to  this  plan,  in  the  case  of  a  patient  under  my  care,  in 
whom  Si.  Vitus's  dance  was  complicated  with  hysteria,  bul  no  improvement 
was  obtained  until  after  several  week.-.    Dr.  Bonfils,  who  superintended  the 


ON    CHOREA.  847 

treatment,  did  uot  look  upon  the  case  as  a  successful  one,  but  it  is  impossi- 
ble to  diaw  any  conclusion  from  a  single  instance.  A  great  many  casi  3, 
however,  have  been  published  by  Dr.  Bonfils,  which  are  not  all  of  ecpaal 
value,  no  doubt,  but  which  yet  seem  to  me  worthy  of  drawing  attention  to 
the  administration  of  tartar  emetic,  according  to  Gillette's  method. 

It  pretty  frequently  happens,  according  to  the  authors  whom  I  have 
mentioned,  that  the  chorea  improves  very  markedly  after  a  first  series,  and 
in  some  instances  even,  if  the  disease  be  only  of  medium  intensitv,  an 
immediate  cure  is  obtained.  But  they  themselves  acknowledge  that  two 
or  three  series  in  succession  are  required  for  a  thorough  and  final  cure. 
Now,  if  it  be  borne  in  mind  that  the  successive  series  comprise  a  period  of 
twenty-one  days,  that  the  duration  of  the  disease  from  its  commencement 
is  also  to  be  taken  into  account,  as  well  as  the  possibility  of  recurrences, 
doubts  will  arise  as  to  the  efficacy  of  the  remedy.  By  carefully  reading 
and  analyzing  the  cases  published  by  Dr.  Bonfils,  it  will  be  seen  that  the 
treatment  was  continued  for  a  period  of  from  fourteen  to  twenty-five  days ; 
that  the  first  manifestation  of  the  disease,  when  this  point  was  noted,  dated 
two  and  even  three  weeks  back ;  lastly,  that  many  of  the  cases  were 
instances  of  recurrence  of  the  complaint,  which  always  lasts  much  less  than 
in  previous  attacks.  It  might  well  be  asked,  then,  what  advantages  tartar 
emetic  has  over  cold  affusions,  sulphur-baths,  and  strychnine  (of  which  I 
shall  presently  speak),  by  which  the  disease  may  in  general  be  cured ;  and 
why,  therefore,  a  plan  of  treatment  should  be  revived  which  has  been 
already  tried,  and  then  laid  aside,  and  which  is  somewhat  violent  in  its 
mode  of  action,  especially  in  delicate  individuals,  as  many  choreic  girls 
are? 

Surely,  gentlemen,  I  am,  less  than  any  one  else,  disposed  to  doubt  the 
efficacy  of  the  various  remedies  wmich  are  habitually  used  against  chorea, 
and  I  admit  that  the  treatment  by  tartar  emetic  .is  in  many  cases  contra- 
indicated.  But  I  must  also  remind  you  that  although  chorea  yields,  in 
general,  to  ordinary  treatment,  and  still  more  to  the  influence  of  time, 
there  are  yet  certain  cases,  unfortunately,  in  which  the  convulsive  agita- 
tion is  so  great,  that  all  known  remedies  are  of  no  avail ;  and  the  phvsician 
sees  unfortunate  girls  die  a  miserable  death,  with  an  excoriated  and  deeply 
ulcerated  skin,  the  result  of  friction  which  no  amount  of  restraint  can  pre- 
vent. Now,  should  tartar  emetic  in  large  doses  be  of  use  in  such  cases, 
after  all  other  remedies  have  failed — (and  a  certain  number  of  cases  tend 
already  to  raise  the  hope  that  this  powerful  drug,  both  jDerturbing  and 
sedative  at  the  same  time,  is  capable  of  mastering  and  in  some  sort  crush- 
ing chorea  which  has  resisted  all  treatment) — even  if  it  should  be  exclu- 
sively restricted  to  such  exceptional  instances,  therapeutics  will  be  really 
indebted  to  Gillette  for  promising  it  another  chance  of  success  where  it  was 
formerly  compelled  to  acknowledge  its  impotence.  The  treatment,  how- 
ever, which  has  seemed  most  beneficial  to  me,  and  which  I  generally  adopt, 
is  that  by  strychnine. 

Lejeune  had  recommended  nux  vomica,  and  Niemann  and  Cazenave  (of 
Bordeaux)  had  also,  as  a  last  resource,  treated  by  it  a  case  of  chorea  with 
complete  success,  when,  in  1831,  I  myself  administered  it  to  a  patient  suf- 
fering from  paralysis  and  chorea  at  the  same  time,  less  with  the  view  of 
curing  his  chorea  than  with  that  of  treating  his  paralysis. 

It  was  in  1841  only  that  I  laid  dowm  distinct  rules  for  treating  chorea 
by  this  method,  and  carried  on  my  experiments  openly  at  the  hospital. 
About  the  same  time  (without  any  of  us  being  aware  of  what  the  others 
were  doing)  Dr.  Fouilloux  and  Dr.  Rougier  (of  Lyons)  recommended  the 
methodized  administration  of  strychnine  in  St.  Vitus's  dance.     While  I 


848  ON    CHOREA. 

was  taking  notes  of  and  publishing  cases  of  chorea  cured  by  mix  vomica, 
Dr.  Rougier  published  also  the  results  of  his  researches ;  but  instead  of 
nux  vomica,  he  recommended  the  use  of  strychnine. 

Since  that  time  I  have  myself  adopted  strychnine,  and  the  preparation 
which  to  me  seems  the  most  easily  managed  is  the  syrup  of  sulphate  of 
strychnine  (one  grain  of  the  salt  to  two  ounces  and  a  half  of  syrup)  ;  and 
I  prefer  the  sulphate  to  strychnine  itself,  because  the  latter  is  very  slightly 
soluble,  whereas  the  former  dissolves  to  any  extent.  Two  ounces  and  a 
half  of  the  syrup  are  equivalent  to  twenty  teaspoonfuls,  each  of  which, 
therefore,  contains  one-twentieth  of  a  grain  of  the  salt.  Two  teaspoonfuls 
are  equal  to  a  dessertspoonful,  which,  therefore,  contains  one-tenth  of  a 
grain  of  the  salt ;  and  a  tablespoon  will  contain  one-fifth  of  a  grain  of  the 
sulphate  of  strychnine.  You  must  remember  that  this  syrup  is  not  offi- 
cinal, and  you  must  therefore  be  careful  when  you  prescribe  it.  In  spite 
of  its  bitterness,  children  do  not  show  very  great  reluctance  to  take  it. 

I  now  wish  to  direct  your  attention  particularly  to  the  mode  of  adminis- 
tering it.  According  to  the  age  of  the  patient,  give  on  the  first  day  from 
two  to  three  teaspoonfuls  of  the  syrup,  and  see  that  they  are  taken  at  equal 
intervals  of  time  during  the  day  (morning,  noon,  and  evening),  so  that  you 
may  watch  the  effect  produced,  in  order  not  to  go  beyond  a  certain  point. 
If  the  dose  of  three  teaspoonfuls  be  well  borne,  it  is  continued  for  two 
days,  and  then  increased  by  one  teaspoonful ;  after  another  two  days,  the 
dose  is  again  increased  by  another  spoonful,  and  so  on,  until  six  teaspoon- 
fuls are  taken  in  the  course  of  the  day — always  at  equal  intervals  of  time. 

When  this  dose  has  been  reached,  a  dessertspoonful  is  substituted  for  one 
of  the  teaspoonfuls  ;  and  by  attending  to  the  same  rules  as  before,  as  many 
as  six  dessertspoonfuls  are  administered,  containing  three-fifths  of  a  grain 
of  sulphate  of  strychnine.  A  tablespoonful  is  then  substituted  for  one  of 
the  dessertspoonfuls,  and  by  gradually  increasing  the  dose,  with  the  same 
prudence,  and  taking  the  essential  precaution  of  giving  the  medicine  at 
perfectly  equal  intervals  of  time  in  the  course  of  the  day,  you  may  in  the 
end  administer  to  the  child  from  three-fifths  to  four-fifths,  and  even  one 
grain  and  one-fifth  of  sulphate  of  strychnine. 

In  the  case  of  adults  the  dose  should  be  larger  from  the  beginning — a 
dessertspoonful,  for  example  ;  and  it  may  be  gradually  increased  to  as 
much  as  two  grains  of  the  active  principle.  But  bear  well  in  mind  this 
most  important  fact,  gentlemen — that  you  should  always  begin  with  small 
doses,  and  watch  their  effects,  and  before  increasing  should  continue  them 
for  a  couple  of  days.  The  treatment  should  be  carefully  watched,  because 
the.  drug  must  be  given  in  sufficient  doses  to  bring  out  its  physiological 
effects  ;  and  the  patient's  friends,  or  the  persons  about  him,  should  be  ion- 
warned  of  what  is  to  happen. 

After  a  very  few  days  have  elapsed,  and  as  soon  as  the  first  doses  are 
increased,  the  patient  complains,  at  certain  periods  of  the  day,  twenty  min- 
utes or  half  an  hour  after  taking  the  medicine,  of  some  stillness  of  the  jaws, 
of  headache,  of  impairment  of  sight,  of  a  little  giddiness,  and  of  Blighl 
rigidity  of  the  muscles  of  the  neck,  lie  complains  also  that  the  hairy 
parts  of  his  person  and  his  seal])  itch;  the  sensation  next  extends  to  the  non- 
hairy  parts,  and  in  some  eases  an  eruption  of  prurigo  comes  out.  As  the 
doses  are  increased  the  stiffness  becomes  general,  and  is  most  marked  in 
the  limbs  that  are  the  most  convulsed  (and  these  are  also  the  most  paral- 
yzed, as  yon  know).  Muscular  jerks  occur  occasionally  also  al  the  same 
time,  and  oftentimes  spasms  and  convulsions  in  hysterical  persons.  These 
starts  happen  in  particular  when  the  patient  is  taken  by  surprise,  or  when 
au  order  is  given  him  before  he  has  time  to  will,  and  they  may  be   so  vio- 


ON    C1IO  UK  A.  849 

lent  that  lie  is  thrown  down.  I  remember  a  young  girl,  18  years  old,  who 
was  under  treatment  for  St.  Vitus's  dance,  at  the  Necker  Hospital,  and 
who,  on  being  unexpectedly  addressed  by  one  of  the  sisters,  was  seized  with 
tetanic  contractions  of  this  kind,  and  thrown  forwards  as  by  a  spring. 
These  tetanic  contractions  are  painful,  especially  when  the  patient  tries  to 
resist  them,  and  to  remain  standing  ;  they  are  instantly  quieted,  however, 
on  the  patient  assuming  a  horizontal  position. 

When  these  physiological  effects  show  themselves  the  doses  should  not  be 
increased,  because  strychnine,  like  all  preparations  of  mix  vomica,  belongs 
to  that  class  of  remedies  which,  by  virtue  of  a  special  therapeutic  influence, 
and  a  very  remarkable  cumulative  action,  as  it  were,  are  apt  to  give  rise 
to  perfectly  unforeseen  accidents,  even  though  the  moderate  doses  in  which 
they  were  administered  had  until  then  given  rise  to  scarcely  appreciable 
effects. 

If  it  be  important  that  the  physician  should  not  be  alarmed  by  the  physi- 
ological phenomena  which  he  must  try  to  produce,  and  which,  however 
uncomfortable  they  may  be,  are  serious  only  when  they  are  pushed  too  far 
(and  this  never  happens  if  the  syrup  be  properly  administered),  it  is  equally 
important  that  he  should  bear  in  mind  that  this  drug  is  variously  tolerated 
by  different  induviduals,  and  by  the  same  individual  at  different  times  ; 
so  that,  even  by  continuing  the  same  doses,  one  cannot  predict  from  the 
effects  obtained  on  the  previous  day  those  which  will  be  produced  on  the 
next.  Thus,  six  spoonfuls  of  the  syrup  may  not  cause  any  appreciable 
physiological  effect  one  day,  while,  on  the  next,  violent  spasms  may  come 
on  immediately  after  the  first  spoonful,  even  when  the  same  preparation  is 
used,  of  known  strength.  I  need  not  add,  that  when  the  administration  of 
the  first  spoonful  brings  on  spasms,  the  medicine  should  be  stopped  for  the 
day.  There  being  nothing  to  account  for  such  results,  I  tried  to  make  out 
whether  meteorological  conditions  had  any  share  in  their  production,  but 
my  inquiries  led  to  no  conclusions. 

This  variability  in  the  degree  of  power  of  the  drug  renders  its  adminis- 
tration a  delicate  matter,  and  demands  the  most  scrupulous  care ;  and  on 
this  account  perhaps  this  method  of  treatment  will  not  obtain  the  impor- 
tance which  its  unquestionable  advantages  ought  to  give  it.  The  reluctance 
with  which  it  is  had  recourse  to  is  all  the  greater  from  the  fact  that  it 
should  be  persisted  in  for  several  days  after  the  chorea  has  ceased,  in  order 
that  its  influence  be  complete.  By  beginning  it  again  iu  smaller  doses,  and 
for  a  shorter  period,  after  an  apparent  cure,  relapses  may  be  prevented. 
This  is  a  rule  which  I  have  laid  down  for  myself,  but  which  it  is  impossible, 
or  very  difficult,  at  least,  to  follow  in  hospitals.  I  shall  merely  say  a  word 
on  the  use  of  electricity  in  the  treatment  of  St.  Vitus's  dance.  De  Haen 
was  the  first  to  recommend  it,  and  his  method  consisted  in  drawing  sparks 
from  the  spine  by  means  of  an  electric  machine  or  of  a  Leyden  jar.  This 
mode  of  applying  electricity  is  nowadays  justly  abandoned,  nor  has  electro- 
puncture  been  more  successful. 

As  to  the  good  results  which  are  said  to  be  obtained  from  faradization  of 
the  skin,  1  have  never  been  able  to  verify  the  accuracy  of  the  statement, 
and  I  have  not  been  convinced  of  its  utility  by  the  perusal  of  cases  in  which 
it  had  been  used.  I  hesitate  before  having  recourse  to  it  when  I  find  that 
the  treatment,  in  five  out  of  eight  cases,  lasted  from  twenty-four  to  forty- 
seven  days ;  and  when,  on  the  other  hand,  I  hear  from  the  very  advocates 
of  the  plan  that  it  is  attended  with  certain  disadvantages ;  that  it  causes 
such  pain,  for  instance,  that  several  patients  had  to  be  rendered  insensible  by 
chloroform  in  order  to  be  faradized. 

As  you  may  imagine,  antispasmodics  and  narcotics  have  been  used  against 
vol.  i. — 54 


850  OH    CHOREA. 

chorea,  such  a?  valerian,  camphor,  assafcetida,  musk,  &c.,  which  have  been 
alternately  recommended,  put  aside,  and  tried  again.  Of  late  an  interesting 
memoir  has  been  published  by  Dr.  Corrigan,  in  the  London  Medical  Times, 
on  the  use  of  Cannabis  indica.  His  first  case  is  that  of  a  little  girl,  10  years 
of  age,  who  had  been  ill  for  five  weeks.  She  took  five  minims  of  the  tinc- 
ture three  times  a  day,  and  in  eleven  days  a  considerable  improvement 
followed  ;  the  dose  was  then  gradually  increased  to  twenty-five  minims  three 
times  a  day,  and  the  patient  was  discharged  cured  in  a  little  less  than  five 
weeks.  The  subject  of  the  second  case  had  been  ill  a  month,  and  had  to 
be  kept  under  treatment  for  forty  days;  she  also  took  twenty-five  drops 
of  the  tincture  three  times  a  day.  Lastly,  a  young  girl,  aged  16,  who  had 
been  choreic  for  the  previous  ten  years,  was  cured  in  a  month. 

These  cases  are  not  very  conclusive,  as  you  see  ;  but  I  will  again  say 
what  I  told  you  regarding  tartar  emetic.  Cannabis  indica  unquestionably 
possesses  an  alterative  action  on  the  nervous  system,  and  may  therefore 
prove  an  additional  resource  in  cases  of  obstinate  chorea,  and  whenever 
narcotics  are  indicated  with  the  view  of  preventing  certain  dangerous  com- 
plications. 

I  have  already  told  you,  gentlemen,  that  death  may  be  the  result  of  ex- 
treme agitation,  aggravated  by  sleeplessness,  in  St.  Vitus's  dance.  Xow, 
chloroform  inhalations  have  been  used  with  benefit  by  M.  Faster  against 
this  agitation. 

When  there  is  obstinate  want  of  sleep,  which  gradually  exhausts  the  pa- 
tient's strength,  I  have  recourse  to  opium,  which  I  gave,  as  you  saw,  to 
the  patient  in  bed  20,  St.  Bernard  Ward.  I  administer  it  in  large  doses  ; 
and  this  patient  took,  for  several  days  in  succession,  a  tablespoonful  of 
syrupus  opii  every  four  hours. 

In  more  severe  cases  I  prescribe  still  larger  doses  of  opium. 

On  September  20,  1842,  a  young  woman,  aged  20,  was  admitted  into  the 
Xecker  Hospital  (bed  Xo.  27,  St.  Anne's  Ward).  She  was  pregnant,  and 
was  suffering  from  a  first  attack  of  chorea,  which  had  set  in  for  the  last 
eight  days.  Her  convulsive  agitation  was  extreme  :  her  limbs,  trunk,  and 
eyes  were  continually  moving.  Her  right  leg  and  arm  wore  paralyzed; 
her  ideas  were  somewhat  confused,  and  she  was  strangely  talkative,  a  cir- 
cumstance which  was  all  the  more  remarkable  that  her  tongue  was  affected, 
and  her  articulation  embarrassed.  The  pupils  were"  moderately  dilated, 
but  sight  was  good  on  both  sides.  Besides  having  no  appetite,  the  patient 
could  not  feed  herself;  and  she  could  scarcely  chew  aud  swallow  her  food 
when  Bhe  was  fed.  There  was  no  disturbance  of  the  digestive  organs  except 
constipation.  On  the  day  of  her  admission  T  gave  her  two  grains  of  alco- 
holic extract  of  nux  vomica,  and  six  grains  on  the  following  day.  The 
physiological  effect  of  the  drug  showed  it-elf  live  hours  after  the  adminis- 
tration of  the  first  pill,  and  la-ted  an  hour  and  a  half.  A  second  pill  was, 
however,  given,  notwithstanding  this,  three  hours  afterwards;  but  before  an 
hour  and  a  half  had  elapsed,  tetanic  jerks  Bupervened,  during  which  she 
screamed  out,  ami  the  attack  lasted  from  half-past  7  to  1  2  P.M.  The  jerks, 
in  the  intervals  <>f  which  the  choreic  convulsions  returned  with  still  greater 
violence  than  before,  were  such,  that  the  patient  jumped  up  in  her  bed,  and 
her  respiration  was  interrupted  at  each  paroxysm,  her  face  becoming  at  first 
pale  and  then  livid.  A  strait-jacket  bad  tube  used  in  oi-der  to  restrain  her, 
and  -he  had  it  on  when  I  .-aw  her  the  next  morning. 

On  seeing  that  instead  of  being  quieted,  the  patient'-  agitation  had  been 
so  exaggerated  that  she  had  not  torn,  but  worn  out,  through  the  violence 
of  her  movements,  her  chemise  and  the  bedclothes,  and  had  excoriated  her 
back,  I  -tupped  the  nux  vomica,  and.  on  account  of  her  want  of  sleep  and 


ON    CHOREA.  851 

her  extreme  exhaustion,  I  prescribed  for  her  a  mixture  containing  four 
grains  of  sulphate  of  morphia,  a  fourth  part  of  which  was  to  be  taken  for  a 
dose',  and  the  whole  in  twenty-four  hours.  The  patient  took  three  doses, 
and  an  hour  after  the  first  she  fell  asleep  quietly,  and  slept  for  two  hours. 
When  she  awoke,  she  remained  pretty  quiet  for  four  hours ;  but  on  her 
getting  excited  for  some  cause  or  another,  she  was  again  as  violently  con- 
vulsed as  before,  so  that  the  remainder  of  the  mixture  was  given  her  during 
the  night,  and  she  slept  till  six  in  the  morning. 

The  choreic  symptoms  then  returning  again,  I  doubled  the  quantity  of 
morphia,  making  it  eight  grains.  But  it  was  remarkable  that  the  improve- 
ment of  the  previous  day  was  less  easily  produced  this  time.  The  agitation 
was  greater  than  ever,  and  although  the  patient  dozed  a  little  after  taking 
the  whole  of  the  mixture,  she  was  so  excessively  agitated  in  the  evening, 
that  my  clinical  assistant  thought  fit  to  prescribe  another  mixture,  contain- 
ing two  grains  of  sulphate  of  morphia,  and  made  her  take  several  spoonfuls 
of  it,  one  after  another,  in  his  presence.  She  became  markedly  quieter, 
and  fell  asleep.  Her  rest  was  disturbed  at  first,  but  became  quiet  for  the 
rest  of  the  night  after  she  had  taken  a  few  more  spoonfuls  of  the  mixture. 

The  next  morning,  wdien  she  awoke,  the  convulsions  returned  with  nearly 
the  same  violence,  and  I  increased  the  quantity' of  morphia  to  12  grains. 
For  two  days  she  took  this  dose  ;  and  on  the  agitation  appearing  again,  I 
successively  increased  it  to  20,  25,  up  to  30  grains.  This  last  quantity  was 
even  given  in  two  doses,  but  the  first  dose  alone  was  kept,  the  second  was 
vomited.  In  spite  of  this  the  same  quantity  was  repeated  for  two  days,  and 
the  patient  bore  it  well.  The  disease  at  last  yielded  completely ;  the 
patient's  sleep  became  calm  and  natural,  the  choreic  movements  were  very 
slightly  marked,  and  the  young  woman,  feeling  comparatively  well,  re- 
quested her  discharge  on  October  17,  that  is  to  say,  after  a  stay  of  twenty- 
seven  days  in  the  hospital. 

You  see,  gentlemen,  what  enormous  doses  of  opium  can  be  given  in  grave 
cases  of  chorea.  I  gave  another  woman  in  the  Hotel-Dieu  fifteen  grains  of 
sulphate  of  morphia,  but  I  do  not  remember  ever  prescribing  such  a  large 
dose  as  the  one  I  gave  my  patient  in  the  Xecker  Hospital. 

While  on  this  point,  let  me  tell  you  that  medical  men  dread  too  much, 
in  my  opinion,  the  use  of  opium  in  large  doses,  in  St.  Vitus's  dance  and 
other  grave  neuroses;  and,  indeed,  in  all  cases  in  which  it  is  indicated. 
They  forget  the  precept  laid  down  by  Sydenham  in  his  letter  to  Robert 
Brady,  and  which  he  repeats  in  his  admirable  letter  to  William  Cole  on 
the  subject  of  small-pox,  namely,  that  "the  dose  of  a  remedy  should  be 
increased  and  repeated  in  proportion  to  the  intensity  of  the  symptoms  " 
(remedii  dosis  et  repetendi  vices  cum  symptomaiis  magnitudine  omnino  sunt 
eonferendce).  A  dose  which  may  be  powerful  enough  to  remove  a  slight 
symptom  will  not  have  any  influence  on  violent  symptoms,  and  a  dose  which 
may  endanger  the  patient's  life  in  certain  cases  will  in  others  save  him  from 
certain  death.  (Quce  enim  dosis  remission  symptomati  coercendo  par  est  ea 
ah  alio  fortiore  superabitur,  et  quce  alias  eegrum  in  manifestum  vitce  discrimen 
conjiciet,  eumdem  ab  orci  faucibus  liberabit.) 

I  have  often  related  the  case  of  a  brush-manufacturer,  who  in  1846  con- 
sulted me,  on  account  of  excessive  nocturnal  pain  in  his  bones.  He  had 
come  to  take  from  about  six  to  eight  ounces  of  Rousseau's  laudanum,  a 
preparation  which  contains  three  times  as  much  extract  of  opium  as  the 
laudanum  of  Sydenham.  He  drank  it  in  tumblers  in  my  presence;  and 
added,  that  on  his  trying  the  sulphur  baths  at  Enghien,  his  pain  had  been 
so  intensified  that  he  determined  on  poisoning  himself,  and  took,  in  one 
dose,  twenty-four  ounces  of  Rousseau's  laudanum,  that  is  to  say,  more  than 


852  ON    CHOREA. 

two  ounces  and  a  half  of  the  aqueous  extract  of  opium.     He  slept  for  three 
hour's  only. 

About  twenty  years  ago,  I  asked  Prof.  Andral  to  see  in  consultation 
with  me  a  young  man,  a  friend  of  mine,  who  was  suffering  from  an  ex- 
tremely painful  neuralgia.  We  prescribed  opium  pills  of  one  grain  each, 
which  were  to  be  taken  until  the  pain  had  been  subdued.  He  took  twenty- 
four  pills  in  the  space  of  twelve  hours  (that  is  to  say,  twenty-four  grains  of 
gummy  extract),  and  got  perfectly  well.  He  was  only  slightly  narcotized  ; 
and  now  that  he  no  longer  needs  this  remedy,  he  could  not,  any  more  than 
any  other  man,  take  even  moderate  doses  of  it  without  feeling  some  incon- 
venience from  it.  You  are  aware  that  in  cerebrospinal  typhus,  Dr. 
Boudin  gives  opium  in  large  doses,  proportionately  to  the  gravity  of  the 
nervous  symptoms.  He  begins  with  ten  and  even  twenty  grains  of  the 
gummy  extract,  which  he  gives  in  one  dose,  and  then  repeats  every  half- 
hour  smaller  doses  of  one  and  two  grains,  until  the  patient  falls  asleep. 
Such  examples  show,  therefore,  that  in  the  administration  of  opium,  the 
dose  of  the  medicine  is  to  be  less  taken  into  account  than  the  effects  which 
it  produces.  This  is  what  Peyrilhe  meant  by  saying  that  when  a  man  is 
as  awake  as  four,  he  should  take  as  much  opium  as  five,  in  order  to  sleep 
as  one. 

In  grave  forms  of  St.  Vitus's  dance,  therefore,  when  it  is  demanded  by 
the  excessive  agitation  and  the  absence  of  sleep,  opium  should  be  given 
largd  manu.  Yet  do  not  believe  that  this  treatment  is  infallible.  It  has 
sometimes  failed  in  my  hands,  but  in  such  cases,  the  patients  did  not  only 
suffer  from  convulsive  agitation  in  the  extreme,  and  non-febrile  delirium, 
but  there  was  fever  present  as  well  as  delirium,  and  nervous  symptoms 
which  do  not  belong  to  chorea,  generally  cerebral  rheumatism,  and  opium 
was  powerless  against  them,  as  in  the  sad  case  which  I  related  to  you  in 
the  course  of  this  lecture. 

Lastly,  gentlemen,  hygienic  measures  play  an  important  part  in  the  treat- 
ment of  St.  Vitus's  dance.  Thus,  nutritious  and  tonic  food  taken  at  regu- 
lar intervals,  open-air  exercise,  within  fatigue,  so  as  to  facilitate  the  organic 
movements  of  repair,  and  to  prevent  the  recurrence  of  the  disease,  cold 
bathing  and  swimming,  are  formally  indicated. 

In  severe  cases  of  chorea,  certain  precautions  should  be  taken  in  order 
to  prevent  the  patient  from  hurting  himself  in  his  disordered  movements. 
The  bed  on  which  he  lies  should  be  of  sufficient  width  and  thickness,  and 
.shut  in  on  the  side-  by  padded  Haps,  so  as  to  save  him  from  falling.  In  those 
extreme  cases  in  which  the  poor  child  tears  and  rubs  off  his  skin,  by  con- 
tinual friction  against  the  bedclothes,  and  when  the  agitation  is  such  that 
he  is  thrown  out  of  bed,  over  the  (laps,  a  strait-waistcoat  is  sometimes  bad 
recourse  to ;  but  instead  of  diminishing  the  risks  which  are  dreaded,  the 
chances  in  i  heir  favor  are  increased,  because  the  strings  give  rise  to  excoria- 
tions of  the  skin,  which  afterwards  turn  into  horrible  wounds. 

For  my  part,  I  allow  my  patients  all  freedom  of  action;  but  I  place 
them  in  conditions  which  prevent  their  hurting  themselves.  When  1  was 
physician  to  the  Children's  Hospital,  I  invented  a  sort  of  apparatus  which 
is  still  used  now.  It  merely  consists  of  a  large  box,  made  of  deal  or  of 
oak,  ahout  2  metres  long,  1]  metres  wide,  and  1  ]  metres  high,  padded  with 

thick  and  sofl   Cushions  on  the  sides   and  al  the    bottom.       The   child,  when 
placed  all  naked    inside   this   box,  may  move   aboul    freely  without    fear  of 

any    accident.     To    proteel     him    againsl    the    cold,  sheets    are    either 

thrown    over    him,  or  are   made   to   close    the    upper   pari  of  the   box ;   or  a 

better  plan  consists  in  putting  hot-water  bottles  between  the  walls  of  the 


ON    CUOREA.  853 

box  and  the  cushions.     Those  boxes  arc  easily  procurable  for  a  small  sum, 
and  may  thus  be  used  in  poor  families  as  well  as  by  the  rich. 

Another  simple  means,  namely,  waddling  the  chrld,  is  of  great  utility  in 
Very  grave  cases.  It  is  now  several  years  since  it  has  been  recommended, 
but  it  is,  in  my  opinion,  too  rarely  employed.  The  upper  and  lower  limbs 
of  the  child  are  first  carefully  wrapped  in  wadding,  which  is  maintained 
by  a  bandage,  and  then  the  lower  limbs  are  kept  closely  approximated, 
and  the  arms  fixed  along  the  sides  of  the  trunk  by  means  of  bandages 
again.  I  need  not  add  that  the  turns  of  the  roller  which  are  meant  to  con- 
fine the  arms,  should  not  be  so  tight  as  to  interfere  with  respiration.  In 
general  it  is  found  necessary  to  apply  the  bandage  twice  in  the  course  of 
twenty-four  hours.  It  is  a  fact  that,  in  the  majority  of  instances,  the  forced 
rest  in  which  the  muscles  are  kept  calms  the  extraordinary  agitation  of 
some  patients.  This  plan  is,  of  course,  had  recourse  to  in  very  grave  forms 
only. 

Of  the  Different  Forms  of  Chorea. 

Chorea  Saltatoria. — Methodical  or  Rhythmic  Chorea, —  Tic  Douloureux 
{Chorea  Neuralgica). — Tic  Non-Douloureux. —  Writer's  Cramp  {Chorea 
Scriptorum,  Functional  Spasm  of  Dr.  Duchenne,  cle  Boulogne). 

Gentlemen  :  A  short  time  ago,  one  of  my  most  eminent  confreres  and 
I  differed  as  to  the  diagnosis  to  be  made  in  the  case  of  a  patient  who  had 
for  more  than  a  year  been  afflicted  with  choreic  movements.  My  learned 
colleague  called  the  disease  chorea  (meaning  thereby  St.  Vitus's  dance), 
while  I  was  of  opinion  that  it  was  a  form  of  chorea,  but  not  St.  Vitus's 
dance. 

Now,  I  based  my  opinion  on  these  facts.  By  questioning  the  patient's 
father  and  the  patient  himself  fa  boy,  12  or  13  years  of  age,  and  full  of  in-' 
telligence)  on  the  character  of  the  symptoms,  I  made  out  that  the  voluntary 
movements  remained  somewhat  regular  in  the  midst  of  these  choreic  con- 
vulsions. Thus  the  boy  declared  that  he  had  not  lost  his  usual  agility,  that 
he  could  leap  without  difficulty,  and  as  well  as  any  of  his  companions,  over 
barriers;  that  he  could,  when  going  up  a  staircase,  take  three  or  four  stairs 
at  a  time;  that  he  had  no  difficulty  in  skipping  with  a  rope;  and  lastly, 
that  he  used  his  hands  as  well  as  anybody  else  to  feed  himself,  and  even  to 
drink;  all  which  actions  cannot  be  performed,  as  you  know,  by  persons 
suffering  from  St.  Vitus's  dance. 

From  some  obscure  disturbance  of  his  nervous  system,  this  child  executed 
curious  movements,  and  was  thrown  forwards,  as  if  by  a  spring,  by  invol- 
untary muscular  contractions,  which  made  him  jump  to  seven  or  eight  feet 
in  front  of  the  place  where  he  might  be  standing,  or  get  up  abruptly,  me- 
chanically (if  I  may  use  the  expression),  from  the  chair  on  which  he  might 
be  sitting ;  he  never  fell  down.  There  was  a  kind  of  harmony  amid  this 
disorder  of  the  locomotor  functions,  for  if  all  the  muscles  contracted  inde- 
pendently of  the  will,  they  all  acted  simultaneously  at  least.  This,  there- 
fore, gentlemen,  is  a  form  of  chorea  Avhich  differs  much  from  St.  Vitus's 
dance,  and  to  which  the  name  of  chorea  saltatoria  has  been  given. 

A  few  years  ago,  another  instance  of  the  kind  came  under  my  notice. 
A  boy  was  brought  to  my  consulting-room  by  his  father,  who  had  begun  to 
relate  to  me  his  case,  when  he  suddenly  got  up,  as  if  pushed  by  a  spring, 
jumped  on  a  piece  of  furniture  with  marvellous  suppleness  and  agility,  and 
then  returned  to  his  chair  and  sat  down  quietly.  What  he  had  done  had 
shown  me  the  nature  of  his  case,  which  his  father  was  going  to  describe  less 


85-4  ON    CHOREA. 

clearly  to  me.  His  illness  had  lasted  some  time ;  these  singular  attacks 
had  set  in  suddenly,  and  his  intellect  had  not  suffered  in  the  least  yet;  in 
the  intervals  between  the  paroxysms  he  was  as  quiet  as  possible.  He  got 
perfectly  well.  Although,  as  in  both  the  above  cases,  there  rarely  is  an 
apparent  impairment  of  the  intellectual  faculties,  chorea  saltatoria  seems  to 
me,  however,  to  belong  to  the  same  great  class  of  mental  disorders  as  taren- 
tisyn  and  the  epidemic  dansomania  of  the  middle  ages.  It  is  only  a  variety 
perhaps  of  the  methodical  or  rhythmic  forms  of  chorea,  which  include  chorea 
festinans  or  procursiva,  chorea  rotatoria,  and  chorea  vibratoria. 

In  chorea  festinans  the  individual  is  irresistibly  impelled  to  run  forwards, 
without  being  always  able  to  avoid  obstacles,  or,  on  the  contrary,  to  go 
backwards  continuously  without  being  able  to  help  himself.  This  affection 
should  not  be  confounded  with  the  semi-delirious  condition  under  the  influ- 
ence of  which  individuals,  who  are  threatened  with  certain  brain  attacks, 
or  who  are  just  recovering  from  an  epileptic  fit,  are  carried  along  in  spite 
of  themselves. 

In  July,  1861,  I  saw,  in  consultation  with  Dr.  Duelos,  a  retired  military 
man,  about  60  years  of  age.  He  was  walking  with  his  brother  along  the 
banks  of  the  St.  Martin  Canal,  when  all  of  a  sudden,  without  any  warning, 
he  began  to  walk  with  extreme  rapidity,  and  almost  to  run.  His  brother 
in  vain  called  out  to  him  to  moderate  his  step;  he  walked  quicker  and 
quicker,  scarcely  avoiding  the  obstacles  in  his  way,  and  it  was  only  with 
difficulty  that  he  could  be  restrained  after  more  than  ten  minutes.  He 
stammered,  looked  strange,  and  a  few  moments  afterward  became  slightly 
hemiplegic  in  consequence  of  hemorrhage  into  his  brain.  It  is  pretty  prob- 
able that  the  first  impression  produced  on  the  brain  by  the  laceration  of  its 
substance  was  the  intellectual  disorder  manifested  by  his  mad  running. 
The  most  curious  case  of  chorea  festinans  which  has  come  under  my  obser- 
vation is  that  of  a  Havre  merchant,  who  came  to  consult  me  in  May,  1860. 
He  was  with  some  other  persons  in  my  waiting-room,  and  he  gut  up  and 
trotted  into  my  consulting-room,  when  his  turn  came,  in  such  a  curious 
manner  that  he  raised  a  laugh  among  the  others.  His  body  was  stiff  and 
inclined  forwards,  with  his  arms  hanging  straight  down  along  his  trunk  and 
thighs,  while  his  eyes  were  fixed.  He  ran  quickly  on  tiptoe,  taking  small 
steps,  as  if  in  fun.  When  he  got  near  me  he  stopped  and  sat  down  without 
difficulty.  1  had  seen  enough  in  order  to  recognize  the  strange  neurosis 
from  which  he  was  suffering.  He  then  told  mo  that  these  symptoms  had 
come  on  almost  insensibly  for  about  a  year;  he  could  no  longer  go  out.  felt 
bodily  and  mentally  weak,  and  could  scarcely  conduct  the  business  of  his 
firm.  His  speech  was  a  little  thick.  One  might,  at  first  sight,  think  of 
incipient  general  paralysis,  but  with  a  little  care  chorea  procursiva  could 
be  recognized.  After  he  had  told  me  his  story,  I  made  him  gel  up  and 
walk  slowly,  pressing  down  his  foot.  lie  had  some  difficulty  in  starting, 
and  seemed  fixed  to  the  ground,  hut  still  ho  took  the  first  step  forward  by 
himself,  and  walked  several  times  round  my  consulting-room  slowly,  lie 
could  therefore  command  his  movements  by  an  effort  of  the  will,  while  this 
is  not  tlio  case  in  general  paralysis  or  in  tremor  senilis,  St.  Vitus'.-  dance,  or 
Locomotor  ataxy.  I  found  by  testing  it  that  bis  cutaneous  sensibility  was 
normal,  and  his  muscular  power,  tried  with  Burq's  dynamometer,  showed  no 
diminution,  while,  as  I  snail  tell  you  on  another  occasion,  the  muscular 
power  in  'paralysis  <i</il'H)-<  (of  which,  at  the  end  of  the  year  I860,  you  .-aw 
so  curious  a  case,  that  of  the  woman  in  bed  No.  2,  St.  Bernard  Ward)  may 
o  considerably  diminished  as  to  mark  only  LO  lbs.  with  Burq's  dyna- 
mometer. 

I  prescribed  for  that  gentleman  ten  turpentine  capsules  a  day    contain- 


ON    CHOREA.  .  855 

ing  about  100  minims),  which  he  was  to  take  for  twelve  or  fifteen  days  a 
month,  and,  in  addition,  I  ordered  warm  baths  of  several  hours'  duration. 

Two  months  later,  when  I  saw  him  again,  he  had  improved  consider- 
ably ;  I  then  sent  him  to  the  Ne'ris  baths,  and  he  had  so  improved  on  his 
ret  inn,  about  the  month  of  August,  that  I  might  have  hoped  for  a  com- 
plete cure  if  I  had  not  been  aware  how  obstinate  this  neurosis  is.  Yet  he 
could  go  into  the  streets,  attend  to  his  business,  work,  and  write,  but  had 
always  a  certain  tendency  to  trot  on  starting.  He  restrained  himself  at 
once,  and  could  walk  more  quietly,  although  with  a  look  of  effort  and  re- 
straint. On  several  occasions  I  made  him  walk  in  step  like  a  soldier  in 
my  own  room — and  this  is  a  very  difficult  kind  of  walk,  which  requires 
great  precision  of  movements.  He  spent  the  winter  of  1860-61  pretty 
well,  and  when  I  saw  him  again  at  the  end  of  May,  1861,  he  had  not  lost 
ground,  and  I  sent  him  to  the  Neris  baths  a  second  time. 

I-  believe  that,  in  some  instances,  general  paralysis  and  paralysis  agitans 
have  been  confounded  with  chorea  fedinans,  but  I  regret  that  I  have  not  in 
my  possession  notes  of  cases  sufficiently  distinct  and  free  from  complications 
that  I  might  give  you  a  complete  sketch  of  this  affection. 

Chorea  rotatoria  is  characterized  by  rotation  or  oscillation  of  the  head, 
or  trunk,  or  of  one  limb,  recurring  from  20  to  30, .  40,  and  80  times  a 
minute.  It  sometimes  terminates  in  death,  and  spares  neither  age  nor  sex, 
although  it  occurs  less  frequently  in  children. 

Chorea  oscillatoria  consists  in  irregular  or  measured  oscillations,  partial 
or  general,  of  the  head,  trunk,  or  limbs. 

These  singular  affections  must  surely  recall  to  your  mind,  gentlemen, 
another  kind  of  partial  chorea,  which  is  very  common,  and  which  goes  by 
the  familiar  name  of  tie.  I  do  not  mean  tie  douloureux,  chorea  neuralgiea, 
or  epileptiform  neuralgia,  of  which  I  spoke  at  length  in  a  previous  lecture, 
but  tic  non-douloureux  (spasmodic  tic),  which  consists  in  instantaneous, 
rapid,  involuntary  contractions,  generally  restricted  to  a  small  number  of 
muscles,  those  of  the  face  usually,  but  which  may  also  affect  the  muscles  of 
the  neck,  trunk,  or  limbs.  Every  one  must  have  seen  such  cases,  Thus, 
there  may  be  only  rapid  winking,  a  convulsive  pulling  of  the  cheek,  of  the 
ala  nasi,  and  of  the  commissure  of  the  lips,  which  gives  to  the  face  a  grin- 
ning look ;  or  there  may  be  nodding  of  the  head,  abrupt  and  transient  con- 
tortion of  the  neck  recurring  every  minute ;  or  again,  the  shoulder  is 
shrugged,  and  the  abdominal  muscles  or  the  diaphragm  is  convulsively 
agitated  ;  in  a  word,  the  disease  may  produce  an  infinite  variety  of  strange 
movements  which  baffle  all  description. 

The  complaint  is  essentially  chronic,  and  is,  so  to  say,  part  and  parcel 
of  the  individual's  constitution  ;  he  is  the  only  one,  sometimes,  who  does 
not  notice  it ;  it  is  cured  with  difficulty ;  but  it  is  a  strange  circumstance 
that  it  may  shift *from  one  place  to  another.  When  by  treatment,  and  by 
exercising  the  affected  muscles,  a  tic  has  at  last  been  cured,  it  may  soon 
reappear  elsewhere ;  thus,  it  may  leave  the  face,  for  instance,  and  seize  on 
the  arm  or  leg.  I  was  lately  consulted  by  a  young  Englishman  who  had 
come  from  Dieppe,  and  who  was  suffering  from  convulsive  and  violent 
movements  of  the  head  and  right  shoulder.  After  submitting  for  some 
time  to  the  methodical  gymnastic  exercises  which  I  prescribed  for  him,  the 
tic  disappeared  from  the  right  side,  where  it  had  for  a  long  time  been 
located,  but  shortly  afterwards  showed  itself  in  the  left  shoulder.  You  re- 
member what  I  mean  by  prescribed  gymnastic  exercises,  and  which  consist 
in  executing  movements,  according  to  order,  with  the  convulsed  muscles, 
and  doing  so  regularly,  keeping  time  to  a  metronome  or  a  clock. 

In  some  cases  of  tic  the  patient  utters  a  more  or  less  loud  cry,  which  is 


856  •  ON    CHOKEA. 

very  characteristic.  Once  I  recognized  one  of  my  old  schoolfellows  (after 
an  interval  of  twenty  years)  as  he  happened  to  walk  behind  me,  through  a 
sort  of  barking  noise  which  he  used  to  utter  in  our  school-days. 

The  tic  may  consist  in  this  cry  or  bark  alone,  which  is  a  true  laryngeal 
or  diaphragmatic  chorea;  there  is,  besides,  a  singular  tendency  always  to 
repeat  the  same  word  or  exclamation,  and  the  person  even  speaks  out 
loudly  words  which  he  should  like  to  keep  back.  This  complaint  is  very 
often  hereditary.  I  was  consulted  by  a  lady  from  Burgundy  who  had 
spasmodic  tic  of  the  face,  while  her  three  daughters  were  suffering  from  tic 
affecting  muscles  in  various  portions  of  the  body ;  and  the  poor  mother, 
who  was  deeply  grieved  at  the  infirmity  of  her  three  daughters,  and  did 
not  notice  her  own,  reproached  them  with  their  nervous  movements  with  a 
bitterness  which  was  curious  to  see.  The  hereditary  influence  may  show 
itself  in  a  different  manner.  By  carefully  questioning  a  patient  suffering 
from  tic,  you  may  sometimes  find  that  his  ancestors,  direct  or  collateral, 
were  all  subject  to  very  different  neuroses. 

I  saw  very  recently  a  boy,  14  years  of  age,  who  was  afflicted  with 
extremely  severe  tic,  throwing  his  head  sideways  with  an  excessively 
abrupt  gyratory  motion,  and  uttering  a  small  sharp  cry.  I  had  seen  him 
before  during  the  summer  of  1860,  and  he  then  used  to  utter  fierce  cries 
every  moment,  without  his  mind  seeming  to  be  in  the  least  impaired.  This 
sad  condition  had  lasted  several  months,  and  had  seemed  to  improve  under 
the  influence  of  atropine  alone.  His  eldest  brother  had,  for  several  years, 
suffered  from  facial  spasm  characterized  by  grimaces,  during  which  all  the 
muscles  of  his  face  were  violently  convulsed.  His  father  has  been  affected 
with  locomotor  ataxy  for  the  last  twenty  years ;  his  paternal  grandfather 
committed  suicide  in  a  fit  of  monomania,  and  several  of  his  relations,  on 
his  mother's  side,  have  been  insane. 

Writer's  cramp  or  chorea  scriptorum  is  the  name  given  to  an  affection  for 
which  Dr.  Duchenne  (de  Boulogne)  has  proposed  that  of  functional  spasm* 
It  is  sometimes  a  consequence  of  the  overuse  of  certain  muscles,  and  comes 
on  when  these  muscles  are  called  into  action  either  instinctively  or  volun- 
tarily. Thus,  it  attacks  individuals  who  write  continuously,  for  a  pro- 
longed period,  or  with  excessive  rapidity.  It  sometimes  consists  in  a  spasm, 
a  voluntary,  continued,  and  more  or  less  painful  contraction  of  the  extensor 
and  flexor  muscles  of  the  fingers,  and  to  such  cases  the  term  writer's  cramp 
is  perfectly  applicable  ;  but  at  other  times  it  is  true  chorea;  when  the  indi- 
vidual wishes  to  write,  his  fingers  move  more  or  less  violently,  shake,  or 
are  actually  convulsed,  so  that  they  are  unable  to  finish  what  they  began 
to  write. 

T)r.  Duchenne  (de  Boulogne)  states  that  this  affection  (which  is  also 
attended  with  paralysis)  may  not  only  affect  the  hand,  but  any  other  part 
of  the  body  also,  and  it  is  on  this  account  that  he  proposes  for  it  the  name 
of  functional  spasm,  a  denomination  which,  however  open  to  criticism,  has 
yet  the  advantage  of  not  particularizing,  as  thai  of  writer's  cramp  does. 
He  relates  a  certain  number  of  eases  showing  the  different  localities  in 
which  the  complaint  may  be  seated. 

"  In  writers  it  may  extend  to  the  muscles  of  the  forearm,  the  hand  per- 
forming a  movement  of  supination  as  soon  as  the  patient  tries  to  write  a 
word,  SO  thai  the  pen  is  turned  upwards  without  his  being  able  to  pre- 
vent it. 

"  In  the  case  of  a  tailor,  the  arm  turned  violently  inwards,  through  eon- 


*  "  De  1 'electrisation  localised  el  de  son  application  h  la  pathologic  et  ft  la  thera- 
peutique."    2*  Edition      Paris,  1861,  p.  928. 


ON    CHOREA.  S.",7 

traction  of  the  subscapularis,  as  soon  as  he  had  clone  a  few  Btitches.  He 
never  had  this  annoyance  when  he  made  any  other  movement. 

"A  fencing-master  found  that  as  soon  as  he  placed  himself  in  a  posture 

of  defence,  the  arm  with  the  hand  of  which  he  held  his  sword,  turned  im- 
mediately inwards. 

"A  turner  complained  that  the  flexor  muscles  of  his  foot  upon  the  leg 
were  thrown  into  contraction,  as  soon  as  he  placed  his  foot  on  the  footboard 
of  his  lathe  ;  but  he  never  felt  the  same  thing  when  he  walked  or  performed 
other  voluntary  movements  with  his  leg. 

"In  the  case  of  a  laborer,  a  paver,  both  sterno-mastoidei  contracted  dur- 
ing the  instinctive  action  of  the  muscles  which  keep  the  head  in  equilibrium 
in  an  intermediate  condition  between  flexion  and  extension.  They  did  so 
with  such  violence,  that  his  head  bent  down  with  excessive  force.  He  had 
only  to  rest  his  head  against  anything  in  order  to  stop  all  contraction  ;  and 
none  took  place  also  when  he  lay  down,  or  reclined  backwards,  leaning  his 
head  against  the  back  of  a  chair. 

"  A  savant,  who  had  spent  several  years  translating  manuscripts,  com- 
plained of  the  following  symptoms  which  had  come  on,  for  the  last  six 
months,  whenever  he  read  or  looked  fixedly  at  anything.  His  sight,  which 
had  been  good  until  then,  and  which  even  then  was  good  when  he  looked 
about,  grew  dim  whenever  he  looked  at  any  object  for  a  few  seconds.  He 
had  double  vision,  and  it  could  be  easily  seen  that  this  was  due  to  the 
spasmodic  contraction  of  the  internal  rectus  of  the  left  eye,  which  disap- 
peared as  soon  as  he  ceased  to  look  fixedly." 

The  most  curious  instance  of  this  singular  neurosis,  which  has  come  under 
Dr.  Duchenne's  observation,  occurred  in  a  country  priest,  whose  inspiratory 
muscles  were  affected.  During  inspiration,  the  whole  right  side  of  his  abdo- 
men was  alternately  tense  and  depressed,  wdiile  his  epigastrium  swelled  out 
normally  on  the  left  side.  A  medical  man  had  diagnosed  paralysis  of  the 
right  half  of  the  diaphragm,  but  the  paralysis  was  merely  apparent.  The 
disturbance  in  the  breathing  was  solely  due  to  the  spasmodic  and  pain- 
ful contraction  of  the  abdominal  muscles  on  the  right  side,  and  of  the 
obliquus  externus  especially,  for  at  each  inspiration  this  latter  muscle 
could  be  felt  to  harden,  and  the  direction  of  its  contracted  bundles  could 
even  be  traced  through  the  emaciated  integuments.  The  spasm  was  so 
violent,  that  the  body  turned  from  right  to  left  at  every  inspiration :  it 
was  accompanied  with  pain,  and  was  a  true  cramp,  which  lasted  during 
the  whole  period  of  inspiration.  This  conflict  between  the  inspiratory  and 
expiratory  muscles  prevented  the  epigastrium  and  the  base  of  the  chest 
from  expanding  on  the  right  side,  and  consequently  prevented  the  lung 
from  dilating.  Hence  it  was  that  breathing  was  considerably  impeded, 
and  that  the  patient  had  always  a  choking  sensation.  There  was  no  fever, 
and  for  two  years  no  treatment  gave  relief.  Faradization  failed  like  the 
rest. 

I  will  quote  another  case  in  illustration,  and  from  Dr.  Duchenne's  work 
again.  A  Strasburg  student,  M.  V ,  overworked  himself  when  pre- 
paring his  examination  for  the  degree  of  baehelier.  The  excessive  strain 
on  his  mind,  and  the  efforts  which  he  made  to  resist  sleep,  gave  rise,  accord- 
ing to  his  statement,  to  a  sensation  of  painful  constriction  in  the  temples, 
forehead,  and  eyes,  so  that  he  had  been  obliged  to  discontinue  his  studies. 
He  could  not  begin  reading  without  this  sensation  returning  at  once.  Dr. 
Duchenne  found  that  at  such  times  the  eyebrows  were  pulled  up  through 
the  contraction  of  the  frontal  muscles,  and  that  the  eyelids  were  closed  by 
the  contracting  orbicular  muscles,  while  the  face  flushed,  and  the  temporal 
veins  swelled."  This  condition  lasted  several  years,  and  was  brought  on  by 


858  ON    CHOREA. 

reading  alone.     The  young  man  committed  suicide  at  last,  in  despair  of 
ever  getting  well. 

Indeed,  gentlemen,  whatever  its  seat  may  be,  this  complaint  is  incurable. 
Absolute  rest  of  the  affected  muscles  can  alone  prevent  it  from  returning. 
All  treatment  has  failed.  Yet  persons  suffering  from  writer's  cramp  can 
still  write  sometimes,  by  using  a  peculiar  penholder  invented  by  Dr.  Caze- 
nave  (of  Bordeaux),  and  the  description  of  which  has  been  given*  by  Val- 
leix  in  his  "  Guide  du  Medecin  Praticien."  I  have  told  you  that  Dr. 
Duchenne  (de  Boulogne)  is  of  opinion  that  functional  spasm  may  be  also 
characterized  by  paralysis,  and  he  relates  two  cases  in  support  of  his  view, 
in  the  memoir  which  I  have  quoted.  One  is  that  of  a  bookkeeper,  whose 
adductor  pollicis  lost  all  power  after  he  had  written  two  or  three  lines,  so 
that  he  dropped  the  pen.  He  could  only  write  by  holding  the  pen  with 
his  index  and  middle  fingers.  Yet  the  muscle  could  act  with  energy  when- 
ever he  had  not  to  hold  a  pen  :  there  was  no  muscular  spasm  in  this  in- 
stance. In  the  second  case,  the  functional  paralysis  was  seated  in  the 
infraspinatus  muscle,  preventing  the  arm  from  rotating  from  without  in- 
wards, and  consequently  the  forearm,  when  flexed  on  the  arm,  from  exe- 
cuting' the  same  movement. 


Hysterical  Chorea. — Hysterical  Cough. 

Gentlemen  :  I  alluded,  in  a  previous  conference,  to  the  case  of  a  girl 
13^  years  old,  who  occupied  bed  No.  6,  in  St.  Bernard  Ward,  and  who  was 
suffering  from  hysterical  choreiform  convulsions.  About  the  same  period, 
you  could  see  another  case  of  the  kind,  namely,  a  young  girl  18  or  19  years 
old,  who  lay  at  No.  33,  in  the  same  ward. 

The  invasion  of  the  disease,  in  the  latter  case,  had  coincided  with  a  sud- 
den suppression  of  the  menstrual  flux,  in  consequence  of  a  fright.  Convul- 
sive agitation  had  immediately  shown  itself,  together  with  jerking  move- 
ments of  the  limbs  and  trunk,  so  violent  as  to  prevent  her  from  standing. 
Her  tongue  was  similarly  affected ;  hence  she  was  unable  to  connect  the 
syllables  together,  although  she  could  articulate  them  separately.  She 
stammered  in  a  singular  manner,  repeating  with  extraordinary  volubility, 
and  for  a  pretty  long  time  without  stopping,  the  last  syllables  of  the  words 
which  she  attempted  to  say,  articulating  the  first  syllables  with  difficulty. 
It  was  a  remarkable  fact,  however,  that  she  did  not  stutter  when  she  sang, 
and  no  modification  of  speech  could  then  be  suspected.  I  at  first  thought 
that  she  was  feigning;  but  this  idea  could  be  entertained  with  difficulty,  in 
presence  of  convulsive  phenomena  which  lasted  a  whole  day,  without  a  mo- 
ment's interruption,  and  ceased  during  sleep  only.  On  reflecting,  however, 
how  painful  it  is  for  a  healthy  individual  to  move  a  limb  for  several  min- 
utes, and  d,  fortiori,  to  agitate  it  in  the  same  manner  as  this  young  girl  did. 
it  could  be  understood  how  impossible  it  must  be  to  act  such  a  pari  during 
sixteen  or  eighteen  hours  out  of  the  twenty-four,  and  without  interruption. 

There  was  a  third  patient  in  bed  No.  11,  who,  from  her  appearance, 
looked  more  like  a  girl   1  5  or  17  than  12£  years  of  age,  as  she   really  was. 

The  attack  for  which  she  had  Keen  admitted  dated  only  two  days  Dack; 

but  .-he  had  fell  thefirsl  symptoms  of  the  complainl  >i\  months  previously. 

Her  mother  was  subject  tO  Convulsive  seizures ;  one  of  her  brothers,  -1  year- 
old,  had  had  several  similar  ones  also  ;  and  from  her  description  of  the  iits 
they  must  have  been  epileptic.      Her  health  had  been  good  until  six  months 


*  Paris,  I860,  t.  1,  p.  906. 


ON    CHOREA.  859 

ago,  when  she  was  suddenly  seized,  without  any  known  cause,  with  violent 
pain  in  the  head  and  very  abundant  hemorrhage  from  the  nose,  after  which 
she  had  become  extremely  weak.  Two  or  three  days  afterwards  her  abdo- 
men had  swollen  considerably,  and  she  had  suffered  from  colic  and  gastral- 
gia.  Her  appetite  was  good,  however,  her  digestion  regular,  and  taking 
food  neither  increased  nor  diminished  the  pain  in  the  stomach  and  abdo- 
men, while  the  swelling  of  the  latter  varied  very  much.  On  her  admission 
I  found  that  her  abdomen  was  swollen  out  to  the  size  of  that  of  a  woman 
in  the  eighth  month  of  pregnancy  ;  and  the  tympanitic  resonance  heard 
all  over  it  on  percussion  was  proof  sufficient  that  the  distension  was  due  to 
meteorismus.  She  complained  also  of  pain  in  the  dorsal  region,  in  the 
loins  and  the  lower  extremities,  which  she  spoke  of  as  cramps  in  the  latter 
regions.     Lastly,  the  headache  continued  still. 

She  took  very  little  notice  of  the  above  symptoms,  when,  two  days  before 
she  applied  for  admission,  she  had,  without  appreciable  cause,  and  without 
any  antecedent  emotion,  what  she  termed  a  nervous  attack,  which  still  per- 
sisted when  I  saw  her.  This  consisted  in  convulsive  movements,  which 
were  at  first  confined  to  the  arms,  and  extended  to  the  legs  twenty-four 
hours  afterwards.  You  must  have  remarked,  gentlemen,  how,  in  spite  of 
the  choreic  convulsions  which  agitated  the  limbs  during  this  true  chorea, 
the  movements  that  were  performed,  however  involuntary  they  might  be, 
were  executed  with  regularity  and  in  harmonious  combination.  Besides, 
contrary  to  what  takes  place  in  St.  Vitus's  dance,  they  stopped  when  the 
patient  was  asked  to  stretch  out  her  arm  ;  she  could  perform  the  latter 
movement  with  the  greatest  facility,  and  in  a  perfectly  straight  line.  She 
could  take  hold,  with  ease,  of  any  object  shown  her,  reached  it  directly, 
and  never  dropped  it  after  getting  it  in  her  hand. 

Cutaneous  sensibility  was  abolished  in  certain  regions  of  the  body :  over 
the  back  of  the  forearm,  along  the  outer  aspect  of  the  left  thigh,  in  certain 
portions  of  the  face  and  of  the  chest,  there  was  analgesia;  when  she  was 
pricked  with  a  pin  she  felt  a  mere  touch,  and  had  not  the  sensation  of 
pricking.  No  doubt  could  exist  as  to  the  nature  of  her  complaint,  for  she 
had  on  several  occasions  regular  hysterical  attacks. 

I  met  in  consultation  my  colleague  and  friend  Dr.  Horteloup  in  the  case 
of  a  young  lady  19  years  old.  She  had  received  an  excellent  education, 
professed  sentiments  of  the  purest  morality  and  of  the  most  enlightened 
piety,  free  from  all  ridiculous  show  of  outward  devotion,  and  was,  in  one 
word,  a  person  of  sense,  whose  intellectual  and  moral  condition  removed 
all  idea  of  deceit  and  of  those  grimaces  with  which  hysterical  girls  seem  so 
unaccountably  anxious  to  deceive  the  persons  about  them,  and  even  their 
medical  attendants  when  they  can.  This  young  lady  had  lost,  eight  or  ten 
months  previously,  a  sister  to  whom  she  was  deeply  and  tenderly  attached. 
Her  grief  was  all  the  greater  that  she  keenly  felt  for  her  mother  as  well  as 
for  herself.  Since  that  time  she  had  been  subject  to  strange  convulsive 
movements  of  the  head  and  upper  limbs  ;  yet,  when  she  came  to  Paris  to 
consult  Dr.  Horteloup,  who  had  attended  her  on  a  former  occasion,  she 
was  less  sad,  looked  more  cheerful,  and  was  pretty  easily  diverted  from  her 
gloomy  ideas.  When  I  saw  her,  her  aspect  was  that  of  perfect  health, 
but  her  whole  left  side  was  the  seat  of  violent  choreic  movements — so  vio- 
lent, indeed,  that  she  was  in  danger  of  hurting  herself  against  the  neigh- 
boring pieces  of  furniture  or  the  wallls.  If  one  attempted  to  arrest  these 
movements  by  taking  hold  of  her  hand,  they  grew  worse,  and  were  accom- 
panied with  a  sense  of  pain,  and  most  unpleasant  general  malaise.  There 
was  one  means,  however,  of  quieting  all  this  agitation,  as  if  by  magic — 
namely,  by  asking  her  to  play  the  piano.     She  could  spend  an  hour  or  two 


860  ON    CHOREA. 

at  the  instrument,  playing  to  perfection,  and  with  the  greatest  regularity  : 
in  excellent  time,  and  without  missing  a  note.  She  played  a  piece  in  my 
presence  with  marvellous  facility  ;  and  this  single  fact,  even  in  the  absence 
of  other  proofs,  would  have  sufficed  to  show  me-that  this  kind  of  chorea 
had  nothing  in  common  with  St.  Vitus's  dance;  for  no  one  suffering  from 
this  latter  disease  is  able  to  do  what  this  young  lady  did.  These  illustra- 
tions, which  I  might  multiply,  if  it  were  necessary,  suffice  to  show  you  the 
difference  which  exists  between  St.  Vitus's  dance  and  hysterical  chorea. 
In  the  latter  affection  I  repeat,  however  powerless  the  will  may  be  to  pre- 
vent the  disorderly  contractions  of  the  muscles,  it  can  still  command  com- 
bined movements,  and  cause  them  to  be  executed  with  regularity  and 
harmony.  When  the  patient  walks  she  trots,  it  is  true  ;  but  she  follows 
any  line  which  she  chooses  without  deviating  from  it.  If  she  wishes  to 
carry  her  hand  in  any  direction,  she  reaches  the  end  she  has  in  view 
directly  and  without  difficulty,  although  her  arm  may  be  convulsively 
agitated ;  if  she  tries  to  seize  an  object,  she  does  so  at  once,  without  erring ; 
and  when  she  has  once  caught,  she  never  drops  it,  and  can  carry  or  place 
it  wherever  she  likes.  I  have  told  you  how  different  the  case  is  in  St. 
Vitus's  dance. 

Thus,  if  we  merely  look  at  the  form  of  the  choreic  phenomena,  it  is  easy, 
with  a  little  attention,  to  distinguish  these  two  kinds  of  chorea  one  from 
the  other,  as  their  nature  is  so  essentially  different. 

It  very  rarely  happens,  besides,  that  the  former  is  not  accompanied, 
preceded,  or  followed  by  some  more  special  and  characteristic  symptoms. 
In  the  absence  of  its  great  manifestations,  of  its  convulsive  seizures,  hysteria 
shows  itself  by  that  group  of  perfectly  special  physical  or  mental  disposi- 
tions which  some  authors  term  hystericism ;  or  there  are  certain  local  phe- 
nomena proper  to  the  disease,  such  as  that  strange  sensation  of  umbilical 
and  epigastric  constriction,  as  if  a  foreign  body  were  going  up  from  the 
oesophagus  to  the  throat,  producing  there  a  sense  of  choking,  to  which  the 
name  of  globus  hystericus  has  been  applied  ;  or,  again,  perversions  of  cuta- 
neous sensibility,  which  is  sometimes  exaggerated  in  certain  parts  of  the 
body,  giving  rise  to  the  so-called  clavus  hystericus,  and  sometimes,  on  the 
contrary,  diminished  or  entirely  abolished  (analgesia  and  anaesthesia ). 

Hysterical  cough,  which  is  nothing  but  a  convulsion  of  the  muscles  of  the 
larynx  and  diaphragm,  presents  great  analogies  to  these  forms  of  chorea. 
However  convulsive  it  may  be,  it  resembles  in  nothing  other  convulsive 
coughs;  for  instance,  the  convulsive  cough  properly  so  called,  which  is  so 
frequently  observed  in  children,  or  that  of  hooping-cough.  It  is  not,  like 
them,  attended  with  those  violent  spasms  which  cause  iits  of  choking, 
threatenings  of  asphyxia,  and  give  rise  to  pulmonary  or  cerebral  conges- 
tions. 

A  young  woman,  who  occupied  for  a  few  days  bed  No.  1,  in  St.  Bernard 
Ward,  was  subject  to  this  cough  ;  and  you  had  an  opportunity  of  verifying 
the  accuracy  of  the  statemenl  made  by  my  excellent  friend,  Dr.  Lasegue, 
in  his  "Memoirs  on  Hysterical  Cough,"*  how  this  kind  of  COUgh,  when 
uncomplicated,  resembles  thai  which  is  excited  by  the  inhalation  of  certain 
gases — chlorine  for  example.  It  is  sometimes  preceded  by  a  sensation  of 
tickling  in  the  larynx,  is  dry,  or  with  a  trifling  mucous  expectoration, 
sonorous,  and  of  a  somewhat  monotonous  rhythm.  The  patient  either 
coughs  at  every  expiration  which  succeeds  an  inspiratory  movement,  or 
makes  two,  three,  or  four  coughing  expirations  before  she  begins  to  breathe 

again.      In  the  intervals  between  the  paroxysms,  the  breathing  18  less  deep 


*  "Archives  Generates  de  B16decine,"  1854. 


ON    CHOREA.  861 

thai)  usual,  because  the  patient  dreads  deep  inspirations,  which  render  the 
cough  more  troublesome;  but  there  is  no  dyspnoea,  and,  on  auscultation, 

no  other  modification  of  the  normal  respiratory  sounds  is  detected  than  a 
slight  diminution  of  the  vesicular  murmur  at  the  moment  when  the  inspi- 
ratory effort  is  withheld. 

While  it  lasts,  an  hysterical  cough  has  the  same  rhythm  and  timbre. 
The  jerks  constituting  the  paroxysm  arc  sometimes  so  often  repeated  that 
it  seems  as  if  the  latter  consisted  of  a  single  cough  instead  of  a  series  of 
coughs  ;  but  there  are  intervals  of  rest  between  each  paroxysm,  that  are 
perfectly  regular.  It  is  a  remarkable  fact — which  speaks  in  favor  of  the 
analogy  which  I  have  sought  to  establish  between  an  hysterical  cough  and 
choreic  convulsions — that,  however  continuous  it  may  have  been,  it  ceases 
entirely  during  sleep,  and,  as  Dr.  Lasegue  justly  remarks,  this  circumstance 
occurs  frequently  enough  to  acquire  great  diagnostic  value. 

These  attacks  may  recur  somewhat  periodically,  and  they  may  be  excited, 
as  well  as  suspended,  by  various  circumstances  which  have  no  influence  at 
all  on  a  cough  due  to  thoracic  disease. 

In  some  cases  which  are,  it  is  true,  very  exceptional,  an  hysterical  cough 
has  a  peculiar  timbre;  it  is  hoarse,  stridulous,  and  resembles  a  bird's  cry; 
but  one  should  be  careful  not  to  confound  this  cough,  which  even  then 
retains  some  of  its  special  characters,  with  the  barking,  the  mewing,  and 
the  strange  cries  which  are  heard  in  hysterical  cases,  and  which  are  related 
to  the  kind  of  tic  of  which  I  have  already  spoken.  An  hysterical  cough 
is  sometimes  complicated  with  hoarseness  and  even  with  aphonia,  some- 
times also  with  obstinate  vomiting,  as  in  the  case  of  a  young  person  who 
came  under  my  notice,  and  whose  history  I  shall  presently  relate  to  you  in 
a  few  words. 

Dr.  Lasegue  makes  the  observation  (in  the  excellent  memoir  from  which 
I  borrow  a  good  deal  of  what  I  am  now  telling  you),  that  "  an  hysterical 
cough  not  only  remains  identically  the  same  throughout  its  course,  but  has 
no  tendency  also  to  assume  other  forms  of  hysteria  ;  so  that  there  are  few 
instances  of  such  a  metamorphosis  occurring."  He  cites,  however,  two  cases 
which  are  exceptions  to  the  rule,  one  of  which  occurred  in  Prof.  Chomel's 
practice,  and  the  other  was  observed  in  my  wards  by  Dr.  Lasegue  himself, 
when  he  was  my  clinical  assistant.  The  subject  of  the  latter  was  a  woman 
who,  for  the  last  three  years,  had  been  troubled  with  a  cough  which  lasted 
almost  continuously  during  several  months  of  the  year,  recurring  with  less 
frequency  in  the  intervals,  and  having  all  the  characters  which  T  have 
pointed  out  to  you.  She  got  rid  of  it  after  some  deep  emotion,  followed  by 
temporary  loss  of  speech,  and  two  days  later  by  left  hemiplegia,  evidently 
of  an  hysterical  nature,  which  got  rapidly  well  without  any  treatment. 

Such  cases  are  not  so  rare  as  my  learned  friend  thinks,  for  it  would  not 
be  difficult  to  collect  a  pretty  large  number  of  instances,  analogous  to  the 
one  which  Chomel  published  in  the  "  Nouveau  Journal  de  Medecine,"  for 
1820,  of  paroxysms  of  an  hysterical  cough,  alternating  with  convulsive 
seizures.  I  could  myself  cite  several  such  ;  and  many  among  you  will 
surely  remember  having  seen  some  of  them  ;  and  only  lately  you  could 
see  a  case  of  this  kind  in  the  wards  under  the  care  of  Dr.  Barth,  my  col- 
league in  this  hospital. 

Lastly,  you  will  find  in  one  of  the  late  numbers  of  the  "  Union  Medi- 
cale,"  the  case  of  a  patient,  under  Dr.  Herard's  care,  whose  hysterical 
cough  was  replaced,  among  other  phenomena,  by  curious  sneezing. 

An  hysterical  cough  may  therefore  alternate  not  only  with  the  most 
common  well-developed  manifestations  of  the  disease  on  which  it  is  itself 
dependent,  such  as  convulsive  seizures  and  attacks  of  hysterical  paralysis, 


862  ON    CHOREA. 

but  it  may  also  be  replaced  by  local  manifestations,  such  as  vomiting  and 
sneezing.  What  usually  happens,  however,  is  this,  that  the  patient  has 
previously  exhibited,  if  not  the  marked  symptoms  of  hysteria,  at  least,  that 
group  of  special  physical  or  mental  dispositions  which  have  been  termed 
hysterieism  by  some  authors,  and  which  consist  in  a  nervous  changeability 
carried  to  the  highest  point. 

You  know,  gentlemen,  what  is  meant  by  nervous  changeability,  namely, 
a  condition  intermediate  between  spasm  and  normal  visceral  innervation. 
It  borders  on  the  state  of  vapors,  immediately  precedes,  and  is  a  necessary 
condition  of  that  state,  and  only  requires  increased  intensity  of  its  phe- 
nomena, or  the  excitation  of  the  slightest  cause,  in  order  to  merge  into  it. 
Kow  this  condition,  which  in  most  cases  is  only  the  highest  degree  of  a 
predisposition  to  spasms,  and  enters  into  the  constitution  of  many  women, 
is  most  marked  in  those  that  are  hysterical. 

An  hysterical  cough  generally  sets  in  more  or  less  suddenly,  and,  like  all 
phenomena  of  a  similar  nature,  without  any  appreciable  cause.  In  the  case 
of  a  young  woman  who  came  under  Dr.  Lasegue's  observation  (the  first  of 
the  examples  which  he  has  collected  in  his  memoir),  the  hysterical  cough 
came  on  after  a  simple  cold  which  had  lasted  several  days.  The  cold  was 
perfectly  well,  and  the  catarrhal  cough  had  ceased  completely  for  the  last 
eight  days,  when  the  hysterical  cough  commenced.  You  will  certainly 
have  an  opportunity  of  seeing  such  cases.  But  although  bronchitis  may 
prove  the  exciting  cause  of  an  hysterical  cough,  the  latter  is  by  no  means 
dependent  on  a  peculiar  predisposition  to  bronchial  catarrhs;  and  although, 
from  its  persistence  and  obstinacy,  it  often  alarms  the  patient's  friends  and 
even  her  medical  attendant,  exciting  in  them  fears  that  pulmonary  phthisis 
is  actually  present,  or  imminent  at  the  very  least,  I  never  have  seen  this 
complaint  begin  with  such  symptoms. 

In  some  cases,  and  always  in  profoundly  hysterical  women,  a  nervous 
cough  sets  in,  in  consequence  of  the  presence  of  worms.  I  have  already 
quoted  the  following  instance,  which  Graves  relates  in  his  "  Clinical  Lec- 
tures." This  illustrious  physician  was  attending,  at  Dublin,  together  with 
Sir  Philip  Crampton,  a  young  lady  who  had  lost  all  her  strength  from  a 
spasmodic  cough,  which  had  lasted  several  months.  Although  no  serious 
lesion  could  be  discovered  by  auscultation,  both  these  gentlemen  could  not 
help,  however,  believing  in  the  existence  of  tubercles  in  the  lungs,  for  there 
were  fever  and  considerable  emaciation.  On  the  patient  taking  some  tur- 
pentine, which  an  empirical  old  woman  recommended,  she  passed  a  tape- 
worm, and  the  cough  disappeared  immediately,  and  her  health  was  quietly 
re-established. 

An  hysterical  cough  is  an  essentially  chronic  complaint,  lasting  for 
months,  and  even  years,  uninfluenced  by  physiological  phenomena,  siicli  as 
menstruation,  which  may  occur  while  it  lasts.  Intercurrent  febrile  dis- 
eases suspend  it,  however,  as  they  do  hooping-cough.  When  it  lias  persisted 
for  a  long  time,  it  influences  at  last  the  patient's  general  health.  The 
appetite  diminishes,  or  is  lost,  and  digestion  is  impaired,  especially  if  the 
cough  be  complicated  with  obstinate  vomiting.  The  patient  becomes  pale 
and  thin,  complains  of  pain  in  the  chest,  and  is.  unable  to  bear  fatigue; 
fever  is  often  Lighted  up;  and  you  can  understand  how  careful  one  must 

then  be  in  order  to  recognize  the  nature  of  the  ease,  and  how  he  must  have 

recourse  to  auscultation  and  percussion,  in  order  to  determine  the  absence 
of  tubercles  in  the  lungs,  which  suggest  themselves  to  the  mind  from  the 
first  as  the  cause  of  the  evil. 

In  spite  of  its  persistence  and  obstinacy,  and  of  the  disturbances  which 
it  produces  in  the  system,  this  singular  neurosis  almosl   never  terminates 


SENILE    TREMBLING    AND    PARALYSIS    AGITANS.  863 

fatally.  Alter  lasting  more  or  less,  it  diminishes  insensibly,  and  then  dis- 
appears completely  ;  in  other  eases  it  ceases  suddenly,  without  any  reason 
to  account  for  this  happy  and  abrupt  termination.  But  whether  it  ceased 
by  slow  degrees  or  suddenly,  the  cure  may  be  merely  temporary.  Like  all 
hysterical  manifestations,  the  cough  may  return  at  the  very  moment  when 
the  patient  thinks  that  she  has  got  rid  of  it  forever;  and,  as  on  its  first  ap- 
pearance, it  comes  on  without  any  appreciable  determining  cause. 

Of  all  the  methods  of  treatment  which  have  been  tried  against  an  hys- 
terical cough,  one  alone  has  seemed  efficacious  to  me,  and  I  have  rarely 
seen  it  fail,  namely,  change  of  place ;  and  the  following  case,  to  which  I 
have  already  alluded,  proves  this  most  conclusively : 

A  young  lady,  17  years  of  age,  whose  health  was  habitually  good,  al- 
though she  looked  delicate,  and  who  menstruated  regularly,  began  to  cough 
in  May,  1852.  Her  mother  was  subject  to  spasmodic  tic  of  the  face,  but 
she  had  never  had  any  nervous  attacks  herself,  although  she  had  all  the 
characters  of  an  hysterical  temperament.  This  cough  attracted  little  notice 
for  the  first  few  days,  but  became  so  frequent  that  it  alarmed  her  friends. 
It  kept  on  all  day,  nearly  without  intermission,  but  ceased  entirely  when 
the  patient  slept  in  the  daytime  or  at  night.  It  was  dry,  sharp,  stridulous, 
acute ;  audible  from  a  pretty  good  distance,  and  recurring  with  a  nearly 
unchanged  rhythm.  The  most  varied  remedies — baths,  cold  affusions,  anti- 
spasmodics, &c. — were  tried,  but  without  modifying  its  frequency  or  its 
characters.  The  breathing  was  such  as  to  leave  no  doubt  as  to  the  regu- 
larity of  the  pulmonary  functions ;  the  fauces  were  neither  red  nor  pain- 
ful, and  there  was  no  alteration  of  the  voice.  This  condition  lasted  through- 
out the  months  of  May  and  June ;  in  the  beginning  of  July  some  fever  set 
in ;  digestion  had  already  become  laborious,  and  the  appetite  w7as  nearly 
lost ;  vomiting  came  on,  and  the  patient  brought  up  her  dinner  half  an  hour 
after  taking  it,  but  not  her  morning  meal.  As  her  general  health  seemed 
to  me  to  be  rather  seriously  impaired,  I  recommended  that  she  should  be 
immediately  sent  to  the  South.  My  advice  was  acted  upon ;  and  on  arriv- 
ing at  Orleans,  after  a  three  hours' journey,  the  patient,  who  felt  fatigued, 
spent  the  night  in  a  hotel.  The  vomiting  ceased  on  that  very  day;  the 
patient  spent  a  good  night,  and  had  no  fever ;  on  the  following  day  the 
cough  ceased,  and  a  complete  cure  ensued,  which  has  lasted  ever  since. 
She  remained  away  besides  for  several  weeks. 

A  few  years  ago  I  saw,  in  consultation  with  my  colleague,  M.  Guibout,  a 
lady,  27  years  old,  who,  for  the  last  six  months,  had  been  suffering  from  a 
cough,  having  the  peculiar  rhythm  which  I  have  described  to  you.  She 
had  lost  her  appetite,  had  become  ansemic  and  thin,  and  this  alarmed  her 
friends  considerably :  yet  nothing  abnormal  could  be  detected  on  auscult- 
ing  her  chest  with  the  greatest  care.  We  prescribed  a  travelling-tour,  and 
she  got  well  immediately. 


LECTURE  XLVII. 

SENILE  TREMBLING  AND  PARALYSIS  AGITANS. 

Gentlemen  :  I  told  you  in  our  conferences  on  St.  Vitus's  dance  that  it 
could  affect  individuals  of  advanced  age,  although  it  most  frequently  at- 
tacked young  adults,  and  I  quoted  in  illustration  a  long  and  interesting 


864  SENILE    TREMBLING    AND    PARALYSIS    AGITANS. 

case  published  by  Dr.  Hemy  Roger,  the  subject  of  which  was  a  woman, 
83  years  old.  This  kiud  of  chorea  should  uot  be  confounded  with  another, 
namely,  chorea  senilis  or  senile  trembling,  as  it  is  more  appropriately  term- 
ed, from  which  it  differs  totally,  not  only  as  to  its  nature,  and  the  condi- 
tions which  favor  its  development,  but  also  as  to  the  form  which  its  symp- 
toms assume,  so  that  the  two  diseases  may  be  easily  distinguished  from  one 
another  at  first  sight. 

Senile  trembling  consists  in  a  convulsive  agitation  of  the  muscles,  pro- 
duced by  a  series  of  involuntary  but  uniform  contractions,  taking  place 
over  a  limited  area,  and  following  one  another  with  excessive  rapidity.  At 
first  generally  confined  to  the  extremities  or  to  the  muscles  of  the  neck,  it 
may  spread  to  the  whole  of  the  body.  It  is  most  marked  when  the  in- 
dividual tries  to  execute  voluntary  movements,  or  when  his  mind  is  un- 
usually stretched,  or  when  he  is  under  the  influence  of  emotion.  Rest  and 
peace  of  mind  diminish  its  violence  or  make  it  disappear  entirely,  while  it 
ceases  completely  during  sleep. 

The  causes  of  this  complaint  are  unknown.  It  is  usually  said  that  this 
kind  of  trembling  is  a  consequence,  of  the  weakness  which  old  age  brings 
on,  but  if  this  be  true  in  some  cases,  it  is  not  so  generally  speaking.  For 
on  the  one  hand,  it  is  not  invariably  seen  in  very  old  people,  and  on  the 
other  hand,  it  pretty  frequently  affects  individuals  of  middle  age,  and  even 
young  adults.  You  have  yourselves  known  instances  of  this  ;  and  on  this 
account,  therefore,  the  term  senile,  when  applied  to  this  kind  of  trembling, 
is  as-inappropriate  as  when  it  is  applied  to  gangrene  due  to  the  oblitera- 
tion of  an  artery,  and  which  may  be  seen  at  all  ages,  even  in  childhood. 

However  this  may  be,  this  kind  of  chorea  is  little  known  to  pathologists, 
although  it  is  pretty  common.  One  point,  however,  is  well  known  about 
it,  namely,  that  it  is  incurable. 

Senile  trembling  should  not  also  be  confounded  with  'paralysis  agitans,  of 
which  the  woman  now  at  No.  2,  in  St.  Bernard  Ward,  presents  us  with  ;m 
instance.  She  is  a  charwoman,  aged  60;  her  complaint  dates  two  years 
back,  since  which  time,  but  especially  for  the  last  six  months,  she  has  coin- 
plained  of  rapid  loss  of  strength.  Since  then  also  she  has  been  subjecl  to 
trembling  which,  from  being  slight  at  first,  became  so  violent  that  tor  the 
last  four  months  she  has  been  obliged  to  give  up  her  usual  occupation,  from 
her  inability  to  use  her  hands.  The  trembling  has  since  become  more 
general  and  involved  the  face,  so  that  now  her  lower  jaw  shakes  convul- 
sively; and  as  she  cannot  shut  her  mouth,  she  dribbles  constantly.  She 
has  retained  all  her  faculties,  and  although  she  complains  of  tin' annoyance 
caused  by  this  perpetual  shaking  which  she  cannot  restrain,  she  does  not 
speak  of  pain  but  only  of  a  sense  of  extreme  fatigue  after  the  paroxysms 
of  trembling.  This  is  more  marked  on  the  right  than  on  the  left  side, ami 
when  the  strength  of  her  right  arm  is  tested  with  the  dynamometer  it  is 
found  to  be  equivalenl  to  a  power  capable  of  raising  a  weight  of  1  I  or  L6 
lbs.,  while  on  the  left  side,  the  instrument  gives  only  4  to  li  lbs.  Cutaneous 
sensibility  is  unimpaired.  In  spite  of  this  marked  diminution  of  her  mus- 
cular power,  there  is  do  paralysis  properly  so  called,  for  when  1  try  to  flex 

or  to  extend  her  legs  or   her   arms   against    her  will,  she  resists  me  with  an 

energy  which  I  only  overcome  with  Borne  difficulty.  I  called  attention,  as 
you  may  remember,  to  the  shape  of  her  hands,  for  her  four  Angers  deviate 

from  their  normal  direction,  and    inclining   towards    the    ulnar  side   of  the 

Limb,  form  with  the  forearm  an  angle  of  aboul  25  ,  so  that  the  metacarpo- 
phalangeal articulation  must,  therefore,  be  partially  dislocated. 
Paralyeu  alitor?*, like  senile  trembling,  is  principally  met  with  in  persons 


SENILE    TREMBLING    AND    PARALYSIS    AGITANS.  865 

of  declining  years,  although  it  may  affect  adults,  and  I  have  seen  a  young 
man,  27  years  of  age,  who  was  suffering  from  iU 

In  some  cases  it  assumes  another  form,  which  it  is  important  for  you  to 
know. 

On  October  16,  1863,  I  was  consulted  by  an  advocate,  aged  58,  of  un- 
common intelligence,  and  who  for  the  last  four  years,  after  deep  emotions, 
had  been  affected  with  the  singular  neurosis  which  I  am  going  to  describe 
to  you,  and  which,  in  my  opinion,  was  only  a  form  of  paralysis  agitans.  As 
he  came  up  from  the  waiting  into  my  consulting-room,  he  inclined  his 
body  forwards,  hurrying  his  step,  with  his  right  arm,  in  a  semiflexed  posi- 
tion, resting  against  his  body,  and  shaking  very  slightly.  He  sat  down 
with  some  difficulty,  and  as  if  his  trunk  and  legs  were  stiff.  He  then  told 
me  his  story ;  how,  in  1858,  he  had  for  more  than  a  twelvemonth  attended 
his  wife  assiduously,  whom  he  loved  deeply  and  had  lost.  Grief  and  sleep- 
less nights  had  exhausted  him.  He  was  then  suffering  from  such  nervous 
irritability  that  he  could  not  bear  to  hear  the  ringing  of  bells ;  the  least 
noise,  the  least  annoyance,  disturbed  him  beyond  measure.  He  soon 
noticed  that  his  arm  seemed  to  shake  slightly,  and  that  the  movements  of 
the  whole  limb,  but  of  the  hand  especially,  became  more  and  more  diffi- 
cult. In  a  short  time,  the  leg  on  the  same  side  became  affected  also,  and 
his  symptoms  grew  worse,  without  being  in  the  least  modified  by  any 
method  of  treatment.  After  a  time,  he  had  to  give  up  writing,  and  when 
I  saw  him,  he  could  sign  his  name  with  extreme  slowness  and  difficulty 
only. 

At  first  sight,  he  looks  like  a  paralytic  but  on  examining  him  carefully, 
it  is  soon  made  out  that  there  is  only  apparent  paralysis,  and  that  the  case 
is  a  very  curious  one,  which  we  cannot  account  for.  For  if  I  ask  the 
patient  to  squeeze  Burq's  dynamometer,  the  instrument  marks  100  lbs. 
much  more  than  it  does  when  I  squeeze  it  myself.  Squeezed  by  the 
patient's  left  or  healthy  hand,  it  marks  84  lbs.  only,  that  is,  16  lbs.  less 
than  when  the  hand  of  the  seemingly  paralyzed  limb  is  used.  If,  when 
his  arm  is  flexed,  I  try  to  extend  it  against  his  will,  he  resists  me  with  ex- 
treme energy,  and  does  the  same  when  I  attempt  to  flex,  adduct,  or  abduct 
it  against  his  will.  There  is  no  rigidity  of  the  limb,  and  when  the  patient 
does  not  exert  his  will,  his  limb  is  perfectly  supple  and  I  can  move  it  in 
every  direction. 

What  takes  place  here  then  ?  The  muscles  have  retained  their  strength, 
and  yet  their  functions  are  nearly  abolished.  But  let  us  try  and  analyze 
this  curious  phenomenon.  When  the  will  commands,  the  muscles  obey  in- 
stantly, and  no  appreciable  interval  intervenes  between  the  act  of  willing 
and  the  muscular  contraction.  The  movement  may  be  repeated  ten,  fifteen, 
twenty,  a  hundred,  or  a  thousand  times  in  succession,  as  in  the  act  of  walk- 
ing, for  instance.  If  you  suppose  that  in  order  to  take  two  steps,  the 
muscles  have  to  expend  an  amount  of  strength  equal  to  twenty  pounds,  if 
the  same  act  be  repeated  a  thousand  times  in  an  hour,  a  power  of  twenty 
thousand  pounds  shall  be  expended. 

Now,  let  us  see  what  occurs  in  the  case  of  the  patient  whose  history  I 
have  related  to  you.  Let  us  suppose  that  he  takes  five  hundred  steps  in 
an  hour ;  each  step  shall  have  cost  a  20-lb  power,  and  he  will  spend  on  the 
whole  a  force  equal  to  ten  thousand  pounds,  instead  of  twenty  thousand, 
or,  in  other  words,  the  motor  power  will  be  only  one-half  of  the  other.  It 
was  a  very  strange  circumstance,  that  when  I  asked  this  patient  to  open 
and  shut  his  hand  as  rapidly  as  he  could,  he  moved  at  first  quickly,  then 
more  slowly  after  scarcely  a  quarter  of  a  minute,  and  next  he  was  unable 
to  move  at  all.  Just  as  a  steam-engine,  which  is  insufficiently  heated,  is 
vol.  i. — 55 


886  SENILE    TREMBLING    AND    PARALYSIS    AG1TANS. 

unable  to  work  continuously.  But  if  the  valves  be  closed  for  a  moment, 
and  the  steam  allowed  to  ^cumulate,  the  machine  regains  power  for  a  time, 
but  soon  becomes  powerless  again  after  this  artificial  development  of  force. 
In  the  case  of  our  patients,  it  would  seem  as  if  they  could  only  spend  a 
determinate  quantity  of  nervous  influence  which  is  not  reproduced  in  them 
with  the  same  rapidity  as  in  other  men.  They  suffer  then  from  a  relative 
and  momentary  loss  of  power,  but  not  from  paralysis  in  the  ordinary  ac- 
ceptation of  the  term. 

The  patient,  whose  history  I  have  just  related  to  you,  was  suffering  from 
that  form  of  the  disease  in  which  there  is  but  slight  shaking.  The  other 
woman,  on  the  contrary,  who  was  in  bed  No.  2,  in  St.  Bernard  Ward,  pre- 
sented considerable  muscular  agitation.  In  the  man's  case,  the  muscles 
were  in  a  state  of  permanent  contraction,  and  the  sensation  complained  of 
was  that  of  a  continuous  effort.  In  the  woman's,  on  the  contrary,  although 
that  sensation  was  complained  of  from  time  to  time,  there  was  more  fre- 
quently muscular  agitation.  She  stated  that  every  paroxysm  of  shaking 
caused  her  as  much  fatigue  as  very  violent  exercise  used  formerly  to  do. 
By  endeavoring  to  analyze  these  two  muscular  conditions,  we  shall  under- 
stand better  what  occurs  in  what  has  been  so  inappropriately  termed 
paralysis  agitans. 

All  our  muscles  are  in  a  state  of  relaxation  during  the  period  of  rest. 
Their  function  ceases  temporarily,  and  during  that  rest  the  aptitude  which 
was  lost  or  diminished  from  excessive  action,  is  entirely  regained.  Sup- 
pose now,  that  in  consequence  of  a  modification  of  the  nervous  centres,  the 
muscles  should  always  be  in  a  condition  analogous  to  that  of  continuous 
effort,  their  excitability  will  be  exhausted  during  their  immobility,  from 
the  extensor  and  flexor  muscles  acting  constantly  and  simultaneously.  In 
the  other  form,  the  alternate  rapid  and  involuntary  movement  of  extension 
and  flexion  which  constitutes  trembling,  expends  the  nerve  force,  as  rigid- 
ity did  in  the  former  case,  and  power  is  wasted  uselessly,  at  the  expense  of 
normal  functions,  so  that  when  it  becomes  necessary  to  exhibit  muscular 
power,  the  patient  is  incapable  of  doing  it  with  the  same  continuity,  or  in 
the  same  degree,  as  before,  and  he  will  be  in  the  same  condition  as  an  indi- 
vidual exhausted  by  extreme  fatigue. 

We  meet  with  an  analogous  condition  in  those  casea  which  I  have  termed 
loss  of  muscular  excitability,  a  curious  neurosis,  of  which  I  have  Been  very 
interesting  instances. 

A  young  lady,  aged  18,  and  married  for  the  last  six  months,  came  from 
Tours  to  Paris  a  few  years  ago,  to  be  treated  tor  this  strange  ueurosis. 
She  was  said  to  be  paralyzed.  When  1  asked  her  to  walk,  she  got  up  with 
determination,  walked  without  staggering,  and  with  perfect  steadiness,  ten, 
fifteen,  twenty,  twenty-five  paces,  then  complained  of  feeling  weak,  and  if 
no  chair  were  near  at  hand,  she  was  compelled  to  sit  down  on  the  floor. 
She  lost  all  strength  after  this  trifling  exercise,  and  exhausted  the  amount 
of  excitability  possessed  by  her  muscular  uervous  system.  A  tew  minutes' 
rest  sufficed  to  give  her  back  the  aptitude  which  she  had  Lost  In  L862  I 
saw  another  young  lady  in  precisely  the  same  condition.  Mark  thai  these 
two  cases  are  only  exaggerated  instances  of  what  we  very  frequently  Bee. 
The  power  of  restraining  movements  varies  indefinitely,  and  we  have  no 

right   t0  look  upon  these  tWO  cases  as  instances  of  paralysis,  any  more  than 

we  can  pronounce  those  whose  strength  is  exhausted  after  a  moderate  exer- 
cise Lasting  from  ten  to  twenty-live  minutes,  to  be  suffering  from  paralysis. 

It  must  be  a  well-undersl I   poinl   then,  gentlemen,  that    there  is  do 

paralysis  at  the  commencement  of  this  strange  form  of  chorea,  which  is  so 
inappropriately  termed  paralysis  agitans,  since  there  are  cases  (an  instance 


SENILE    TREMBLING    AND    PARALYSIS    AGITANS.  867 

of  which  came  very  recently  under  my  observation)  in  which  the  muscular 
power,  tested  by  the  dynamometi  r,  is,  temporarily  at  Least,  greater  on  the 
shaking  than  on  the  opposite  side.  In  the  long  run,  however,  real  weak- 
3upervenes,  and  towards  the  close  of  the  disease  the  loss  of  muscular 
power  is  such  that  the  existence  of  paralysis  cannot  be  denied.  Yet,  it 
should  be  observed,  that  sensation  is  unimpaired. 

The  weakness  of  the  genito-urinary  organs  is  still  more  marked  than  that 
of  the  muscles.  In  males  impotence  sets  in  rapidly,  and  towards  the  last 
the  mine  is  retained  with  difficulty,  and  there  is  sometimes  incontinence, 
which  may,  however,  be  due  to  continued  tonic  contraction  of  the  fibres  of 
the  bladder. 

There  may  also  occur  another  phenomenon  which  makes  paralysis 
agitans  resemble  very  much  paralysis,  due  to  hemorrhage  into,  or  softening 
of,  the  brain,  namely,  rigidity. 

I  was  consulted,  in  1863,  by  a  superior  naval  officer,  who  for  the  last  two 
years  of  a  difficult  command  had  been  affected  with  paralysis  agitans.  At  the 
end  of  a  year  he  lost  the  power  of  writing,  and  when  I  saw  him  for  the  first 
time,  the  two  last  fingers  of  his  right  hand  were  firmly  flexed  into  the  palm 
of  the  hand,  and  it  was  only  with  slowness  and  with  extreme  difficulty  that 
he  could  extend  his  thumb  and  his  index  and  middle  fingers. 

Paralysis  agitans,  which  some  authors  of  eminence  have  confounded,  not 
without  some  reason,  perhaps,  with  chorea  festinam,  is  partial  in  the  begin- 
ning, and  may  affect  one  arm  alone,  for  instance.  The  limb  shakes  con- 
tinually, and  the  patient  complains  of  its  feeling  weak ;  this  weakness, 
which  is  very  slight  at  first,  makes  rapid  progress ;  the  corresponding  leg 
shortly  becomes  affected  in  the  same  way,  and  involuntary  convulsive 
movements  show  themselves  simultaneously  with  a  sense  of  diminution  of 
muscular  strength.  The  patient  only  hops  when  he  tries  to  walk.  As  the 
disease  progresses,  it  becomes  general ;  the  limbs  of  the  opposite  side  are 
involved,  and  the  patient's  gait  then  becomes  so  characteristic,  that  his 
complaint  can  no  longer  be  mistaken,  although  it  cannot  be  satisfactorily 
described.  His  body  inclines  forwards  as  he  walks,  and  he  keeps  the  arm 
on  the  affected  side  in  a  semiflexed  attitude,  and  closely  pressed  against  the 
trunk.  As  his  centre  of  gravity  is  thus  displaced,  he  is  obliged  to  run 
after  himself,  as  it  were,  so  that  he  keeps  trotting  and  hopping  on.  He  is 
unable  to  move  without  help,  and  in  some  cases,  as  he  requires  more  assist- 
ance than  is  afforded  by  leaning  on  a  stick,  he  can  only  walk  by  resting 
both  his  hands  on  the  shoulders  of  an  attendant,  or  supported  from,  behind, 
otherwise  he  is  sure  to  fall  down. 

I  must  add,  however,  that  the  complaint  always  occurs  in  paroxysms, 
and  that  after  a  paroxysm  which  may  last  from  ten  to  forty  minutes,  and 
even  more,  the  patient  complains,  not  of  pain,  but  of  a  sense  of  muscular 
fatigue,  as  after  violent  exercise. 

When  the  disease  becomes  still  more  general,  the  muscles  of  the  neck 
are  convulsed,  and  the  head  then  shakes  continually ;  the  muscles  of  the  face 
are  not  spared,  and  as  you  saw  in  the  case  of  the  woman  in  my  wards,  the 
lower  jaw  drops,  the  mouth  is  always  open,  and  allows  the  saliva  to  dribble 
out,  which  wets  and  messes  the  patient's  clothes.  Speech  is,  of  course,  em- 
barrassed and  indistinct.  On  the  other  hand,  as  the  bladder  gets  paralyzed, 
there  supervenes  retention,  and  subsequently  incontinence  of  urine.  All 
sexual  power  is  lost.  The  convulsive  movements  are  so  often  repeated, 
although  they  are  not  violent,  that  deformities  result  from  them.  Thus, 
from  the  patients'  pressing  against  their  hands  constantly,  their  fingers  get 
dislocated  on  the  metacarpal  bones,  and  their  dorsal  surface  makes  an  angle 
with  the  back  of  the  hand. 


868  SENILE    TKEMBLING    AND    PARALYSIS    AGITANS. 

The  intellect  is  at  first  unaffected,  but  gets  weakened  at  last ;  the  patient 
loses  his  memory,  and  his  friends  soon  notice  that  his  mind  is  not  so  clear 
as  it  was :  precocious  caducity  sets  in. 

Paralysis  agitam  is  an  inexorable  complaint,  which  always  terminates 
fatally  within  a  shorter  or  longer  period,  in  spite  of  all  treatment.  Iu  three 
cases,  however,  which  were  under  my  observation  until  the  end,  I  made  the 
curious  remark  that  death  was  caused  by  pneumonia.  There  is  little  prob- 
ability that  other  practitioners  shall  have  an  opportunity  of  noticing  a 
similar  coincidence  between  a  neurosis  and  pueumonia. 

I  am  not  aware  that  the  anatomical  lesions  special  to  paralysis  agitans 
have  been  studied  in  France,  and  it  seems  that  those  who  looked  out  for 
them,  did  not  find  any.  We  must  pay  great  attention,  however,  to  the 
alterations  which  Parkinson,  Oppolzer,  and  Lebert  have  described ;  and 
allow  me  to  quote  a  case,  most  cai'efully  observed  by  Professor  Oppolzer. 

A  man,  aged  72,  very  thin  and  of  very  diminutive  stature,  was  admitted 
into  the  "Clinique"  on  June  20,  on  account  of  a  violent  trembling  which 
prevented  him  from  using  his  hands.  He  gave  the  following  account  of 
the  origin  of  his  complaint:  he  had  never  had  a  serious  illness  until  the  age 
of  60,  when  during  the  bombardment  of  Vienna,  in  1848,  he  happened  by 
chance  to  get  in  the  midst  of  the  fight.  He  was  struck  with  such  terror, 
that  he  could  not  return  home  by  himself,  and  had  to  be  taken  there.  He 
had  scarcely  got  over  his  fright,  when  a  bomb  burst  near  his  house  and 
alarmed  him  again.  A  few  hours  afterwards,  on  trying  to  take  some  food, 
he  found  himself  perfectly  unable  to  use  his  hands,  because  as  soon  as  he 
tried  to  move  them,  they  began  immediately  to  tremble  violently.  He 
noticed  also  after  a  short  time  that  his  lower  limbs  trembled  in  the  same 
manner,  but  less  violently,  so  that  he  could  still  walk.  The  disease  not  only 
resisted  all  the  measures  employed  against  it,  but  also  grew  gradually  worse. 
The  trembling  persisted  even  when  he  was  at  rest,  and  involved  other 
muscles;  lastly,  paralysis  was  superadded  to  it.  After  a  few  years,  he 
became  incapable  of  standing  erect,  and  as  soon  as  he  made  the  attempt, 
he  had  an  irresistible  tendency  to  fall  forwards,  so  that  iu  order  to  avoid 
falling  down,  he  was  obliged  to  lay  hold  of  neighboring  objects,  or  to  walk 
hurriedly.  The  keenness  of  his  senses  and  of  his  intellectual  faculties  bad 
diminished  slowly  but  progressively. 

The  use  of  tea,  of  coffee,  or  of  spirituous  liquors  always  increased  the 
trembling;  and  the  agitation  of  the  lower  limbs  was  especially  marked  in 
the  evening,  when  the  patient  had  walked  during  the  day.  About  six 
months  ago,  the  sphincters,  that  of  the  bladder,  in  particular,  became  para- 
lyzed; the  patient  was  then  admitted  into  the  general  hospital  on  account 
of  these  complications,  which  seemed  to  improve  at  the  end  of  a  month. 
Five  weeks  ago,  after  a  severe  attack  of  vertigo,  the  patient  dropped 
down  suddenly,  and  was  unable  to  rise,  hut  never  lost  consciousness  t li i-< .ultIi- 
out.  Since  that  time,  the  emaciation  basincreased  very  rapidly;  the  patient 
can  stand  and  walk  for  a  veryshorl  time  only,and  with  very  great  efforts; 
and  in  addition,  his  articulation  is  embarrassed.  lie  was  in  the  following 
state  when  admitted  into  the' Clinical  Hospital:  emaciation  very  marked; 
earthy  tint  of  the  integuments,  the  surface  of  which  is  covered  with  numer- 
ous epithelial  scales  ;  the  -ecretion  of  perspirat inn,  which  is  increased  on  the 
face,  seems  on  the  contrary  to  he  diminished  in  other  regions  of  the  body; 
the  temperature  of  the  -kin  seem-  to  he  lower  than  it  normally  is. 

The  muscles  of  the  face,  tongue,  neck,  and  upper  limbs  are  affected  with 
violent  trembling,  which  never  ceases  during  the  waking  Btate,  ami  Lb  com- 
pletely suspended   only  during  profound  Bleep.     The  lower  limbs  shake 

periodically  only,  and  when  there  is  general  exacerbation  of  all    the  .-yinp- 


SENILE    TREMBLING    AND    PARALYSIS    AGITANS.  869 

toms.  The  muscles  which  are  the  seat  of  the  trembling  are  rigid  at  the 
same  time,  especially  the  muscles  of  the  ueck  and  shoulders. 

The  pupils  are  equally  dilated,  and  contract  equally  well  under  the  influ- 
ence of  light.  The  mouth  is  only  incompletely  closed,  and  the  saliva  dribbles 
out  of  both  corners  over  the  chin.  There  seems  to  be  no  visceral  lesion; 
there  is  merely  slight  dulness  in  front  and  at  the  back  over  the  apex  of  the 
right  lung.  Auscultation  detects  besides,  at  those  spots,  a  diminution  of 
the  respiratory  murmur.  The  temporal  arteries  and  the  arteries  of  the 
limbs,  especially  the  right  brachial,  are  tortuous  and  rigid.  Sensibility  is 
normal  everywhere ;  and  the  muscles  contract,  although  somewhat  feebly, 
under  the  influence  of  galvanic  excitation. 

The  patient  frequently  complains  of  vertigo,  and  more  rarely  of  cephal- 
algia. The  stools  are  passed  normally ;  the  urine  is  alkaline  and  contains 
some  pus.  The  patient  answers  very  slowly  but  pretty  clearly  the  questions 
which  are  put  to  him.  His  physiognomy  is  expressive  of  indifference  and 
apathy.  Treatment :  carbonate  of  iron  (a  drachm  for  six  doses  to  be  taken 
in  three  days).  The  following  is  a  summary  of  the  further  progress  of  the 
case:  From  the  22d  to  the  24th  of  June,  a  pretty  severe  diarrhoea  set  in, 
with  involuntary  stools,  which  yielded  to  the  use  of  opiate  injections.  On 
the  24th,  the  carbonate  of  iron,  which  had  been  suspended  during  the 
presence  of  diarrhoea,  is  resumed. 

June  25.  The  patient  slept  only  a  little  last  night,  and  was  delirious : 
about  ten  in  the  morning,  he  had  an  epileptiform  seizure,  during  which  his 
head  was  pulled  convulsively  to  the  right,  while  his  right  eye  turned  out- 
wards and  upwards,  and  his  left  eye  downwards  and  inwards.  The  eyelids 
and  the  tongue  kept  at  the  same  time  oscillating  continually,  while  the 
muscles  of  the  face  were  rigid  and  hard.  The  upper  and  lower  limbs,  on 
the  contrary,  remain  flaccid,  offering  little  resistance  when  moved  about. 
The  fit  lasted  about  eight  minutes,  and  during  that  time,  the  respiration 
and  the  pulse  were  weak  and  irregular,  and  there  was  complete  loss  of  con- 
sciousness. 

On  the  1st  and  the  7th  of  July,  fresh  eclamptic  seizures  came  on,  after 
which,  on  each  occasion,  the  trembling  ceased  for  about  half  an  hour,  recur- 
ring after  this  with  its  former  severity.  General  sensibility  seemed  to 
diminish  from  day  to  day,  and  the  face  had  a  stupid  expression,  reminding 
one  of  the  physiognomy  of  individuals  laboring  under  typhoid  fever,  in  the 
second  stage.  The  abdomen  was  swollen ;  there  were  involuntary  stools, 
the  urine  contained  some  carbonate  of  ammonia  and  a  few  pus-cells  as 
before;  the  patient  lay  in  a  sort  of  imperfect  sleep,  and  it  was  almost  im- 
possible to  fix  his  attention.  He  answered  in  monosyllables  the  questions 
that  were  put  to  him  ;  his  strength  diminished  rapidly,  and  pneumonia 
came  on  towards  the  close  of  his  life.     Death  took  place  on  July  11. 

On  making  a  post-mortem  examination,  several  tubercular  cavities  were 
found  at  the  apex  of  the  right  lung,  and  there  was  granular  hepatization 
of  the  lower  lobe  of  the  same  lung.  Both  ventricles  of  the  heart  were 
dilated  and  full  of  coagulated  blood ;  their  walls  were  discolored  and  friable  ; 
the  aortic  valves  were  indurated  at  the  base,  the  arch  of  the  aorta  dilated 
and  ossified,  the  spleen  of  voluminous  size,  the  mucous  membrane  of  the 
bladder  red,  injected,  and  the  muscular  wall  of  the  organ  likewise  injected. 
The  other  abdominal  organs  presented  besides  no  other  notable  alteration. 

The  cranial  bones  were  very  thin,  and  their  inner  surface  was  rough. 
The  dura  mater  was  thickened  and  adherent,  here  and  there,  to  the  inner 
table  of  the  cranial  vault;  the  pia  mater  opaque  and  infiltrated  with  serosity  : 
there  was  also  a  pretty  large  quantity  of  serosity  in  the  subarachnoid  cel- 
lular tissue.      The  cerebral  convolutions  were  thinner,  the  sulci  between 


870  SENILE    TREMBLING    AND    PARALYSIS    AGITANS. 

them  seemed  deeper  than  usual,  the  cortical  substance  was  of  a  pale  brown 
color,  while  the  medullaiy  was  perfectly  white,  and  traversed  by  dilated 
vessels ;  the  cerebral  substance  was  moist  and  of  good  consistency.  The 
ventricles  contained  several  drachms  of  transparent  serosity,  and  the  epen- 
dyma,  principally  on  a  level  with  the  posterior  cornu,  was  granular.  In 
the  substance  of  the  right  optic  thalamus  there  was  an  apoplectic  cyst  of 
the  size  of  a  small  bean,  the  walls  of  which  contained  pigment.  The  pons 
Varolii  and  the  medulla  oblongata  were  very  manifestly  indurated.  The  spinal 
cord  was  firm,  and  the  medullary  substance  of  the  lateral  columns,  prin- 
cipally in  the  lumbar  region,  presented  opaque  gray  striae.  On  making  a 
microscopical  examination,  there  was  found  in  the  substance  of  the  pons 
Varolii  and  of  the  medulla  oblongata  an  abnormal  production  of  connective 
tissue,  accounting  for  the  induration  of  those  parts.  The  opaque  strice  in 
the  lateral  columns  of  the  cord  were  due  to  the  presence  of  connective  tissue  in 
process  of  development. 

In  this  case  of  Professor  Oppolzer,  then,  gentlemen,  the  medulla  oblon- 
gata and  the  pons  Varolii  were  found  indurated,  while  in  the  lateral  columns 
of  the  cord,  especially  in  the  lumbar  region,  the  medullary  substance 
exhibited  gray  opaque  strise.  All  these  changes,  as  well  as  the  analogous 
ones  noted  by  Parkinson  and  by  Lebert,  were  the  result  of  an  hypertrophy 
of  the  connective  tissue  which  enters  into  the  composition  of  the  nervous 
tissue.  This  hyperformation  had  produced  compression  of  the  nervous 
elements,  whence  their  atrophy  and  fatty  degeneration.  Such  alterations, 
attended  with  induration  of  the  affected  parts,  are  termed  sclerosis.  In  the 
cases  in  which  dissection  has  shown  incipient  softening  of  the  columns  of 
the  cord,  in  the  same  regions,  this  may  perhaps  have  been  a  consequence 
merely  of  hyperseniia  and  vascular  dilatation,  which  cause  great  modifica- 
tions in  the  nutrition  of  nervous  elements. 

Such  alterations  account  for  the  powerlessness  of  treatment,  for  none  as 
yet  seems  to  have  been  attended  with  certain  and  continued  success.  I 
must  mention,  however,  that  Elliotson  has  ascribed  the  cure  of  a  case  of 
paralysis  agitans,  in  a  man  35  years  of  age,  to  the  administration  of  carbo- 
nate of  iron.  But  he  admits  that  he  was  completely  successful  in  one  case 
only,  and  that  no  appreciable  improvement  was  obtained  in  others. 

Romberg  tried  the  same  treatment,  and  states  that  it  failed;  so  that, 
although  we  may  ascribe' some  part  of  the  cure  to  the  carbonate  of  iron  in 
Dr.  Elliotson's  case,  we  may  ascribe  as  great  a  share  to  the  patient's  age  as 
to  the  medicine  itself.  Sulphur  baths,  iodide  of  potassium,  and  all  power- 
ful alterative  remedies,  should  be  tried,  especially  with  the  view  of  placing 
the  patient  in  the  most  favorable  condition  for  resisting  the  progress  of  the 
disease.  Perhaps  also,  as  in  a  case  published  by  Dr.  Axenfeld,  the  hyper- 
semic  process  which  goes  on  might  be  arrested  by  revulsives  applied  to  the 
upper  portion  of  the  vertebral  column. 

I  have  myself,  in  some  cases,  obtained  good  results  from  the  use  of  large 
doses  of  spirits  of  turpentine,  and  from  hydropathy  ;  but  I  have  not  cured  a 
single  patient:  and  this  sad  complaint  is,  in  my  opinion,  aa  intractable  as 
progressive  locomotor  ataxy. 


CEREBRAL    FEVER.  871 


LECTURE  XLVIII. 

CEREBRAL  FEVER. 

Instances  of  Different  Forms  of  Cerebral  Fever. — Description  of  the  Disease: 
Three  Stages  wh  ich  are  generally  pretty  Distinct — Premonitory  Stage,  char- 
acterized by  a  Group  of  General  Phenomena,  which  may  be  seen  in  other 
Diseases,  but  which  are  never  so  Marked  and  never  so  Prolonged  as  in 
this  Complaint. — Second  Stage:  Absence  of  Fever ;  the  Pulse  becomes  re- 
markably Sloiv,  and  the  breathing  peculiarly  Irregular. —  This  Irregular- 
ity of  the  Respiratory  Movements  is  a  Sign  of  Greed  Value. — Differential 
Diagnosis  between  Cerebral  Fever  and  Typhoid  Fever. —  Third  Period: 
The  Pulse  Quickens  again,  and  often  to  an  Extraordinary  Degree. — 
Prostration,  Delirium ;  Convulsions,  at  first  Partial,  then  General;  Pa- 
ralysis.—  Cerebral  Fever  is  nearly  always,  not  to  say  ahvays,  Fatal,  what- 
ever be  the  Treatment  adopted. — The  Post-mortem  Appearances  are  more 
indicative  of  Cerebro-Meningitis  than  of  Meningitis. —  Whether  Tubercular 
or  not,  the  Complaint  runs  the  same  Course. —  Chronic  Hydrocephalus. — 
It  is  not  a  Consequence  of  Cerebral  Fever. 

Gentlemen  :  At  No.  33,  in  St.  Bernard  "Ward,  there  died  a  young 
woman,  23  years  old,  who  had  been  admitted  on  March,  13,  1866,  on 
account  of  paralysis  of  the  right  limbs,  without  implication  of  the  face,  and 
due  to  cervical  arthritis,  marked  externally  by  great  swelling  of  the  first 
vertebrae,  and  by  pain  exaggerated  by  the  least  movement  of  the  head, 
which,  on  that  account,  the  patient  kept  perfectly  motionless. 

The  paralysis  had  supervened  under  the  following  circumstances.  The 
patient  stated  that  she  had  in  general  enjoyed  good  health,  although  she 
was  of  a  delicate  constitution.  Eighteen  months  before  she  was  admitted 
into  the  Hotel-Dieu  she  was  seized  with  pain  in  the  neck,  acute  enough  to 
prevent  her  from  turning  her  head,  especially  to  the  right,  She  had  at  the 
same  time  a  sensation  of  constriction  and  stiffness  in  that  region,  which  was 
markedly  swollen.  Ointments  (the  composition  of  which  she  could  not  tell 
us),  poultices,  and  subsequently  the  application  of  leeches,  did  not  arrest 
the  progress  of  the  disease.  Within  ten  months  the  complaint  had  made 
such  advances  that  the  poor  patient  could  no  longer  lie  with  her  head  on 
the  pillow,  as  the  pressure  exaggerated  her  pains,  which  were  much  worse 
on  the  right  side  of  the  neck.  She  complained  at  the  same  time  of  a  sense 
of  constant  numbness  in  that  part.  The  phenomena  of  the  disease  soon 
assumed  a  more  complicated  form,  and  fifteen  months  after  their  invasion 
she  complained  of  a  diminution  of  strength  in  the  right  arm  and  leg.  This 
weakness  went  on  increasing,  and  in  a  month's  time  passed  into  paralysis, 
Avhich  never  was  complete,  however.  The  patient  could  still  walk,  although 
she  could  only  raise  her  leg  with  difficulty,  and  dragged  it ;  she  had  not 
lost  entirely  the  power  of  moving  her  arm,  although  she  could  not  use  her 
hand  to  do  her  customary  work,  not  *even  to  carry  her  food  to  her  mouth. 
Formication,  followed  by  numbness,  preceded  and  accompanied  the  paral- 
ysis of  motion,  and  was  the  only  disorder  of  sensibility,  which  was,  in  other 
respects,  perfectly  normal  everywhere.     There  was  no  impairment  of  the 


872  CEREBRAL    FEVER. 

intellect ;  the  special  senses  were  normal,  and  there  had  been  at  no  time  the 
least  febrile  reaction.  For  the  last  two  months  or  so  the  appetite  alone 
had  failed,  and  the  patient  ascribed  it  to  her  being  unable  to  take  as  much 
exercise  as  before.     Her  digestion  was  perfectly  regular,  notwithstanding. 

From  the  first  day  that  I  saw  her,  I  easily  made  out  that  the  hemiplegia 
was  due  to  disease  of  the  vertebrae.  My  attention  was  attracted  by  the 
swelling  of  the  neck,  which  was  much  larger  superiorly  on  the  right,  espe- 
cially on  a  level  with  the  two  first  cervical  vertebrae.  The  swollen  part 
was  painful,  and  the  least  movement  of  the  head,  either  when  the  patient 
herself  attempted  to  raise  or  turn  it,  or  when  I  tried  to  move  it  with  great 
caution  and  slowness,  was  attended  with  acute  suffering. 

The  case  was  evidently  one  of  white  swelling  of  the  atloido-axoidean 
articulation ;  and  although  auscultation  of  the  chest  revealed  no  signs  of 
pulmonary  tuberculization,  and  the  patient  declared  that  she  was  not  liable 
to  colds,  and  that  there  was  no  tendency  to  phthisis  in  her  family,  I  could 
not  but  diagnose  scrofulous  disease  of  the  vertebral  column.  Although  I 
could  not  discover  any  trace  of  syphilitic  diathesis,  still  suspecting  that  the 
disease  might  arise  from  constitutional  syphilis,  I  prescribed  mercury 
(corrosive  sublimate  baths  and  calomel  in  divided  doses) ;  but  as  salivation 
was  soon  induced,  I  suspended  the  calomel. 

The  disease  continued  to  make  progress.  In  order  to  calm  the  pain, 
which  had  become  more  intense,  I  ordered  poultices,  made  with  powdered 
conium  leaves,  and  kept  on  the  neck  day  and  night.  The  pain  still  weut 
on  increasing,  and  it  was  not  only  felt  in  the  head  by  July  17,  but  in  the 
legs  also,  the  hypogastrium  and  the  groins.  As  menstruation  (which  had 
been  regular  until  eight  months  ago)  had  been  suppressed  at  that  time,  I 
thought  that  the  pain  might  be  due  to  a  tendency  to  a  re-establishment  of 
that  function,  but  vomiting  having  set  in,  I  began  to  fear  that  it  might 
announce  the  invasion  of  a  cerebral  affection.  Indeed,  in  the  course  of  the 
day  the  patient,  whose  mind  was  perfectly  clear,  began  to  exhibit  some 
embarrassment  of  speech.  The  pain  in  the  neck  grew  much  worse,  the 
paralysis  of  the  limbs  became  more  marked,  and  by  the  next  day  tin  ex- 
pression of  the  face  had  altered  appreciably. 

The  disease  remained  stationary  until  the  23d:  calomel,  which  had  been 
resumed  on  the  18th,  was  continued  in  the  same  divided  closes.  The  drug 
had  no  apparent  effect  on  the  digestive  tube,  and  the  stools  were  regular 
as  usual.  On  July  23,  we  found  strabismus,  and  for  several  days  previously 
the  patient  had  complained  of  seeing  double.  On  the  24th,  deafness  came 
on  ;  the  patient  had  an  attack  of  syncope  during  the  night,  ami  on  the  next 
day  I  found  her  in  a  feverish  state,  with  a  hot  skin,  and  the  pulse  heating  at 
the  rate  of  120  in  the  minute.  The  abdominal  walls  were  retracted  and  boat- 
shaped;  the  cerebml  macula  was  produced  with  the  greatest  facility,  and 
persisted  for  a  long  time.  The  patienl  had  fits  of  absence  during  the  day, 
and  did  not  know  the  persons  about  her;  delirium  set  in  during  the  night, 
but  disappeared  in  the  morning.  The  strabismus,  and  the  changes  in  the 
expression  ami  the  color  of  the  face,  which  was  alternately  very  red  ami 
of  a  deadly  pallor, became  more  and  more  characteristic,  ami  in  the  even- 
ing, the  .-tools  were  passed  involuntarily. 

The  symptoms  grew  worse  and  worse.  The  respiration  became  very 
irregular,  from  four  to  five  or  eight  inspiratory  acts  following  one  another 
with  extreme  rapidity,  ami  being  then  followed  by  a  considerable  pause. 
There  was  extreme  vascularity  of  the  -kin,  and  the  cerebral  macula  was 
brought  out  by  the  leasl  friction;  the  strabismus  was  pushed  to  it-  ex- 

treinest  limits,  and  the  pupils  were  dilated.   The  in  I  el  led  was  Still  pretty  clear, 


CEREBRAL    FEVER.  873 

and  the  patient  answered  questions,  but  without  separating  her  teeth,  her 
jaws  being  firmly  closed.     Death  took  place  on  July  28,  at  4  p.  m. 

You  remember,  gentlemen,  what  we  found  on  examining  the  body.  I 
had,  during  life,  diagnosed  white  swelling  of  a  vertebral  joint  as  the  start- 
ing-point of  a  cerebro-meningitis  of  the  base,  and,  indeed,  we  found  tracas 
of  a  violent  inflammation  of  the  pia  mater,  which  was  infiltrated  with  pus, 
and  covered  as  with  a  greenish  transparent  veil  the  annular  protuberance 
and  the  space  between  it  and  the  optic  commissure.  The  fissure  of  Sylvius 
was  filled  with  a  sero-fibrinous  material.  On  making  sections  of  the  brain, 
the  fornix  and  the  septum  lucidum  were  found  in  a  pulpy  condition;  the 
lateral  ventricles  contained  a  notable  quantity  of  serosity,  and  their  posterior 
part  was  softened  as  well  as  the  corpus  callosum.  There  were  no  tubercles, 
and  no  granulations  anywhere.  The  spinal  meninges  were  injected,  and 
the  cord  itself  was  softened  on  a  level  with  the  articulation  of  the  atlas  with 
the  axis,  while  those  vertebras,  which  were  markedly  larger  on  the  right 
than  on  the  left  side,  exhibited  all  the  characters  of  osteitis.  Their  articular 
surfaces  and  that  of  the  odontoid  process  were  deprived  of  cartilage,  rough- 
ened, and  pierced  with  numerous  foramina,  but  they  contained  no  tubercular 
matter,  either  collected  in  masses,  or  in  a  state  of  infiltration.  The  cellular 
tissue  in  the  neighborhood  was  infiltrated  with  plastic  lymph  and  with  pus. 

The  lungs  looked  healthy,  and  showed  no  traces  of  tubercular  deposit. 

About  the  same  time  as  this  patient  was  admitted  into  St.  Bernard  Ward, 
another  young  woman  died  there  also,  but  much  more  rapidly,  of  cerebral 
fever,  which  had  supervened  under  different  circumstances.  She  came  to 
the  hospital  during  the  day,  stating  that  she  had  been  unwell  for  the  last 
nine  or  ten  days.  She  gave  a  pretty  good  account  of  her  sensations,  but 
seemed  by  no  means  uneasy  about  them ;  she  laughed  at  and  joked  about 
her  own  condition  (note  this  well,  gentlemen).  Yet,  I  was  far  from  being 
satisfied  with  her  state.  I  noticed  that  her  face  was  flushed,  her  aspect 
dull,  her  pupils  dilated,  and  that  her  left  limbs  were  somewhat  weaker  than 
the  right  ones ;  the  cerebral  macula  was  produced  with  the  greatest  facility. 
When  my  clinical  assistant  saw  her  in  the  evening,  he  diagnosed  encepha- 
litis, and  I  made  the  same  diagnosis  the  next  morning.  Three  days  after- 
wards the  patient  died.  She  had  conversed  with  me  very  pertinently  on 
that  very  same  morning,  and  had  even  joked,  but  an  hour  after  my  visit,  she 
fell  into  a  profound  stupor,  and  died  suddenly. 

Dissection  disclosed  on  the  surface  of  the  brain,  at  its  upper  and  under 
aspects,  the  presence  of  granulations  in  the  meninges,  and  a  small  mass  of 
tubercle  at  the  base.  The  corpus  callosum  was  completely  softened,  and 
reduced  to  a  pulpy  condition,  as  well  as  the  posterior  part  of  the  walls  of 
the  lateral  ventricles,  the  cavity  of  which  contained  some  serosity.  The 
septum  lucidum  and  the  fornix  were  also  softened. 

Some  of  you  may  also  recollect  the  history  of  a  third  patient,  a  male,  Avho 
died  of  cerebral  fever  about  the  same  time  as  these  two  women.  He  occu- 
pied bed  No.  19,  in  St.  Agnes  Ward.  He  was  21  years  old,  and  had  been 
seized,  about  eighteen  months  previously,  with  rheumatic  pain  in  the  left  leg, 
which  resisted  all  treatment.  Two  months  before  the  complaint,  of  which 
he  afterwards  died,  set  in,  he  came  to  Paris  and  took  a  situation  as  shop 
messenger.  He  worked  beyond  his  strength  at  that  place,  he  says,  and  a 
fortnight  before  his  admission  into  the  hospital  he  complained  of  a  violent 
pain  in  the  head,  which  set  in  suddenly.  He  went  on  working  as  usual ; 
but  he  felt  so  exhausted  every  evening  that  he  could  scarcely  find  strength 
to  get  home.  Three  or  four  days  went  by.  His  appetite  had  failed  sensibly 
for  about  a  month,  and  since  he  had  come  to  Paris  he  had  been  subject  to 
diarrhoea,  passing  two  or  three  liquid  stools  in  the  twenty-four  hours.    Dur- 


874  CEREBRAL    FEVER. 

ing  the  above  three  or  four  days  he  had  lost  his  appetite  completely,  and 
he  soon  was  compelled  to  give  up  work.  His  headache  increased  markedly 
in  violence,  especially  across  the  forehead,  at  which  part  he  complained  of 
continued,  unbearable  throbbings,  giving  him  the  sensation  as  if  his  skull 
was  going  to  burst.  He  had  pain  in  the  eyes  also ;  and  did  not  sleep  at 
night.  From  the  beginning,  he  had  had  during  the  day  very  copious 
vomiting,  and  could  keep  no  liquid  on  his  stomach.  The  matters  which  he 
vomited  contained  bile;  and  he  complained  of  a  bitter  taste  in  his  mouth. 
The  tongue  was  coated  with  a  thin,  whitish  fur;  the  skin  was  not  abnor- 
mally hot,  but  the  slowness  of  the  pulse  (which  beat  25  times  in  the  minute) 
coinciding  with  intense  cephalalgia,  sleeplessness,  and  dilatation  of  the 
pupils,  made  me  anxious. 

Constipation  had  replaced  the  diarrhoea,  and  in  order  to  produce  revul- 
sion towards  the  lower  part  of  the  large  intestine,  I  prescribed  a  purgative 
(calomel  and  jalap). 

On  the  next  day  the  pulse  was  slower,  46  ;  the  vomiting  was  less  frequent, 
but  the  cephalalgia  being  still  more  violent,  if  possible,  I  tried  to  relieve  it 
by  the  application  on  the  forehead  of  compresses  steeped  in  a  solution  of 
cyanide  of  potassium  (20  grains  to  3  ounces  of  distilled  water).  The  pain 
began  to  diminish  forty-eight  hours  afterwards;  but  the  patient  had  com- 
plained for  the  last  three  days  already  of  some  disturbance  of  vision  ;  his 
eyes  looked  like  those  of  a  drunken  man  ;  the  pupils  were  not  dilated  to  an 
extraordinary  degree,  but  contracted  badly  under  the  influence  of  light. 
Lastly,  the  cerebral  macula  was  easily  produced.  In  the  course  of  that  even- 
ing (the  fifth  day  after  his  admission)  he  was  found  in  a  very  prostrate  con- 
dition, with  staring  eyes,  and  a  stupid  look,  apparently  insensible  to  every- 
thing around  him,  and  picking  the  bedclothes.  His  skin  was  hot,  but  his 
pulse  was  not  more  than  64.  He  had  an  attack  of  syncope  some  time  after- 
wards, and  during  the  night  he  uttered  plaintive  cries  without  coming  out 
of  his  somnolent  state.  The  sopor  was  more  marked  the  next  morning,  and 
his  eyes  remained  half-closed  without  the  pupils  being  dilated.  The  breath- 
ing was  uneven,  and  the  patient  uttered  plaintive  cries  again,  as  during  the 
night.  Although  apparently  insensible  to  everything  around  him,  he  felt 
very  well  when  he  was  pinched,  and  withdrew  his  arms.  The  carphology 
persisted,  the  fever  was  more  intense  than  on  the  preceding  day,  and  yet 
the  pulse  was  not  more  than  84  or  88.  There  was  again  very  obstinate 
constipation,  so  that  I  ordered  an  enema  to  be  given  (an  ounce  of  decoc- 
tion of  senna  leaves,  and  half  an  ounce  of  sulphate  of  soda).  This  produced 
very  slight  effects.  On  the  18th,  in  the  morning,  profound  coma  had  suc- 
ceeded to  the  somnolence;  the  pulse  was  small,  and  140  in  the  minute; 
there  was  left  hemiplegia.  On  the  right  side  sensation  was  still  retained, 
for  when  pinched  the  patient  withdrew  his  arm  and  leg,  while  on  the  led, 
pinching  was  not  felt.     The  bladder  was  distended. 

Death  took  place  at  4  a.m.  We  had  already  ascertained  that  two  brothers 
of  this  patient  had  died  at  the  same  a<re  and  in  the  same  manner. 

The  autopsy  showed  the  presence  of  encephalitis.  In  the  posterior  part 
of  the  right  optic  thalamus  there  was  found  an  indurated  mass,  of  a  yellow 
color,  and  dotted  with  numerous  red  points  (capillary  hemorrhage).  In 
tin'  centre  of  this  mass  were  Other  small  nuclei,  not  larger  than  millet-seeds 
and  having  all  the  characters  of  tubercular  matter.  The  cerebral  tissue 
was  softened,  but  not  dillluent  around  the  whole  mass.  The  lateral  ventri- 
cles contained  about  a  teaspoonful  of  reddish  serositv.and  small  gray  gran- 
ulations were  scattered  over  the  meninges,  which  were  very  dry. 

The  two  layers  of  the  pleura'  adhered    firmly  to  one  another,  and    in  the 


CEREBRAL    FEVER.  8<0 

substance  of  the  lungs,  which  were  congested,  a  few  small  tubercles  were 
scattered. 

I  wished  to  recall  these  cases  to  your  memory,  gentlemen,  before  speaking 
to  you  of  cerebral  fever  d  propos  of  two  babies,  one  of  whom  died  a  few  days 
ago,  and  the  other  only  yesterday,  so  that  I  shall  have  an  opportunity  of 
showing  you  once  more  the  characteristic  lesions  of  this  cruel  and  inexor- 
able complaint. 

The  first  of  these  children  was  a  little  boy  ten  months  old.  Xinc  weeks 
previously  his  mother  had  brought  him  to  me  for  the  first  time,  on  account 
of  an  unhealthy-looking  ulcer  which  he  had  in  the  neck,  and  which  was 
covered  with  pultaceous  concretions.  The  perpendicular  and  indurated 
edges  of  the  ulcer,  its  uneven  and  hard  bottom,  and  its  color,  had  all  the 
appearances  of  a  scrofulous  ulcer.  I  had  it  painted  with  tincture  of  iodine, 
and  three  weeks  afterwards,  the  surface  of  the  ulceration  had  been  modified, 
a  complete  cure  was  brought  about,  and  the  baby  was  discharged  from  the 
Hotel-Dieu.  I  had,  however,  been  struck  with  the  patience  with  which  the 
child  bore  the  pain  produced  by  the  iodine  paint,  which  is  generally  very 
acute  when  applied  to  a  raw  surface ;  but  this  baby  evinced  very  little  sen- 
sibility. I  was  surprised  at  this,  and  wondered  whether  something  serious 
was  not  hidden  under  it.  The  cause  soon  became  apparent,  for  my  fears 
were  realized  in  a  short  time.  A  fortnight  after  he  had  been  discharged, 
the  child  was  brought  back,  suffering  from  cerebral  fever  which  was  incu- 
bating during  his  first  stay  in  the  hospital.  The  development  and  evolu- 
tion of  this  fever  were  so  regular,  so  classical  (if  I  may  be  allowed  the  ex- 
pression), that  there  could  be  no  doubt  as  to  the  nature  of  the  case,  although, 
in  too  many  instances,  the  deceptive  course  of  the  disease  misleads  men  of 
the  most  consummate  experience. 

The  child's  mother  gave  us  the  following  statement  as  to  the  manner  of 
invasion  of  the  complaint.  She  brought  the  child  back  on  a  Monday; 
eleven  days  previously  she  had,  on  her  own  authority,  given  him  some 
ipecacuanha  on  account  of  a  cold  in  the  head.  The  ipecacuanha  brought 
on  vomiting,  which  had  not  ceased  even  when  I  saw  the  child ;  he  was 
strangely  agitated,  had  no  sleep,  but  merely  dozed,  rousing  himself  at 
intervals,  and  uttering  a  loud  cry. 

These  symptoms,  namely,  vomiting,  insomnia,  somnolence,  with  sudden 
awakenings  and  utterance  of  loud  cries,  too  clearly  indicated  incipient 
brain-fever.  The  pulse  gave  no  indication  yet,  but  in  another  week,  its 
inequality,  and  the  diminution  in  the  number  of  pulsations,  became  a  new 
feature  of  the  disease.  Yet  the  child  continued  to  take  the  breast.  As  the 
vomiting  had  ceased,  one  who  was  not  forwarned  might  have  thought  that 
the  child  was  better.  But,  independently  of  the  signs  which  I  have  men- 
tioned, and  which  left  no  doubt  on  my  mind,  I  already  noticed  that  the 
child  was  singularly  agitated  when  I  came  near  him,  but  soon  became 
calm  again,  and  fell  into  a  doze.  This  was  a  symptom  of  considerable 
significance ;  and  all  the  others  showed  themselves  in  succession,  namely, 
cerebral  macula,  dilatation  of  the  pupils,  paralysis  more  marked  on  one 
side  of  the  body  than  on  the  other ;  lastly,  convulsions,  and  extraordinary 
frequency  of  the  pulse,  which  from  68  rose  to  80,  100,  140,  160,  up  to  208 
on  the  day  preceding  death. 

On  making  the  autopsy,  I  found  notable  thickening  of  the  meninges, 
which,  about  the  optic  commissure  and  in  the  fissure  of  Sylvius,  were  infil- 
trated with  fibro-plastic  elements  and  concrete  albumen,  while  there  were 
numerous  granulations  disseminated  on  the  surface,  especially  over  the  left 
cerebral  hemisphere.     The  septum  lucidum  was  in  a  perfectly  pulpy  con- 


876  CEREBRAL    FEVER. 

ditiori ;  the  fornix  was  less  softened,  but  tore  on  the  least  pulling,  and  the 
softening  had  also  involved  the  posterior  wall  of  the  lateral  ventricles. 

There  were  granulations  in  the  lungs  also,  while  the  bronchial  glands 
were  converted  into  tubercular  masses,  and  similar  ones  were  found  in  the 
spleen. 

The  other  child,  who  died  yesterday,  and  whose  body  I  am  going  to 
examine  in  your  presence,  was  a  little  girl  eighteen  months  old,  nursed  by 
her  own  mother.  Although  of  an  apparently  sound  constitution,  she  had 
been  seized  about  six  weeks  ago,  when  she  was  noticed  to  have  an  unusual, 
sad  look.  This  could  not  be  ascribed  to  the  process  of  teething,  because 
she  had  cut  her  first  group  of  teeth  for  the  last  four  months,  and  there  was 
no  indication  that  the  evolution  of  the  upper  incisors,  which  were  to  form 
the  second  group,  had  commenced.  Sadness  setting  in  unaccountably,  is  a 
premonitory  sign  of  great  value  in  a  child ;  it  points  to  a  condition  of 
malaise,  surprises  the  child's  friends,  makes  them  uneasy,  and  is  often  men- 
tioned by  them,  as  it  was  in  this  case  by  the  mother  of  the  little  girl.  She 
added  besides,  that  the  child's  sleep  was  not  continuous,  and  was,  as  it 
were,  disturbed;  yet  a  symptom  which  is  very  common  at  the  onset  of  cere- 
bral fever  was  absent  in  this  case — the  child  did  not  start  out  of  her  sleep 
and  did  not  utter  the  peculiar  cries  noted  in  the  case  of  the  little  boy 
which  I  related  to  you  just  now,  and  which  constitute  a  sign  of  some  value 
in  the  history  of  cerebro-meningitis.  Vomiting  set  in  a  week  ago  :  the 
child  brought  up  everything  that  she  took,  panadas,  her  mother's  milk, 
sugared  drinks,  so  that  her  mother  began  to  feel  seriously  uneasy.  These 
fears  increased  three  days  later  on  account  of  another  symptom  which  she 
described  very  well  and  which  it  is  essential  I  should  point  out  to  you. 
The  child  cried  whenever  she  was  taken  up,  as  if  in  great  pain  ;  and,  indeed, 
there  was  general  hypercesthesia.  Lastly,  four  days  ago,  convulsions  came 
on,  at  first  on  the  right,  then  on  the  left  side  ;  and  it  was  then  that  the 
mother  came  to  the  hospital. 

Let  us  now  rapidly  review  the  symptoms  which  this  child  presented,  and 
compare  them  with  one  another,  as  well  as  with  those  which  are  common 
to  brain  fever  and  other  diseases. 

When  I  first  saw  the  child,  I  was  struck  with  the  motor  disorders  of  her 
visual  organs.  There  was  very  marked  convergent  strabismus  of  the  right 
eye,  the  pupil  of  which  was  dilated,  although  less  notably  than  that  of  the 
left  eye:  consequently,  the  muscles  supplied  by  the  sixth  nerve  must  have 
been  paralyzed.  Sight  seemed  to  be  abolished  on  the  left  side,  because 
when  I  held  my  finger  in  front  of  that  eye,  there  was  no  longer  the  invol- 
untary and  instinctive  winking  which  usually  occurs  for  the  protection  of 
the  threatened  eyeball.  There  was  probably  blindness,  or  at  least,  a  very 
marked  diminution  of  sight.  More  or  less  complete  amaurosis  is  a  symp- 
tom which  you  have  noted  yourselves  in  all  our  cases  of  brain  lever,  and 
which  is  complained  of  also  by  children  old  enough  to  talk  and  give  an 
account  of  their  sensations.  In  the  little  girl  in  question,  the  greater  dila- 
tation of  the  pupils,  the  absence  of  all  movement  of  the  eyelids,  the  Strabis- 
mus of  the  righl  eye,  very  clearly  indicated  thai  sighl  was  impaired. 

The  head  was  .-lightly  pulled  hack  also,  the  left  arm  was  stiff,  and  was 
from  time  to  time  the  seat  of  clonic  movements  of  flexion  and  extension. 
The  thumb  of  the  left  hand,  forcibly  adducted  into  the  palm,  was  covered 

Over  by  the  fingers,  which  were  like  itself  convulsively  bent  :  when  an  attempt 
was  made  to  Btretch  them  OUt,  they  yielded  with  some  facility.  <  Mi  expos- 
ing the  child's  abdomen,  it  was  seen  to  be  excavated  -hollowed  out  like  a 
boat  from  the  sinking  in  of  its  walls.  This  Bigll  IS  of  great  value  in  the 
history  of  cerebral  fever,  because   it   is  nearly  constant.      In  a  great    many 


CEREBRAL    FEVER.  877 

cases  it  may  help  to  distinguish  the  brain-symptoms  of  cerebro-meningitis 
from  those  which  appear  secondarily  in  the  course  of  other  diseases,  such  as 

typhoid  fever,  for  example.  You  must  not  think,  however,  that  there  is 
no  chance  of  error  when  this  symptom  exists ;  its  diagnostic  significance, 

although  of  great  value,  is  not  always  absolute,  and  not  long  ago  I  found 
among  my  papers  notes  of  a  case  which  shows  how  difficult  it  is  in  some 
cases  for  a  medical  man  to  decide. 

The  subject  of  that  case  was  a  little  girl  seven  years  and  a  half  old,  who 
was  under  my  care  at  the  Children's  Hospital,  towards  the  close  of  the 
year  1852.  She  was  of  a  lymphatic  constitution,  and  had  had  for  months 
past  a  cough,  and  some  diarrhoea.  She  had  been  worse  for  two  or  three 
days,  and  had  been  seized  with  vomiting.  She  was  delirious  the  night 
after  her  admission,  and  on  the  next  morning  she  was  very  prostrate,  al- 
though conscious.  Her  pupils  were  dilated,  more  so  on  the  right  than  on 
the  left;  her  belly  was  retracted  in  the  manner  I  have  described  above, 
and  was  tender  on  pressure.  Her  pulse  was  excessively  slow,  56  in  the 
minute.  (I  insist  on  this  fact,  which  is  almost  constant  in  brain  fever.)  In 
addition,  the  meningeal  or  cerebral  macula  (which  I  will  presently  describe 
more  particularly),  was  easily  produced,  and  became  still  more  marked  on 
the  following  days.  She  never  uttered,  it  is  true,  the  hydrocephalic  cry, 
nor  was  her  breathing  unequal ;  but  with  these  exceptions,  all  her  symptoms 
seemed  to  point  to  cerebro-meningitis.  Yet,  the  case  was  one  of  typhoid 
fever,  and  after  death  I  found  no  changes  in  the  brain  and  its  meninges, 
while  the  swelling  and  ulceration  of  Peyer's  patches,  in  the  small  intestines, 
were  characteristic  of  typhoid  fever. 

Dilatation  of  the  pupils,  even  when  it  is  not  equal  on  both  sides,  retrac- 
tion of  the  abdominal  walls,  constipation  (for  the  girl's  bowels  from  being 
loose  had  become  costive),  and  the  cerebral  macula  itself,  are  not  therefore 
absolute  pathognomonic  signs,  although  they  are  phenomena  of  very  great 
value. 

Now,  what  are  the  characters  of  that  cerebral  or  meningeal  macula  which 
I  have  taken  care  to  point  out  to  you  in  the  above  cases,  and  which  you 
always  see  me  carefully  look  for  in  individuals  whom  I  suspect  of  being 
the  subjects  of  cerebro-meningitis  ?  When,  in  order  to  ascertain  how  many 
teeth  the  little  girl  in  St.  Bernard  Ward  had  cut,  I  opened  her  mouth  with 
my  hands,  you  must  have  been  struck  with  the  bright  red  tint  which  her 
skin  immediately  assumed.  Again,  when  I  very  gently  made  on  her  abdo- 
men with  my  nail  cross  markings,  longitudinally  and  transversely,  in  less 
than  half  a  minute  the  portion  of  skin  which  I  had  touched  was  suffused 
with  a  very  bright  red  tint,  which  was  diffused  at  first,  but  grew  by  degrees 
fainter,  leaving  along  the  track  where  the  nail  had  passed,  lines  of  a  deeper 
red  color,  which  persisted  for  a  pretty  long  time.  This  is  what  I  mean  by 
cerebral  macula.  I  was  the  first  to  call  attention  to  it  more  than  twenty 
years  ago,  and  I  then  called  it  meningeal  macula.  This  singular  phenome- 
non, which  can  only  be  explained  by  a  deep  modification  in  the  vascularity 
of  the  skin,  is  a  sign  of  sufficiently  great  importance  to  arrest  our  attention 
for  awhile,  although  I  repeat,  it  is  not  of  absolute  value  when  the  differen- 
tial diagnosis  of  cerebral  fever  has  to  be  made. 

The  regions  where  the  macula  appears  most  easily  are  at  first,  and 
above  all,  the  anterior  aspect  of  the  thighs,  the  abdomen,  and  the  face.  I 
have  just  described  its  characters.  If  after  exposing  the  patient,  his  skin 
be  gently  rubbed  with  a  hard  body,  such  as  a  pencil,  or  simply  with  the 
nail,  the  part  touched  rapidly  becomes  of  a  bright  red  color,  which  persists 
for  a  more  or  less  prolonged  period,  eight,  ten,  or  fifteen  minutes.  Its  ex- 
istence has  not  been  denied  (for  it  is  unquestionably  brought  out  under 


878  CEREBEAL    FEVER. 

those  conditions),  but  the  importance  which  I  attach  to  it  has  been  ques- 
tioned, on  the  ground  that  it  was  met  with  in  other  diseases  than  cerebral 
fever.  I  admit  that  this  may  occur,  and  the  case  which  I  related  to  you 
just  now  proves  it ;  but  whereas  it  is  an  invariable,  constant  phenomenon 
in  cerebral  fever,  observed  throughout  the  whole  course  of  the  disease 
nearly,  from  the  beginning  to  the  end,  it  only  appears  exceptionally  and 
accidentally  in  other  affections.  It  has  been  said  that  this  mottling  was 
always  observed,  when  looked  for,  in  children  suffering  from  simple  feb- 
ricula.  But  I  protest  against  this  assertion,  gentlemen ;  and  I  have  more 
than  once  shown  you  in  our  clinical  wards  young  children  laboring  under 
intense  fever,  attending  sometimes  violent  stomatitis,  and  at  other  times 
grave  pulmonary  catarrh,  or  grave  pneumonia,  and  when  I  have  in  such 
cases  tried  to  produce  the  mottling  by  rubbing  the  skin,  and  even  so  roughly 
as  to  scratch  it,  I  indeed  made  the  parts  which  I  touched  red,  but  the 
redness  was  never  to  be  compared,  as  regards  intensity  and  duration,  with 
the  redness  produced  in  individuals  suffering  from  brain  fever,  even  by  the 
gentlest  frictions.  In  the  latter,  it  persisted  for  a  good  while;  and  it  not 
only  involved  the  parts  which  had  been  directly  touched,  but  spread  also 
for  several  centimetres  beyond  them,  while  in  other  complaints  it  is  ex- 
clusively limited  to  the  points  where  it  had  developed  itself.  I  lay  so 
much  stress  on  this  point,  because  it  is,  in  my  opinion,  of  great  significance 
in  a  good  many  cases,  when  the  possible  confusion  between  brain  fever  and 
other  diseases  has  to  be  avoided,  such  as  typhoid  fever,  attended  with  cere- 
bral phenomena  or  convulsions,  either  idiopathic,  or  occurring  at  the  outset 
of  exanthematous  fevers,  or  grave  pulmonary  or  other  inflammations.  The 
mottling  is  almost  never  produced  in  eclampsia;  and  when  it  occurs  in 
typhoid  fever,  as  in  the  instance  I  mentioned  to  you,  it  rarely  has  the  same 
intensity  and  persistence,  and  rarely  shows  itself  at  all  stages  of  the  fever. 

From  w7hat  I  have  said,  it  follows,  therefore,  that  there  is,  properly 
speaking,  no  one  invariable  pathognomonic  sign  of  cerebral  fever.  But  in 
this,  as  in  all  clinical  questions  besides,  it  is  not  isolated  symptoms,  but 
groups  of  symptoms,  the  manner  in  which  they  appear  and  are  evolved, 
and  their  mutual  relations,  which  characterize  the  disease.  We  must  not 
look  at  a  portion  of  the  picture  only,  but  at  the  whole  at  once ;  in  order  to 
know  the  drama  well,  the  whole  play  must  be  seen,  and  not  one  scene  alone. 
Yet,  in  order  to  write  the  history  of  the  disease,  we  are  obliged  to  analyze 
its  symptoms,  and  to  make  divisions  with  the  view  of  facilitating  descrip- 
tion. I  will,  therefore,  speak  of  cerebral  fever  as  having  three  stages, 
which,  although  they  are  far  from  being  constantly  present,  and  from  being 
always  perfectly  distinct  from  one  another,  are  yet  sufficiently  distinguish- 
able by  certain  predominating  symptoms.  The  first  of  these,  the  premoni- 
tory stage,  is  of  great  importance.  Killiet  (of  Geneva  i  the  joint  author 
with  my  esteemed  colleague,  Dr.  Barthez,  of  a  work  on  diseases  of  children, 
has  laid  most  stress  on  this  point,  and  he  has  recorded  a  pretty  good 
number  of  cases  which  came  under  his  own  observation,  and  in  which  be 
was  enabled  to  foretell  the  more  or  less  immediate  invasion  of  brain  fever 
by  means  of  certain  Bigns  which  1  am  going  to  enumerate  to  you. 

A  change  in  the  child's  manner  in  ;i  ureal  many  cases,  but  not  in  all,  i-  a 
sign  thai  brain  fever  is  imminent.    This  change  shows  itself  for  a  more  or 

less   prolonged    period,  for    four   or   six  weeks,  or  for  two,  three,  and    more 

months  sometimes,  before  thecomplainl  actually  sets  in.  The  child  is  un- 
accountably sad,  and  takes  less  pleasure  than  usual  in  his  games;  his 
temper  becomes  sour,  and  he  shows  himself  more  irritable  towards  his 

parents,  his  brothers,  and  his  companions.      There  is  at  the  same  t  i me  I  and 

this  is  a  valuable  sign)  marked  emaciation.    Sometimes  there  is  bilious 


CEREBRAL    FEVER.  879 

vom it ing  which  cannot  be  accounted  for,  and  which  recurs  at  more  or  less 
distant  intervals.  Sleep  is  not  so  profound  as  it  used  to  be,  and  may  even 
be  replaced  by  complete  watchfulness;  in  some  cases  this  imperfect  sleep  is 
agitated,  disturbed  by  painful  dreams,  by  sudden  starts,  accompanied  by 
those  characteristic  cries  which  become  subsequently  more  frequent,  and  of 
which  I  shall  speak  more  particularly  by  and  by.  Rilliet  ascribes  this 
series 'of  symptoms  to  already  existing  lesions,  more  especially  to  cerebral 
lesions,  which,  although  latent  and  assuming  a  chronic  or,  at  the  most,  a 
subacute  course,  still  exercise  from  that  very  period  an  injurious  influence 
on  the  organic  functions — those  of  the  brain  chiefly.  As  in  children  who 
die  of  brain  fever  tubercles  are  almost  invariably  found — not  in  the  viscera 
themselves,  but  in  the  bronchial  or  the  mesenteric,  or,  more  rarely,  in  the 
cervical  glands,  it  is  conceivable  how  a  tubercular  affection  may  give  rise 
to  the  general  disorders  which  I  have  mentioned,  and  how  more  or  less 
marked  emaciation  may  result  from  it.  As  to  the  brain-symptoms,  the 
change  of  temper,  the  watchfulness,  or  the  disturbed,  interrupted  sleep,  the 
cries  uttered  by  the  child,  apparently  indicating  a  sharp  pain  in  the  head, 
they  are  accounted  for,  according  to  Rilliet,  by  the  brain-lesions  which  are 
nearlv  always  met  with  when  a  post-mortem  examination  is  made.  These 
lesions  consist  in  granulations  scattered  in  the  meninges  over  the  surface  of 
the  brain,  and  in  the  Sylvian  fissure,  and  which  have  been  shown  by  the 
microscope  to  be  of  a  tubercular  nature.  We  may  imagine,  therefore, 
what  an  injurious  influence  the  morbid  process  which  precedes  and  accom- 
panies the  evolution  of  these  morbid  products,  however  slow  it  may  be, 
exercises  on  the  functions  of  the  central  apparatus  of  innervation. 

I  do  not  deny,  gentlemen,  that  these  premonitory  symptoms  occur  more 
frequently  at  the  outset  of  brain  fever  than  of  any  other  complaint ;  but 
one  would  exaggerate  their  import,  if  he  were  to  regard  them,  as  Rilliet 
has  done,  as  characteristic  of  cerebral  fever  exclusively.  They,  indeed, 
seem  to  me  to  depend  much  less  on  an  actual  lesion  than  on  the  general 
condition  which  in  this  case  passes  into  cerebro-meningitis,  but  in  other 
cases,  into  latent  pleurisy,  or  into  pulmonary  tuberculization,  or  at  least 
into  tuberculization  of  the  bronchial  glands,  and  in  other  instances,  again, 
into  tabes  mesenterica,  namely,  tuberculization  of  the  peritoneum  and  tuber- 
cular infiltration  of  the  mesenteric  glands. 

The  premonitory  symptoms  indicate,  therefore,  the  imminence  of  some 
disease  rather  than  an  actual  disease.  We  know  how  the  temper  of  a  child 
changes  under  the  influence  of  the  least  malaise,  and  such  changes  are, 
besides,  common  enough  in  adults,  and  there  are  very  few  among  us  who 
have  not  experienced  them  even  in  slight  indispositions.  They  strike  all 
the  more  in  children,  and  occur  all  the  more  easily  that  their  temper  is 
more  mpbile.  There  is  no  need,  therefore,  in  order  to  explain  the  sadness 
and  surliness  of  individuals  threatened  with  brain  fever,  or  their  unusual 
repugnance  to  join  in  games  of  children  of  their  age,  to  appeal  to  the  pres- 
ence of  a  brain-lesion,  when  such  morbid  phenomena  are  accounted  for  by 
the  malaise  resulting  from  the  deep  perturbation  of  the  functions  of  the 
whole  system,  caused  by  the  slow  and  fatal  manifestation  of  the  tubercular 
diathesis. 

Although  these  morbid  phenomena  may  usher  in  other  affections,  it  must 
be,  nevertheless,  admitted  that  they  are  never  so  marked  as  in  the  pro- 
dromic  stage  of  cerebral  fever;  and  there  is  one  point  concerning  them  to 
which  I  must  particularly  call  your  attention.  Yuu  may  have  observed 
these  premonitory  symptoms  in  a  child  who  is  scrofufous,  or  who  is  the 
issue  of  phthisical  parents,  and  have  either  imparted- your  fears  to  the 
friends,  or  kept  them  to  yourself,  when  you  see  the  child  suddenly  regain 


880  CEREBRAL    FEVER. 

Lis  former  cheerfulness  and  be  restored  to  health,  with  the  exception  of 
some  loss  of  flesh ;  then,  the  symptoms  recur  and  disappear  again  until  the 
day  when  the  disease  breaks  out.  I  perfectly  remember  the  case  of  a  little 
boy  whom  I  saw  in  the  Tours  Hospital,  when  I  was  a  medical  student. 
He  was  from  time  to  time  seized  with  fearful  pains  in  the  head,  with  vom- 
iting, somnolence,  slowness  of  the  pulse,  &c.  These  symptoms  lasted  for 
three  or  four  days,  and  on  every  occasion,  Bretonneau  diagnosed  the  ap- 
proach of  cerebral  fever ;  but  the  storm  blew  over.  At  last,  one  day  the 
symptoms  did  not  intermit,  and  we  had  occasion  to  witness  all  the  seenes 
of  the  sad  drama  of  tubercular  cerebro-meningitis.  Dissection  disclosed,  in 
addition  to  the  ordinary  lesions  of  brain  fever,  the  presence  of  a  large 
tubercular  mass  in  the  convolutions  of  the  cerebellum,  with  softening  of 
the  surrounding  tissue.  It  rarely  happens,  indeed,  that  in  such  cases  the 
symptoms  be  not  dependent  on  the  presence  of  some  organic  brain-lesion, 
and  particularly  on  tubercular  deposit.  In  such  cases,  independently  of 
the  symptoms  which  I  have  already  mentioned,  intermittent  cephalalgia, 
convulsions,  and  partial  paralysis  may  supervene  at  more  or  less  distant 
intervals,  until  brain  fever  sets  in,  which  rapidly  draws  to  a  fatal  termina- 
tion. 

Whenever,  therefore,  the  above  group  of  moi'bid  phenomena  are  found 
to  exist,  the  practitioner  should  be  on  his  guard,  especially  if  the  family 
history  of  the  patient  points  to  a  tubercular  diathesis,  because  he  may  soon 
witness  the  characteristic  phenomena  of  the  invasion  of  brain  fever.  In 
general,  vomiting,  of  an  obstinate  character,  opens  the  scene ;  very  often, 
this  does  not  excite  much  anxiety  at  first ;  it  is  ascribed  to  a  trifling  indis- 
position, and  as  a  moment  before  it  set  in  the  child  seemed  to  enjoy  his 
usual  state  of  health,  and  ate  with  some  appetite,  it  is  put  down  to  indiges- 
tion. This  opinion  is  retained  for  a  day  or  two ;  but  as  the  vomiting  per- 
sists and  recurs  frequently,  alarm  is  excited.  This  symptom,  namely,  per- 
sistent vomiting,  is  of  primary  importance,  and  whenever  it  shows  itself 
without  attendant  fever,  in  a  child  who  has  been  vaccinated  and  who  has 
already  had  exanthematous  fevers,  brain  fever  should  be  suspected. 

There  is,  in  general,  constipation  also. 

Persistent  vomiting  and  constipation  are  already  two  symptoms  of  great 
value.  The  patient  complains  at  the  same  time  of  intense  cephalalgia, 
which  is  usually  general,  although  more  acute  across  the  forehead  and 
sometimes  at  the  vertex.  This  symptom  alarms  the  frieuds  most,  and  is 
the  one  to  which  they  call  the  practitioner's  attention.  This  headache  is 
not  by  itself,  however,  a  sufficiently  characteristic  sign,  for  there  are  many 
other  diseases  which  set  in  with  a  more  or  less  violent  cephalalgia,  pro- 
portionate to  the  intensity  of  the  febrile  reaction  of  which  it  is  an  epiphe- 
nomenon. 

Its  persistence,  however,  and  that  of  the  vomiting,  are  all  the  more 
peculiar  in  cerebral  fever,  that  the  initial  fever  of  the  disease  does  not  run 
the  same  course  as  in  other  affections.  Thus,  it  consists  of  several  parox- 
ysms, instead  of  a  single  one.  The  patient  has  two  or  three  rigors  in  the 
course  of  the  twenty-four  hours,  and  after  each  rigor  some  heat  of  skin  and 
perspiration;  sometimes  this  rigor  recurs  several  days  in  succession,  at  the 
same  hour;  in  other  very  rare  instances,  the  fever  is  continuous  hut  is 
moderate,  with  frequent  remissions.  Thus,  febrile  action  running  a  pecu- 
liar course,  violent  cephalalgia,  more  or  less  limited  to  a  portion  of  the 
head,  constipation,  obstinate  vomiting,  interrupted  sleep,  or  complete  wake- 
fulness, alteration    of  temper;   such    are  the  symptoms  of  the  first    Stage  of 

cerebral  fever,  to  which  are  pretty  frequently  superadded  singular  perver- 
sions of  sight,  amblyopia,  hemiopia,  and  strabismus. 


CEREBRAL    FEVER.  881 

I  have  often  related  the  following  cases,  which  are  so  interesting  that 
they  are  deeply  impressed  on  my  memory.  About  twenty  years  ago  I  saw 
with  my  excellent  friend,  Dr.  Pidoux,  a  girl,  6  years  old,  affected  with 
cerebral  fever.  She  had  usually  a  very  strange  temper,  and  although  her 
mother  was  full  of  kindness  and  indulgence  for  her,  perhaps  on  that  ac- 
count she  had  no  caresses  nor  affectionate  Avords  to  offer  her  in  return. 
From  the  time  when  she  began  to  complain  of  a  pretty  violent  pain  in  the 
head,  attended  with  vomiting,  she  insisted  on  always  sitting  in  her  mother's 
lap,  kissing  her  repeatedly,  and  addressing  her  so  tenderly,  that  the  poor 
mother  was  deeply  moved.  The  disease  (for  it  was  incipient  cerebral 
fever)  had  gone  on  for  three  or  four  days,  when  the  child,  who  was  sitting 
near  a  window,  called  out,  "  Oh  mamma !  how  strange !  look  at  that  little 
boy  who  is  running  after  his  hoop  in  the  street ;  he  has  only  half  a  blouse 
and  half  a  face!"  This  hemiopia  lasted  a  few  minutes  only;  but  the 
child's  persistence  and  astonishment  made  such  an  impression  on  the 
mother,  that  she  told  us  of  the  circumstance  the  first  time  we  called. 

About  ten  years  ago,  I  was  sent  for  to  see  an  English  boy,  12  years  old. 
He  was  a  very  good  violinist,  and  his  father,  himself  an  eminent  artist, 
superintended  his  musical  studies.  One  day,  on  his  playing  false,  and  on 
his  father  complaining  of  it,  he  answered  that  the  music  was  badly  written, 
and  that  he  only  played  what  he  saw ;  but  as  he  repeated  the  same  fault 
several  times  again,  his  father  took  the  violin  from  him  and  played  cor- 
rectly. The  boy,  however,  asserted  that  he  did  not  play  the  music  as  it 
was  written,  and  reading  it  aloud,  transposed  as  he  did  so,  and  changed 
the  bars.  He  used  at  that  time  already  to  complain  of  headache,  and  the 
aberration  of  sight  was  the  prelude  of  a  cerebral  fever  which  broke  out  a 
few  days  later,  and  carried  him  off — as  this  terrible  and  inexorable  com- 
plaint always  does. 

In  the  second  stage,  a  delusive  quiet  and  rest  follow  upon  the  sleeplessness, 
the  febrile  action,  and  the  cephalalgia.  The  child's  friends,  and  even  the 
practitioner,  if  not  on  his  guard,  are  deceived  by  this  apparent  calm  and 
believe  in  an  improvement  which  is  soon  shown  to  be  unreal.  An  experi- 
enced practitioner  is  too  well  forewarned  by  the  symptoms  of  the  preceding 
stage,  which  have  been  described  to  him  or  have  been  observed  by  himself 
personally,  to  share  in  those  illusive  hopes.  He  is  aware  that  the  cere- 
bral fever  has  entered  on  its  ajoyretic  stage,  and  that  it  will  run  a  fatal 
course,  in  spite  of  the  apparent  improvement.  The  pulse  in  this  stage  takes 
on  special  characters.  Generally  regular  in  the  first  stage  of  the  disease 
(I  say,  generally,  because  it  sometimes  presents  even  at  this  period  irregu- 
larities which  should  be  taken  into  account)  it  now  becomes  remarkably 
slow,  and  excessively  irregular  and  unequal.  Whereas,  in  a  child  from 
four  to  five  years  old,  the  pulse  normally  ranges  between  90  and  100  in  the 
minute,  and  in  an  infant  at  the  breast,  between  100  and  120;  it  falls  to  60, 
55,  50,  and  even  lower,  in  the  second  stage  of  cerebral  fever. 

Somnolence  contrasts  with  the  agitation  which  existed  at  the  beginning  ; 
and  this  apparently  calm  sleep,  following  on  distressing  wakefulness,  at 
first  delights  the  patient's  friends,  glad  of  catching  at  the  least  ray  of  hope ; 
but  within  a  short  time,  on  seeing  this  sleepiness  persist,  alarm  is  justly 
excited.  It  lasts  for  two,  four,  or  five  days.  If  attempts  be  made  to  rouse 
the  child,  he  utters  a  few  impatient  cries  and  dozes  off  immediately  again. 
He  is  no  longer  alarmed  now  by  the  presence  of  the  practitioner,  whose 
sight  he  previously  disliked.  Formerly,  he  exhibited  symptoms  of  annoy- 
ance when  his  pulse  was  felt,  or  at  the  least  thing;  but  now  he  is  indifferent 
to  all  that  is  done  to  him.  His  eyelids  may  be  separated  with  impunity,  so 
as  to  examine  the  state  of  his  pupils ;  and  if  his  skin  be  pinched  in  order  to 
vol.  i. — 56 


882  CEREBRAL    FEVER. 

ascertain  the  degree  of  sensibility  (which  in  the  first  stage  is  sometimes  ex- 
alted, as  was  the  case  in  the  little  child  in  St.  Bernard  Ward),  he  shows 
but  momentary  impatience,  and  immediately  again  lapses  into  his  former 
sleepy  condition.  This,  gentlemen,  is  a  sign  of  the  most  serious  import, 
which  you  will  scarcely  meet  with  in  other  diseases. 

Another  symptom  now  shows  itself  which  is  per  se  of  considerable  sig- 
nificance. The  child  who  in  the  first  stage  was  exacting,  capricious,  calling 
for  his  mother  and  driving  her  away,  asking  every  minute  for  food  or  drink, 
and  refusing  to  have  what  he  has  just  been  asking  for  so  pressingly,  as  soon 
as  the  second  stage  begins,  no  longer  asks  for  anything,  even  when  he  is 
most  violently  agitated,  and  with  the  most  distressing  obstinacy  keeps  utter- 
ing the  hydrocephalic  cries,  which  I  shall  presently  describe  to  you.  When 
he  is  offered  drink  he  sometimes  accepts,  but  he  never  shows  that  he  is 
thirsty  by  his  gestures,  or  by  those  movements  of  the  lips  and  mouth  which 
are  so  characteristic  in  infants,.  He  seems  to  have  lost  all  instinctive  sen- 
sations. This  sort  of  indifference  continues  to  the  end ;  and  even  in  the 
third  stage,  when  there  is  intense  thirst,  he  never  asks  for  drink.  If  he  be 
at  the  breast  still,  his  mother  must  needs  press  him,  separate  his  lips,  and 
insert  the  nipple  between  them :  he  then  sucks  with  avidity,  or  refuses 
entirely. 

This  symptom  is  all  the  more  important  that  in  other  febrile  affections 
attended  with  brain  symptoms,  and  which  might  consequently  be  confounded 
with  cerebral  fever,  there  is  generally  very  intense  thirst,  which  is  manifested 
in  a  most  striking  manner. 

In  the  last  stage  of  cerebral  fever  the  child  no  longer  drinks,  even  when 
liquids  are  poured  into  his  mouth,  not  only  because  he  has  not  the  sensa- 
tion of  thirst,  but  probably  also  because  his  pharynx  and  tongue  are  para- 
lyzed, as  various  other  parts  of  the  body  are. 

In  the  space  of  forty-eight  hours  his  face  exhibits  strange  phenomena. 
He  from  time  to  time  opens  his  eyes  wide,  which  shine  as  they  do  in  indi- 
viduals that  are  drunk.  His  face,  which  is  usually  extremely  pale,  blushes 
for  a  minute  or  two ;  then  he  closes  his  eyes  again,  and  resumes  his  former 
aspect.  This  sort  of  congestion  of  the  face,  which  recurs  several  times  in 
the  course  of  the  day,  is  also  of  value.  It  recurs  less  frequently  as  the  dis- 
ease progresses.  Generally,  as  he  thus  opens  his  eyes,  and  as  his  face  colors 
up,  the  child  utters  a  sharp,  plaintive  cry,  which  is  perfectly  characteristic. 
This,  the  hydrocephalic  cry,  was  first  pointed  out  by  Coindet,  and  it  may 
recur  every  hour  or  half  hour,  at  variable  intervals.  Although  it  is  most 
frequent  in  infants,  it  is  heard  also  in  the  case  of  adults. 

This  cry  is  of  such  value  that  I  must  dwell  more  on  its  characters. 
Most  frequently  it  is  single,  and  loud  like  the  cry  of  a  person  frightened  In- 
some  sudden  danger.  I  do  not  think  that  it  is  due  to  an  acute  pain,  be- 
cause a  child  who  is  in  pain  generally  utters  several  cries  in  succession, 
and  is  not  consoled  in  a  second.  Besides,  if  the  cry  be  indicative  of  an- 
guish, the  expression  of  the  face  i-  rarely  that  of  suffering. 

In  the  majority  of  instances  the  hydrocephalic  cryis  uttered  in  the  second 
or  apyretic  stage  of  the  disease,  lmt  it  i>  pretty  frequently  beard  at  the  out- 
set and  before  the  invasion  of  the  complaint  even  ;  in  other  words,  it  may 
constitute  one  of  the  premonitory  Bymptoms.  In  some  cases,  again,  it  is 
only  uttered  in  the  third  Btage;  as  in  the  case  of  a  little  girl  whom  I  saw, 
at  the  end  of  August,  1861,  in  the  department  of  Maine-et-Loire,  with  I  >ra. 
Desperiere  (of  Baumur)  and  Duclos  '(if  Tours),  and  who,  during  the  first 
two  -tap-  of  cerebral  (ever,  had  not  uttered  the  characteristic  cry,  while 
in  the  third  stage  her  friends  were  distressed  by  the  violence  and  frequency 

of  her  cries. 


CEREBRAL    FEVER.  883 

A  practitioner  need  not  have  been  very  long  in  practice  in  order  to  have 
met  with  cases  in  which  the  hydrocephalic  cry  is  heard  from  the  very  begin- 
ning, and  does  not  cease,  even  for  five  minutes,  during  four,  six,  eight,  or 
ten  days.  In  such  cases,  which  are  the  most  dreadful  form  of  the  disease, 
and  the  most  distressing  to  the  friends,  the  poor  little  patient  never  sleeps 
for  a  moment,  but  tosses  himself  to  the  right  and  left,  rolling  in  his  bed, 
and  not  soothed  by  caresses  nor  quieted  by  threats  ;  and  one  feels  surprised 
that  such  a  frail  organization  can  resist  such  a  prodigious  and  incessant 
agitation.  It  is  a  strange  circumstance,  however,  that  although  the  prog- 
ress of  the  disease  is  usually  a  little  more  rapid  in  this  form,  yet  the  pa- 
tient sometimes  calms  down,  and  from  that  time  the  disease  runs  the  same 
course  as  in  the  simplest  forms. 

Besides  the  signs  gathered  from  an  observation  of  the  patient's  face  and 
the  hydrocephalic  cry,  there  is  another  sign  to  which  your  attention  should 
be  particularly  called,  namely,  retraction  of  the  abdominal  parietes.  The 
abdomen  is  excavated,  hollowed  out  like  a  boat,  although  not  tender  on 
pressure.  Although  I  attach  much  importance  to  this  symptom,  partic- 
ularly as  it  helps  to  distinguish  cerebral  fever  from  typhoid  fever,  in 
which  latter  the  abdomen  is  usually  prominent,  you  must  bear  in  mind 
what  I  told  you  at  the  beginning  of  this  lecture,  namely,  that  retraction  of 
the  abdominal  parietes  is  not  a  pathognomonic  symptom. 

Another  phenomenon  which  deserves  more  serious  consideration,  and 
which  must  have  struck  those  of  you  who  looked  for  it,  is  irregularity  of 
the  respiration.  It  was  present  in  the  little  girl  who  was  in  St.  Bernard 
Ward,  although  it  was  much  less  marked  in  her  case  than  in  a  great  many 
others  which  have  come  under  my  observation.  At  times  it  was  very  dif- 
ficult to  follow  the  movements  of  the  chest,  when  counting  the  breathing 
with  a  watch  in  hand.  First  came  a  feeble  inspiration,  before  a  small  ex- 
piration, then  a  deeper  inspiration  with  a  more  prolonged  expiration,  and 
next  a  weaker  respiratory  movement,  and  another  still  weaker,  followed  at 
last  by  a  pause.  These  four  respiratory  movements  were  quickly  perform- 
ed ;  the  chest  then  remained  motionless  for  three,  four,  five,  or  six  seconds. 
This  observation  was  made  one  day,  but  on  the  ensuing  days  the  pause 
lasted  ten,  twelve,  and  even  fifteen  seconds,  instead  of  only  from  three  to 
six.  In  a  child  of  two  years  old,  who  was  once  under  my  care  in  the 
Necker  Hospital,  I  noted,  watch  in  hand,  intervals  of  rest  lasting  from 
thirty  to  thirty-five,  forty,  and  even  fifty-seven  seconds.  This  irregularity 
of  the  respiration  occurs  independently  of  the  slowness  of  the  circulation 
which  characterizes  this  second  stage,  for  it  continues  in  the  third  stage, 
while  the  pulse  then  becomes  extremely  frequent.  You  will  meet  with 
this  singular  anomaly  in  no  other  complaint;  neither  in  idiopathic  convul- 
sions of  infants  nor  in  typhoid  fever.  I  am  right,  therefore,  in  attaching 
considerable  importance  to  this  symptom,  which  is  of  greater  value  than 
all  others  in  making  a  differential  diagnosis  between  typhoid  fever  with 
brain-symptoms  and  cerebro-meningitis.  Thus,  in  typhoid  fever  there  may 
be  as  violent  and  as  localized  a  headache  as  in  cerebral  fever ;  vomiting 
may  be  as  obstinate ;  the  ordinary  diarrhcea  may  be  replaced  by  obstinate 
constipation;  the  swelling  of  the  spleen,  epistaxis,  rose-spots,  and  sudamina 
may  be  absent ;  the  abdomen  may  be  boat-shaped  instead  of  being  tym- 
panitic ;  the  cerebral  macula  may  be  developed,  although  in  a  less  marked 
manner,  but  yet  sufficiently  to  raise  a  doubt ;  lastly  the  pain  in  the  head 
may  be  so  acute  as  to  cause  the  patient  to  utter  cries  which  may  be  mis- 
taken for  the  hydrocephalic  cry.  But  it  is  in  cerebral  fever  alone  that 
the  respiration  presents  the  inequality  and  irregularity  to  wdiich  I  have 
called  your  attention.     This  symptom,  which  is,  so  to  say,  pathognomonic, 


884  CEREBRAL    FEVER. 

is  all  the  more  important,  that  the  prognosis  in  typhoid  fever  is  considera- 
bly different  from  the  prognosis  in  cerebral  fever,  in  the  case  of  children 
at  least.  For  you  are  aware  that  typhoid  fever,  even  when  complicated 
with  brain-symptoms,  is  a  much  less  grave  complaint  in  childhood  than  in 
youth  and  in  adult  age.  The  same  does  not  apply  to  cerebral  fever,  which 
is  nearly  always,  not  to  say  invariably,  fatal.  In  the  course  of  my  medi- 
cal career,  which  has  already  extended  over  a  long  period,  I  have  known 
two  cases  only  terminate  favorably.  One  of  these  occurred  in  my  wards 
in  the  Children's  Hospital,  and  I  had  an  opportunity  of  verifying  my 
diagnosis  some  time  afterwards  by  a  post-mortem  examination.  The  child 
got  well  of  his  acute  disease,  which  left  paralysis  behind  it,  however,  but 
he  died  of  dysentery  five  months  afterwards.  Dissection  disclosed  the  most 
unmistakable  traces  of  the  former  cerebral  affection.  The  other  case  was 
that  of  a  child  whom  I  saw  at  Boulogne-pres-Paris,  in  consultation  with 
Dr.  Blache. 

These  two  instances  are  the  only  ones  which  I  have  known,  I  repeat,  in 
my  lengthened  career,  of  this  complaint  terminating  favorably ;  and  when 
to  such  exceptional  cases  so  very  many  others  may  be  opposed  which  ter- 
minate in  death,  it  may  well  be  laid  down  as  a  law  that  this  complaint  is 
almost  always  incurable.  This  statement  will  perhaps  be  regarded  as  ex- 
aggerated, and  you  have  doubtless  heard  parents  say  that  they  had  children 
who  had  been  cured  of  brain  fever;  and  perhaps  you  have  even  heard  prac- 
titioners boast  of  having  mastered  a  disease  said  to  be  incurable,  while 
others,  as  experienced  and  skilful  as  themselves,  confess  that  they  have 
always  failed.  The  reason  of  this  is  that  the  former  men  mistook  for  cere- 
bro-meningitis  typhoid  fever  complicated  with  brain-symptoms,  which  gets 
well  in  most  cases. 

But  to  return  to  the  description  of  cerebral  fever.  The  third  stage  is 
chiefly  characterized  by  the  return  of  fever.  I  have  said,  that  in  the  begin- 
ning fever  came  on  in  paroxysms  of  short  duration,  recurring  three  or  four 
times  in  the  course  of  the  twenty-four  hours,  and  that  although  it  was  occa- 
sionally continuous  with  frequent  remissions,  it  was  never  very  high.  In 
the  second  stage  the  pulse,  as  wTe  have  seen,  becomes  remarkably  slow  ;  but 
in  the  third  stage  it  becomes  extremely  frequent,  and  goes  on  increasingly 
so  until  death  closes  the  scene. 

The  stupor  grows  more  and  more  profound.  It  was  already  difficult,  in 
the  second  stage,  to  rouse  the  child,  who  exhibited  impatience  by  his  grunts 
and  cries,  but  who  answered  still  the  questions  that  were  put  to  him  ;  but 
in  this  stage  no  sign  of  intelligence  can  be  got  from  him,  and  the  most 
powerful  irritation  can  scarcely  rouse  him.  The  stupor  is  much  more  pro- 
found than  that  of  the  gravest  forms  of  typhoid  fever,  for  in  the  latter, 
there  is  usually  marked  agitation  coexisting  with  other  signs  of  ataxy,  there 
is  mussitation,  carphology,  and  delirium,  sometimes  quiet  and  sometimes 
Qoisy.  In  the  third  stage  of  cerebral  fever,  although  the  patient's  aspeel 
does  not,  at  first  sight,  very  notably  differ  from  thai  of  an  individual  labor- 
ing under  typhoid  fever,  the  prostration  which  exists  indicates  a  much 
deeper  organic  lesion  of  the  brain.  Delirium  is  at  this  period  very  rare, 
but  it  is  sometimes  presenl  in  the  firel  and  second  stages,  although  it  is  very 
rare  even  then.  Sometimes,  but  rarely  (especially  if  the  child  be  above 
four  years  old),  convulsions  may  occur  in  the  firsl  stage  of  cerebral  lever, 
but  they  do  not  show  themselves  in  the  second  or  apyretic  period,  or  they 
assume  al  leasl  a  different  form,  and  resemble  thou  epileptic  vertigo.    The 

patient  opens  his  eyes  suddenly  and  stares  fixedly  J  but  this  part  ial,  con- 
vulsive movement  shows  itself  more  in  the  third  stage  simultaneously  with 
symptoms  of  paralysis. 


CEREBRAL    FEVER.  885 

Strabismus  is  occasionally  noted  at  the  onset  of  cerebral  fever,  and  as  it 
pretty  commonly  occurs  together  with  convulsions,  it  may  be  ascribed  to 
spasm  of  some  of  the  motor  muscles  of  the  eye.  But  the  squint  which 
appears,  and  pretty  frequently  continues  towards  the  close  of  the  second 
stage,  and  nearly  always  in  the  course  of  the  third,  is  owing  to  paralysis, 
because  there  is  evident  palsy  of  other  muscles  supplied  by  the  third  or 
sixth  pair.  The  third  nerve  is  the  one  most  commonly  affected  ;  the  pa- 
tient opens  one  eye  less  than  the  other,  from  the  levator  palpebral  on  that 
side  having  lost  some  power.  Strabismus  and  dilatation  of  the  pupils 
(which  precedes  and  accompanies  the  strabismus),  and  the  diminished 
power  in  raising  the  upper  lid,  are  not  the  only  signs  of  paralysis,  for  other 
regions  of  the  body  are  also  affected.  Thus,  if  while  the  child  is  lying  on 
his  back,  the  soles  of  his  feet  be  tickled  one  after  the  other,  it  is  found  that 
he  withdraws  one  leg  more  powerfully  than  the  other.  Mobility  is,  there- 
fore, impaired  on  one  side,  and  sensibility  is  affected  as  well  on  that  side, 
because  the  child  apparently  feels  any  irritation  of  the  skin  there  only 
when  it  is  considerable  and  prolonged.  The  persons  about  him  also  notice 
that  he  has  greater  difficulty  in  lifting  one  arm  than  the  other,  and  that 
he  lets  it  drop  alongside  of  his  body  ;  on  testing  it,  sensibility  in  that  arm 
is  also  found  to  be  diminished. 

The  paralysis  which  occurs  in  cerebral  fever  presents  this  remarkable 
feature,  that  it  seems  to  shift  about  from  one  hour  to  the  other.  One  day, 
for  instance,  the  right  leg  is  found  to  be  drawn  up  with  greater  energv  than 
the  left,  when  the  sole  of  the  right  foot  is  tickled,  but  on  repeating  the  ex- 
amination a  few  days  afterwards,  you  are  surprised  to  find  that  it  is  the  left 
leg  which  now  feels  and  moves  better  than  the  right.  It  would  seem  from 
this,  as  if  the  paralysis  had  shifted  from  one  side  to  the  other  ;  but  such  is 
not  the  case  :  the  limb  which  was  first  palsied  is  still  so,  but  the  illusion 
arises  from  the  circumstance  that,  the  palsy  has  not  increased  in  degree  in 
the  first  limb,  while  the  second  limb  has  become  involved  to  a  greater 
degree.  Motor  power  has  not  returned  in  the  former,  but  has  been  more 
gravely  impaired  in  the  latter.  The  lesions  which  are  found  after  death 
subsequently  account  for  these  facts.  When  the  right  limbs  alone  were 
paralyzed,  the  brain  is  found  to  be  disorganized  on  the  left  side ;  but  when 
the  paralysis  apparently  shifted  from  one  side  to  the  other,  both  hemi- 
spheres are  found  diseased,  but  more  deeply  and  more  extensively  on  the 
opposite  side  to  that  of  the  limbs  which  were  most  palsied.  This  apparent 
mobility  of  paralytic  symptoms  more  frequently  occurs  in  cerebral  fever 
than  in  any  other  complaint. 

In  this  stage  there  pretty  often  occurs,  as  in  grave  fevers,  particularly  in 
typhoid  fever,  serious  inflammation  of  the  eye  and  ulceration  of  the  cornea, 
from  the  absence  of  winking.  Sensibility  being  either  abolished  or  deeply 
impaired,  and  the  muscles  of  the  eyelids  moving  imperfectly  only,  the  lids 
remain  half  opened,  so  that  the  conjunctiva  gets  inflamed  and  becomes  the 
seat  of  a  considerable  sanguineous  suffusion :  the  cornea  being  constantly 
exposed  to  the  air,  and  being  no  longer  moistened  by  the  tears,  becomes 
dry,  ulcerates,  and  is  at  last  perforated.  This  last  accident  rarely  occurs, 
but  there  is,  in  nearly  every  case,  congestion  of  the  conjunctiva  and  pretty 
abundant  secretion  of  mucus.  Convulsions,  which  are  rare  in  the  first  stage 
of  the  disease,  and  in  the  second  assume  the  form  of  epileptic  vertigo,  show 
themselves  again  in  the  third  stage,  and  constitute  an  important  feature  of  it. 
They  are  sometimes  inward  convulsions,  and  sometimes  consist  of  regular 
eclamptic  seizures.  Thus  .the  child's  face  is  seen  to  be  contorted  at  times, 
his  eyes  roll  upwards  and  inwards,  and  are  the  seat  of  slight  oscillations, 
and  his  jaw  moves  as  if  he  were  chewing.     The  thumb  is  turned  into  the 


886  CEREBEAL    FEVER. 

palm,  and  the  fingers  fixed  over  it ;  and  then  perfect  relaxation  follows  on 
these  contractions.  These  convulsions,  which  are  almost  exclusively  tonic, 
sometimes  recur  for  hours  together,  and  affect  not  only  the  limbs  and  face, 
but  the  muscles  of  the  larynx  also  and  the  diaphragm,  impeding  respiration 
to  a  considerable  degree. 

In  proportion  as  the  complaint  draws  to  a  fatal  termination,  the  convul- 
sions become  general  and  assume  the  form  of  grave  eclamptic  seizures.  They 
recur  every  hour  or  every  half  hour,  and  even  oftener,  and  it  is  after  one  of 
these  attacks  generally  that  the  child  dies  in  a  state  of  semi-asphyxia.  In 
other  cases,  death  supervenes  during  profound  coma,  and  trembling  of  the 
limbs,  subsultus  tendinum,  and  carphology  are  the  closing  symptoms  of  a 
more  or  less  prolonged  agony. 

It  very  often  happens,  gentlemen,  that  an  arrest  takes  place  in  this  fearful 
development  of  symptoms,  and  that  the  patient  who,  for  several  hours  or 
days,  was  in  such  a  condition  that  death  was  thought  to  be  impending, 
seems  suddenly  to  return  to  life.  He  wakes  up  from  his  stupor,  recognizes, 
or  seems  to  recognize,  the  persons  around  him,  answers  their  questions  and 
converses  with  them  ;  and  one  must  have  a  sad  experience  of  this  complaint 
in  order  not  to  share  the  hopes  which  this  gleam  of  improvement  excites  in 
a  poor  mother's  heart ;  and  the  practitioner  must  needs  have  great  courage 
to  moderate  that  joy  which  he  cannot  share,  and  which,  in  a  few  hours,  will 
be  replaced  by  so  cruel  a  grief. 

How  often,  gentlemen,  have  I  been  received  with  cries  of  joy  by  happy 
friends,  but  how  often  also  have  I  been  compelled  to  meet  such  transports 
with  words  expressing  my  gloomy  presentiments !  Yet  I  must  confess  that, 
at  the  beginning  of  my  medical  career,  I  could  not  help  entertaining  hopes 
myself,  in  presence  of  such  an  extraordinary  improvement. 

What  shall  I  say  now,  gentlemen,  as  to  the  treatment  of  a  complaiut 
which  involves  such  a  fatally  grave  prognosis  ?  Many  remedies  have  been 
used  against  it,  and  I  have  tried  them  myself,  but  have  failed  with  all  of 
them  ;  and  in  the  two  instances  of  cure  which  I  mentioned  to  you  as  being 
too  rare  and  too  exceptional  for  modifying  the  general  rule,  the  credit  is 
due  to  nature  and  not  to  art. 

Purgatives,  calomel  in  large  doses,  or  in  divided  doses  according  to  Law's 
method,  iodide  of  potassium  (which  Dr.  Otterburg  states  he  has  used  with 
good  effect),  large  blisters  over  the  shaven  scalp,  cold  affusions,  ice  constantly 
applied  to  the  head,  have  all  been  tried  by  me,  and  always  without  success. 

Next,  by  instituting  a  comparison  between  the  results  of  energetic  treat- 
ment, and  those  of  the  expectant  method,  I  found  that  death  came  on  at  an 
earlier  date  in  the  first  class  of  cases  than  in  the  second. 

Yet,  however  convinced  I  may  be  of  my  powerlessness,  I  cannot  decide 
on  remaining  perfectly  passive,  and  although  taught  by  a  long  experience 
that  my  efforts  will  be  unsuccessful,  I  still  try  to  struggle,  and  by  so  doing 
I,  at  least,  do  not  crush  all  hope  in  the  patient's  friends.  I  keep  up  their 
courage,  and  do  not  cause  them  to  regret  afterwards  that  they  did  not  try 
to  save  the  child.  But,  convinced  as  1  am  also  that  too  active  a  treatment 
more  promptly  exhausts  the  vital  energy,  1  try  to  do  the  least  possible  harm, 
since  I  can  do  no  good. 

Calomel,  in  very  small  doses,  and  given  more  with  the  view  of  purging 
than    as   an    alterative,  musk    suspended    in    syrupus   :ethcris,  and    antispas- 

modics,  are  the  simple  remedies  to  which  I  have  now  recourse  when  I  am  tree 
to  act.     I  lied  the  patient  at  the  same  time,  and  1  regard  Light  feeding  as 

the  best   means  of  prolonging  his  life  a  Little  more. 

When  alter  death  the  nature  of  the  anatomical  lenOM  of  cerebral  lever  is 


CEREBRAL    FEVER.  887 

determined,  the  inexorable  gravity  of  the  prognosis  becomes  intelligible,  as 
well  as  the  powerlessness  of  the  practitioner. 

Here  is,  gentlemen,  the  brain  of  the  child  who  gave  rise  to  this  lecture. 
At  the  base,  on  a  level  with  and  behind  the  optic  commissure,  the  meninges 
are  thickened  and  infiltrated  with  a  purulent  fibro-plastic  material.  The 
infiltration  does  not  in  this  case  extend  to  the  fissures,  between  the  cerebral 
lobes,  where  it  usually  is  very  marked  ;  and,  as  happens  in  some  rare  cases, 
there  is  no  tubercular  matter  to  be  seen,  either  accumulated  in  masses  or 
scattered  here  and  there,  nor  are  there  any  gray,  transparent  granulations, 
of  variable  size,  but  generally  not  larger  than  grains  of  semola. 

On  making  incisions  through  this  brain,  we  come  to  the  lateral  ventricles, 
which  contain  some  rather  turbid  serosity.  The  great  nervous  centres,  the 
fornix,  septum  lucidum,  corpus  callosum,  and  floor  of  the  ventricles  are 
perfectly  softened;  the  cerebral  mass  is  reduced  to  a  pulpy  condition. 

In  the  lungs,  which  you  see  here,  there  are  no  traces  of  tubercles,  nor 
are  there  any  in  the  bronchial  glands ;  the  mesenteric  glands  were  not  tu- 
bercular either.  On  this  point,  this  case  is  an  exception  to  the  rule,  for  of 
thirty  children  who  die  of  cerebral  fever,  dissection  reveals  the  presence  of 
tubercular  deposits  in  twenty-nine. 

This  case  seems  to  me  to  prove  once  again  that  cerebral  fever,  when  said 
to  be  idiopathic,  that  is,  occurring  in  individuals  that  are  not  tubercular, 
does  not  run  a  different  course  from  the  one  it  affects  in  tubercular  persons. 
The  prodromata  alone  differ ;  one  may  conceive  how  the  more  or  less  rapid 
development  of  granulations  and  tubercular  masses  in  the  meninges  gives 
rise  to  peculiar  symptoms  which  constitute  the  prodromic  stage  of  cerebral 
fever;  just  as  the  development  of  granulations  in  the  peritoneum  or  the 
pleura  is  accompanied  by  peculiar  symptoms.  But  when  acute  pleurisy  or 
peritonitis  sets  in,  the  presence  of  these  granulations  has  no  influence  on  the 
symptoms  of  the  first  stage  of  the  disease,  and  will  only  influence  its  ter- 
mination. It  must  be  added,  however,  that  the  presence  of  granulations 
and  tubercles  in  the  meninges,  is  such  a  powerful  cause  of  congestive  flux 
to  the  brain,  that  the  children  must  sooner  or  later  die  of  inflammation. 

I  reject  the  name  of  meningitis  for  cerebral  fever,  because  the  lesions  of 
the  meninges  seem  to  me  to  be  secondary  only,  and  much  inferior  in  impor- 
tance to  the  deep  anatomical  alterations  seated  in  the  brain  itself,  such  as 
the  softening  which  destroys  the  fornix,  the  septum  lucidum,  the  corpus 
callosum,  thalami  optici,  and  posterior  part  of  the  cerebral  lobes,  to  a  more 
or  less  considerable  extent.  Hence,  if  the  disease  should  be  named  after 
the  organic  lesions  which  characterize  it,  it  ought  to  be  called  cerebro-men- 
ingitis. 

Chronic  Hydrocephalus. 

The  cerebro-meningitis  of  which  I  have  just  now  spoken,  differs  greatly 
from  and  is  never  the  starting-point  of  what  is  called  chronic  hydrocephalus, 
an  affection  of  which  you  may  now  see  an  instance  in  a  young  child  in  St. 
Bernard  Ward. 

The  first  thing  which  strikes  an  observer,  when  he  looks  at  a  hydroce- 
phalic individual,  is  the  enormous  size  of  the  head,  out  of  all  proportion 
with  the  rest  of  the  body.  You  have  seen  the  child  in  the  ward:  when  he 
was  admitted,  the  circumerence  of  his  skull  measured  50  centimetres  (20 
inches)  on  a  level  with  a  line  drawn  a  little  above  the  eyebrows.  Cases 
have  been  recorded,  and  I  have  brought  here  from  the  anatomical  museum 
of  our  faculty,  this  head,  which  you  may  see,  and  which  measures  1  metre 
(40  inches)  round  its  circumference.     On  opening  it,  it  was  found  to  con- 


CEREBRAL    FEVER. 

tain  within  its  ventricles,  30  lbs.  of  fluid  and  more.  Frank  mentions  a  case 
in  which  the  fluid  effused  amounted  to  50  lbs. ;  in  another  case,  the  circum- 
ference of  the  skull  measured  52  inches. 

You  have  observed  the  peculiar  deformity  of  the  head  of  the  child  in  my 
wards,  and  although  it  is  not  exaggerated  in  his  case,  it  still  gives  you  an 
idea  of  what  it  may  be  in  hydrocephalus.  There  is,  first,  a  considerable 
disproportion  between  the  face  and  the  skull,  the  former  looking  excessively 
small,  for  the  very  reason  that  the  latter  is  enormously  developed,  and  be- 
cause also  the  frontal  bones  project  enormously  forwards  on  a  level  with  the 
superciliary  arches,  so  that  the  orbits  are  pushed  down,  as  it  were,  and  the 
vertical  diameter  of  the  face  is,  therefore,  diminished.  This  disposition, 
according  to  Camper,  suffices  to  enable  one  to  recognize  hydrocephalus. 
Moreover,  the  two  frontal  bones  separate  from  one  another,  from  their 
median  suture,  which  is  incompletely  united  in  a  child,  widening  more  or 
less.  The  same  obtains  with  the  sagittal  and  lambdoidal  sutures,  the  two 
parietal  bones  separating  from  one  another  and  from  the  occipital  bone, 
which,  like  themselves,  is  pushed  outwards.  The  cranial  bones  are,  there- 
fore, soldered  together  at  the  base  only  and  fall  back  (if  I  may  be  allowed 
the  comparison)  like  the  petals  of  an  opening  flower.  On  looking  at  the 
patient's  head,  one  might  think  that  it  was  soft,  for,  when  it  is  moved,  un- 
dulations are  noticed  at  its  upper  part,  and  these  are  again  produced  when 
the  child  cries  or  draws  in  a  deep  breath.  The  upper  part  of  the  head  ex- 
pands, and  is  raised  during  forced  expiration,  but  not  during  inspiration. 
By  applying  the  hand  over  this  deformed  skull,  the  separation  of  the  bones 
may  be  detected,  and  this  is  particularly  marked  about  the  fontanelles. 
The  interval  between  the  parietal  bones  and  between  the  latter  and  the  two 
frontal  bones,  may  sometimes  measure  15,  20,  30  centimetres  (6,  8,  12 
inches),  and  even  more.  Over  those  parts,  the  cranial  cavity  is  merely 
closed  by  a  soft  membrane,  the  pericranium.  In  some  cases,  small  wormian 
bones  are  found  in  these  membranous  spaces,  in  variable  numbers.  (There 
is  one  of  these  at  the  posterior  part  of  the  sagittal  suture,  in  the  child  in 
St.  Bernard  Ward.) 

Hydrocephalus  may  last  for  a  long  time,  especially  when  it  tends  to- 
wards a  cure  (a  very  rare  mode  of  termination).  It  may  be  stationary  at 
least  for  four,  five,  six,  and  ten  years,  as  in  cases  on  record,  and  even 
more;  for  individuals  who  were  afflicted  with  this  complaint  almost  from 
birth,  have  been  known  to  live  to  a  very  advanced  age.  Frank  relates  the 
history  of  two  men,  one  72  years  of  age,  and  the  other  78,  who  were  hydro- 
cephalic from  birth.  In  such  cases,  the  wormian  bones  increase  in  number, 
and  becomes  centres  of  a  process  of  ossification  by  which  bony  causeways 
are,  as  it  were,  formed  between  one  bone  and  another,  indicating  a  ten- 
dency to  union,  which  is  always  incomplete,  however.  This  enormous  en- 
largement of  the  skull  can  only  be  accomplished,  as  you  may  conceive,  by 
distending  the  skin;  hence,  after  a  certain  time,  from  the  integuments 
yielding  less  easily,  the  distension  takes  place  al  the  expense  of  the  con- 
tiguous parts,  namely,  of  the  face,  and,  especially,  at  the  expense  of  the 
skin  of  the  eyelids.  The  physiognomy  of  the  patient  henceforward  assumes 
a  peculiar  and  extraordinary  aspect.  The  eyebrows  are  pulled  upwards, 
so  that  the  projection  of  the  upper  ridge  of  the  orbil  which  they  previously 

concealed  is  left  exposed  ;    while  the  upper  Lid,  in  consequence  of  the  same 

traction,  becomes  too  short  to  cover  the  eyeball,  which  seems  to  project, 

and  to  look    down    and    towards    the    lower  lid.      In  nearly  every  instance, 

there  is  then  weakness  of  sight,  or  even  complete  blindness  j  and,  as  in  con- 
genital blindness,  the  eyes    which,  in  hydrocephalus,  remain  bright  and 


CEREBRAL    FEVER.  889 

clear)  do  not  gaze  at  anything,  and  are  the  seat  of  nearly  incessant  oscilla- 
tions. 

The  patient  looks  sad,  but  he  generally  has  no  pain.  Commonly  also, 
the  general  health  seems  to  be  triflingly  disturbed  ;  the  child,  if  at  the 
breast,  takes  it  easily,  and  all  his  functions  are  performed  regularly.  In 
a  certain  number  of  cases,  however,  hydrocephalus  is  pretty  frequently 
accompanied,  at  the  outset,  by  convulsive  phenomena.  This  was  the  case 
in  the  child  in  St.  Bernard  Ward.  When  only  three  weeks  old,  and  there- 
fore almost  at  birth,  he  was  seized  with  convulsions,  which  recurred  from 
four  to  six,  eight,  ten,  and  even  twenty  times  in  the  course  of  twenty-four 
hours.  Three  months  ago,  his  mother  brought  him  to  me  for  the  first  time 
on  account  of  those  convulsions,  the  cause  of  which  I  could  not  make  out, 
for  nothing  could  make  me  suspect  hydrocephalus,  as  the  head  was  then 
of  normal  size.  Eclampsia  may,  therefore,  be  the  only  symptom  announc- 
ing the  invasion  of  the  disease,  and  it  is  caused  by  the  sub-inflammatory 
condition  of  the  serous  lining  of  the  cerebral  ventricles,  which  condition 
also  brings  on  the  serous  effusion  which  is  poured  out  into  those  cavities. 
The  frequent  recurrence  of  convulsions  for  some  length  of  time  should  even 
cause  a  medical  man  to  suspect  the  possible  supervention  of  hydrocephalus. 
In  the  case  of  the  child,  at  present  in  the  ward,  the  convulsive  seizures 
recurred  for  two  months  and  a  half  before  the  head  began  to  enlarge. 
These  convulsions  generally  increase  in  violence  by  degrees,  and  it  very 
frequently  happens  that  when  they  have  lasted  for  a  certain  time,  the 
patient  is  carried  off  by  an  attack  of  cerebral  fever,  and  the  lesions  of 
cerebro-meningitis  are  then  found,  on  dissection. 

When  hydrocephalic  individuals  die  of  some  intercurrent  affection,  and 
an  opportunity  is  thus  afforded  of  examining  their  heads,  the  ventricles  of 
the  brain  are  found  to  be  enormously  enlarged  ;  the  brain,  the  convolutions 
of  which  are  flattened,  is  generally  sound  at  the  base,  but  the  convolutions 
of  its  upper  surface  are  completely  effaced  and  not  recognizable  from  the 
sulci  which  have  disappeared,  and  the  organ  is  reduced  to  a  kind  of  lamina, 
which  the  unassisted  eye  can  scarcely  recognize  as  cerebral  tissue,  the  ele- 
ments of  which  are,  however,  made  out  by  the  microscope.  The  mem- 
branes themselves  (pia  mater,  arachnoid,  and  dura  mater)  participate  in 
this  thinning,  and  you  may  imagine  how  considerable  it  must  be  in  those 
cases  in  which  the  fluid  effused  amounts  to  30  and  50  lbs. 

Although  hydrocephalus  almost  invariably  terminates  in  death,  it  may, 
however,  progress  very  slowly,  and  I  mentioned  to  you  just  now,  instances 
of  individuals  who  lived  four,  five,  ten,  and  even  (as  in  cases  recorded  by 
Frank)  seventy-two  and  seventy-eight  years.  Apart  from  these  exceptional 
cases,  which  are  not,  however,  very  rare,  this  complaint  lasts  habitually  a 
year  or  two,  unless  it  presented  acute  symptoms  from  the  beginning,  in 
which  case  death  sets  in  rapidly.  But  how  lamentable  the  life  to  which 
the  unhappy  individuals,  whose  existence  is  prolonged,  are  condemned ! 
What  a  sad  spectacle  to  those  around  them !  and  what  a  source  of  con- 
tinual affliction  they  are  to  their  parents !  So  long  as  they  are  infants 
in  arms,  they  can  scarcely  bear  the  weight  of  their  head  :  by  and  by,  when 
they  begin  to  walk  (and  they  always  walk  later  than  other  children),  their 
gait  is  vacillating,  and  as  the  disease  progresses,  they  can  no  longer  stand, 
and  are  confined  to  their  beds. 

Several  reasons  concur  in  causing  this  inability  to  stand  or  to  sit  up. 
There  is,  on  the  one  hand,  the  enormous  weight  of  the  head,  which  is  no 
longer  balanced  on  the  trunk  ;  and  on  the  other,  blindness,  which  accom- 
panies hydrocephalus,  and  which,  by  rendering  the  patient  incapable  of 
guiding  himself,  prevents  his  walking ;  and  lastly,  there  is  a  kind  of  paral- 


890  CEREBRAL    FEVER. 

ysis,  resulting  from  the  compression  of  the  nervous  centre.  I  say  a  kind 
of  paralysis,  because  the  paralysis  is  not  carried  to  the  degree  which  might 
have  been,  perhaps,  expected.  In  the  case  of  the  child  at  present  in  our 
wards,  although  the  amount  of  fluid  poured  out  into  the  ventricles  must  be 
considerable,  if  we  estimate  it  by  the  size  of  the  head,  there  is  no  symptom 
of  paralysis ;  the  child  moves  his  legs  and  arms  easily,  and  his  bladder 
freely  expels  the  urine.  The  reason  of  this  is,  that  the  skull  has  yielded 
to  the  pressure  from  within,  and,  as  a  consequence  of  its  enlargement,  the 
brain  has  escaped  compression.  But  when  hydrocephalus  has  reached 
such  a  degree  that  the  skull  can  no  longer  expand,  there  comes  a  time  when 
compression  is  unavoidable,  and  the  functions  of  the  organ  being  abolished, 
loss  of  motility  results. 

Even  when  the  disease  is  stationary  for  a  very  long  period,  there  is 
arrest  of  mental  development ;  the  intellect  fails,  and  this  failure  generally 
passes  into  nearly  complete  imbecility. 

In  all  these  cases,  therefore,  prognosis  is  of  the  most  serious  character, 
and  medicine  is  always  powerless  to  cure  or  even  to  relieve  the  sufferer. 
Yet  there  has  been  no  lack  of  methods  of  treatment.  With  the  view  of 
combating  the  subacute  inflammation  which  causes  the  effusion,  purga- 
tives, calomel,  and  even  bloodletting,  have  been  recommended  ;  diuretics, 
sudorifics,  and  sialagogues  have  been  vaunted. 

Methodical  compression  of  the  head  has  been  particularly  lauded,  and  I 
long  had  recourse  to  it  myself;  but  I  have  now  completely  set  it  aside,  on 
account  of  a  case  which  fell  under  my  notice. 

I  was  once  consulted  about  a  child,  five  months  old,  who  was  suffering 
from  chronic  hydrocephalus,  and  whose  head  was  of  about  the  same  size  as 
that  of  the  child  in  the  ward.  I  had  hopes  that,  by  compressing  the  head 
by  means  of  strips  of  sticking-plaster,  I  might  prevent  a  further  increase  of 
the  effusion :  at  the  end  of  a  week,  I  went  to  see  the  child,  and  to  apply  fresh 
.-trips  of  plaster,  after  removing  the  old  ones.  The  size  of  the  head  had 
appreciably  diminished,  but  the  child  died  suddenly,  five  or  six  weeks  after 
the  second  application  of  the  compressing  plaster.  He  had  suddenly  cried 
out  as  he  was  going  to  take  the  breast,  a  copious  flow  of  liquid  had  taken 
place  through  the  nostrils,  and  the  head  had  shrunk  like  a  bladder  which 
empties  itself.  Now,  what  had  occurred  ?  As  the  compression  of  the  upper 
part  of  the  cranium  prevented  a  further  effusion  of  liquid,  the  base  of  the 
skull  had  yielded,  as  it  does  when,  in  order  to  separate  the  cranial  bones, 
anatomists  fill  it  with  water  and  haricot  beans,  which  latter,  on  swelling, 
disarticulate  the  bones.  In  the  case  of  my  young  patient,  the  base  of  the 
skull  had  yielded  to  the  pressure  of  the  fluid,  disarticulation  had  occurred, 
and  the  fluid,  finding  a  channel  through  the  ethmoid  bone,  had  flowed 
out  through  the  nasal  fossae.  Death  had  then  resulted  from  the  sudden 
change  which  bad  taken  place  in  the  anatomical  conditions  of  the  brain. 

The  brain  has  been  tapped  through  the  sutures  and  fontanelles  by  cele- 
brated surgeons, and  the  operation  has  been  even  repeated  several  tine 
the  same  individual ;  but  many  of  those  who  had  praised  it  at  firel  have 
finally  proscribed  it,  for  its  advantages  do  not  counterbalance  its  disad- 
vantages. Of  late,  iodide  of  potassium  has  been  very  much  lauded  ;  and 
for  the  lasl  few  years,  1  have  myself  used  iodine  lotions  to  the  head. 
I  give  iodide  of  potassium  internally  at  the  same  time,  in  doses  of  two 
grains  at  first,  which  I  gradually  increase  to  four,  five,  .-ix.  and  even  eight 

-rain-,  according  as   it    is   tolerated.      The  end  which    I    have    in   view   hy 

prescribing  iodine  lotion-  is  to  favor  the  absorption  of  the  effused  fluid, 
guiding  myself  on  the  Bucceae  obtained  by  means  of  these  lotion.-,  in  effu- 
-ion.-  into  the  serous  membranes  of  the  pleura,  the  abdomen,  or  the  joints. 


CROSS-PARALYSIS,    OR    ALTERNATE    HEMIPLEGIA.  891 


LECTURE   XLIX. 

CROSS  -  PAR ALYSIS    OR   ALTERNATE   HEMIPLEGIA. 

In  most  Cases  it  is  owing  to  a  Lesion  of  the  Pons  Varolii,  but  it  is  not  an  Ab- 
solute Sign  of  such  Lesion.  It  should  not  be  Confounded  ivith  Glosso- 
Larxjngeal  Paralysis. 

Gentlemen:  When  an  individual  is  struck  down  with  hemiplegia,  the 
paralysis  affects  the  limbs  and  the  face  on  the  same  side.  There  are,  how- 
ever, exceptions  to  this  general  rule ;  and  for  those  rare  cases  in  which  the 
face  is  paralyzed  on  one  side,  and  the  limbs  on  the  opposite  side,  Dr.  Gubler 
has  proposed  the  name  of  alternate  hemiplegia. 

Very  recently,  in  September,  1861,  I  saw,  in  consultation  with  my  col- 
league and  friend,  Dr.  Hillairet,  a  little  girl  from  Clermont-Ferrand,  seven 
years  old,  who  had  met  with  a  severe  fall  backwards  a  few  months  pre- 
viously, and  had  knocked  the  back  of  her  head  and  the  upper  part  of  her 
neck  against  a  piece  of  furniture.  She  complained  almost  immediately  of 
heaviness  of  the  head  and  of  feeling  drowsy,  but  after  a  few  days  she  felt 
well  again.  Shortly  afterwards,  however,  she  complained  of  a  pain  both  in 
the  occiput  and  the  forehead.  Her  friends  noticed  also  that  she  hesitated 
in  her  gait,  and  that  she  had  grown  irritable  and  made  grimaces. 

Three  months  after  the  occurrence  of  the  accident,  there  was  found  weak- 
ness in  the  whole  left  side  of  the  body,  as  well  as  a  very  marked  paralysis 
of  the  right  side  of  the  face.  She  was  then  sent  to  Paris  by  Dr.  Bourgard,  and 
on  our  seeing  her  we  thought  that  the  pons  Varolii  and  the  upper  part  of 
the  medulla  oblongata  were  injured,  and  we  gave  an  unfavorable  prognosis. 

We  lost  sight  of  the  patient,  so  that  we  could  not  verify  the  accuracy  of 
our  diagnosis ;  but  we  thought  we  could  make  it  in  this  instance,  on  the 
ground  of  its  analogy  to  the  cases  recorded  by  Dr.  Gubler,  showing  the 
relations  which  generally  exist  between  cross-paralysis  and  injuries  to  the 
pons  Varolii. 

The  body  of  a  woman,  however,  who  died  at  No.  6  in  St.  Bernard  Ward, 
of  some  cerebral  affection  which  had  produced  cross-paralysis,  was  exam- 
ined, after  death,  in  your  presence.  But  the  results  of  the  autopsy  disap- 
pointed us,  and  seemed  in  contradiction  to  the  law  laid  down  by  my  learned 
colleague  of  the  Beaujon  Hospital. 

The  patient  was  a  servant  thirty  years  of  age.  She  was  admitted  into 
the  Hotel-Dieu  for  a  violent  pain  in  the  head,  which  only  dated  a  few  days 
back,  and  was  not  localized  in  any  one  spot  more  than  another.  She  was 
not  feverish,  her  appetite  was  good,  and  she  complained  of  nothing  else  but 
the  headache.  Her  menses  had  come  on  a  few  hours  before  admission,  and 
she  stated  that  she  was  usually  liable  to  this  pain  in  the  head  at  her  men- 
strual periods. 

The  next  day,  by  the  time  I  went  round  the  wards,  nothing  fresh  had 
occurred  to  call  for  my  attention ;  yet,  although  the  patient  gave  clear  an- 
swers to  the  questions  put  to  her,  I  noticed  that  she  labored  under  a  certain 
amount  of  hebetude,  of  mental  languor,  which  could  be  after  all  accounted 
for  by  the  cephalalgia. 


892  CROSS-PARALYSIS,   OR    ALTERNATE    HEMIPLEGIA. 

The  absence  of  all  febrile  symptoms,  the  good  condition  of  her  functions 
in  general,  did  not  call  for  active  medical  interference ;  and  I  had  decided 
on  waiting  before  adopting  any  treatment,  when  fresh  symptoms  manifested 
themselves  during  the  day,  which  towards  evening  alarmed  my  clinical 
assistant.  The  patient  had  been  suddenly  paralyzed.  There  was  incom- 
plete motor  paralysis  of  the  right  arm  and  leg,  while  tactile  sensibility  was 
preserved.  When  the  palsied  limbs  were  pinched  or  merely  tickled,  the 
patient  drew  them  away,  although  less  easily»and  less  quickly  than  she 
withdrew  her  left  arm  and  leg  under  the  same  circumstances.  The  head 
was  inclined  to  the  left  and  the  face  turned  to  the  right,  from  the  contrac- 
tion of  the  left  sterno-cleido-mastoid,  whilst  the  analogous  muscle  on  the 
right  side  was  relaxed.  There  was  hemiplegia,  therefore,  but  the  paralysis, 
while  involving  the  right  limbs  and  the  right  half  of  the  trunk,  affected  the 
left  side  of  the  face.  The  face  wore  a  singular  expression,  and  was  dragged 
to  the  right,  that  is,  to  the  same  side  as  the  paralysis  of  the  limbs.  The 
mouth  was  distorted,  the  labial  commissure  on  that  side  was  higher  than 
the  other,  whilst  the  left  cheek  was  more  flaccid  than  the  right.  Moreover, 
the  patient,  who  gave  distinct  answers  to  questions  put  to  her,  stated  that 
she  could  not  see  with  her  right  eye,  whilst  on  the  left  side  her  sight  was 
good ;  both  pupils  were  equally  contracted.  The  paralysis  of  the  left  side 
of  the  face,  which  coincided  with  the  diminution  of  sight  on  the  right  side, 
was  evidently  less  marked  than  the  paralysis  of  the  limbs. 

The  pain  in  the  head  was  as  violent  as  ever,  and  there  was  no  fever. 
The  patient  asked  for  food,  although  her  tongue  had  a  yellowish  coating 
of  fur.  An  emetic  was  ordered,  but  on  the  following  morning  the  symp- 
toms had  become  more  marked.  Motion  was  more  impeded  and  sensation 
duller  than  on  the  preceding  clay.  The  paralysis  of  the  face,  although  less 
marked  than  that  of  the  limbs,  had  increased,  although  it  was  not  so  marked 
as  in  cases  where  it  is  clue  to  a  lesion  of  the  seventh  pair  exclusively.  The 
intellect  was  impaired,  and  although  the  patient  was  awake,  and  seemed 
to  hear  when  she  was  sj)oken  to,  she  no  longer  answered.  Death  took  place 
at  4  o'clock  the  next  morning. 

A  post-mortem  examination  was  made  about  thirty  hours  afterwards. 
On  removing  the  calvarium,  a  pretty  considerable  quantity  of  black  blood 
escaped  from  the  gorged  vessels  of  the  pia  mater  over  the  whole  surface  of 
the  hemispheres.  The  congestion  was  most  marked  at  the  base  of  the  brain, 
and  there  was  found  in  the  interpeduncular  space  a  black  mass,  consist  ing 
not  only  of  vessels  distended  with  blood,  but  of  extravasated  blood  also, 
which  was  in  part  liquid,  and  in  part  coagulated,  and  had  made  its  way 
into  the  fissure  of  Bichat.  The  nerves  of  the  seventh  pair  exhibited  do 
alteration  at  their  superficial  origin,  behind  the  pons  Varolii,  although  the 
right  nerve  seemed  to  tear  more  easily  than  the  other.  Independently  <>f 
the  meningeal  hemorrhage,  the  brain  was  softened  in  its  central  parts,  on 
the  left  especially,  where  the  corpus  callosum,  the  fornix,  and  the  septum 
lucidum  were  broken  down  when  a  small  stream  of  water  was  poured  upon 
them.  There  was  no  effusion  into  the  interior  of  the  ventricles;  and,  lastly, 
the  pons  Varolii  presented  no  lesion,  either  on  its  surface  or  more  deeply; 
on  making  numerous  sections  through  it,  no  tumor  was  found,  nor  traces 
of  hemorrhage  or  of  softening. 

The  results  of  this  examination,  then, as  I  have  told  you  already,  are  in 
contradiction  to  what  Dr.  Gubler  has  taughl  us  on  the  relations  between 
alternate  hemiplegia  and  lesions  of  the  pons.  For  in  this  ease — which  was, 
it  is  true,  anomalous   (since   the   phenomena  observed   during   Life   did   not 

correspond  regularly  with  the  organic  alterations  found  after  death) — the 

pons    presented    no    appreciable    sign    of    disease,    however    carefully    we 


CROSS-PARALYSIS,   OR    ALTERNATE    HEMIPLEGIA.  893 

examined  it.  As  no  such  lesions  were  found,  it  has  been  doubted  by  some 
that  there  had  been  cross-paralysis;  and  it  has  been  asked  whether  I  had 
not  made  a  mistake  as  to  the  side  of  the  face  which  was  paralyzed,  and 
whether  I  had  not  mistaken  contraction  of  the  muscles  of  the  right  side  of 
the  face  for  paralysis  of  the  left  side.  The  objection,  I  admit,  was  all  the 
more  founded  that  the  softening  of  the  right  facial  nerve  did  not  harmonize 
with  the  retention  of  motor  power  on  the  corresponding  side  of  the  face. 
But  my  answer  is,  that  however  obscure  and  inexplicable  the  facts  may  be, 
I  have"  no  doubt  in  my  own  mind  that  the  case  wras  not  one  of  contraction 
of  the  right  side,  but  of  left  facial  paralysis  (the  left  cheek  being  more 
flaccid  than  the  right),  and  that  this  coincided  with  paralysis  of  the  right 
limbs ;  lastly,  that  whatever  the  other  lesions  of  the  brain  might  be,  the 
pons  Varolii  showed  no  trace  of  disease. 

Although  I  admit  that  a  rigorous  conclusion  cannot  be  drawn  from  an 
exceptional  case,  full  of  anomalies  and  of  obscurity,  it  would  yet  seem  that 
the  law  laid  down  by  Dr.  Gubler  is  not  so  absolute  as  he  has  asserted. 
Those  among  you  w7ho  have  read  the  two  interesting  memoirs  which  he  has 
published  on  this  subject,*  know  that  he  regards  cross-paralysis  as  a  sign 
of  disease  of  the  pons;  and,  localizing  still  more  specially  the  seat  of  the 
anatomical  change,  he  places  it  in  the  bulbous  portion  of  the  pons.  Hence, 
this  particular  form  of  hemiplegia  is,  according  to  him,  explained  in  the 
following  manner:  As  the  lesion  involves  the  facial  nerve  after  its  decus- 
sation, the  face  is  paralyzed  directly,  while  the  parts  that  are  supplied  by 
nerves  from  the  spinal  cord  are  paralyzed  in  a  crucial  manner,  the  decussa- 
tion of  the  anterior  pyramids  taking  place  below  the  pons  only. 

I  am  far  from  denying  the  value  of  the  reasons  urged  by  Dr.  Gubler  in 
support  of  his  position.  The  cases  which  he  brings  forward,  and  discusses 
with  great  talent,  are  sufficiently  imposing  in  number  and  of  undoubted 
value ;  but  yet  I  cannot  refrain  from  thinking  that  the  law  which  he  has 
laid  down  is  too  absolute.  Setting  aside  the  case  of  the  woman  in  St.  Ber- 
nard Ward,  T  shall  find  in  Dr.  Gubler's  memoirs  themselves  arguments  in 
favor  of  my  opinion;  for  when  he  comes  to  the  differential  diagnosis  of 
cross-paralysis,  and  what  'he  terms  false  cross-paralysis  (namely,  cases  in 
which  there  is  more  than  one  cerebral  lesion),  Dr.  Gubler  meets  with 
embarrassing  cases,  which  he  tries  to  explain  by  hypotheses  which  cannot 
be  demonstrated.  Such,  for  instance,  are  Cases  XII  and  XVI  of  his 
second  memoir.  In  both  of  these  the  paralysis  involved  the  right  side  of 
the  face  and  the  left  limbs,  and  had  set  in  after  a  ligature  had  been  put 
round  the  right  common  carotid  artery.  The  first  of  these  cases  was  pub- 
lished by  Professor  Sedillot,  of  Strasburg,  in  the  "Gazette  Medicale  de 
Paris,"  for  September  3,  1842.  A  post-mortem  examination  disclosed 
softening  of  the  right  hemisphere  of  the  brain,  while  the  pons  is  not  men- 
tioned. Dr.  Gubler  analyses  these  cases,  and  justly  rejects  the  explanation 
of  the  facial  paralysis  given  by  Professor  Sedillot — namely,  that  it  was 
owing  to  the  facial  nerves  supplying  directly  the  side  of  the  face  correspond- 
ing to  that  of  their  origin.  Although  the  decussation  of  the  nerves  of  the 
seventh  pair  is  not  regarded  as  proved  by  all  anatomists,  since  M.  Sappey 
has  never  been  able  to  see  it,  in  spite  of  the  most  minute  dissections,  the 
fact  is  admitted,  and  has  been  ascertained  by  Professor  Jobert  (de  Lam- 
balle),  by  Messrs.  Vulpian  and  Philippeaux,  and  by  Stilling,  although  the 
last  three  state  that  the  decussation  is  not  complete.     Besides,  the  fact  that 

*  "  De  l'Hemiplegie  alterne  envisaged  comme  signe  de  lesion  de  la  protuberance 
annulaire,"  &c.  (Gaz.  Hebd.  de  Med.  et  de  Chir.,  Paris,  1856),  et  "  Memoire  sur 
les  Hemiplegies  alternes,"  (in  idem,  1859). 


894  CROSS-PARALYSIS,    OR    ALTERNATE    HEMIPLEGIA. 

in  most  cases,  paralysis  of  cerebral  origin  affects  the  face  and  limbs  on  the 
same  side,  tends  to  prove  the  existence  of  a  decussation.  But  if  Professor 
Bedillot's  interpretation  be  faulty,  Dr.  Gubler's  may  also  raise  objections. 
The  arrest  of  the  flow  of  blood  consequent  on  ligaturing  the  common  carotid 
is  not,  to  my  mind,  sufficient  to  explain,  as  my  colleague  thinks,  the  impair- 
ment of  motion  and  sensation  which  occurred  in  the  corresponding  side  of 
the  face.  No  one  surely  denies  the  existence  of  paralysis,  or  rather  of 
varieties  of  paralysis,  due  to  an  arrest  of  the  arterial  or  venous  circulation; 
but  such  paralysis  is  seen  in  the  limbs  only,  not  in  the  face,  in  which  there 
are  large  and  numerous  anastomoses  between  the  divisions  of  the  two 
carotid  arteries,  which  easily  permit  of  a  supplementary  circulation. 

The  second  case  is  that  of  an  individual  in  whom  both  common  carotid 
arteries  were  ligatured  successively,  at  an  interval  of  twenty-eight  years, 
for  a  circoid  aneurism  of  the  head.  The  first  ligature  was  placed  round 
the  right  common  carotid  by  Dupuytren,  and  no  accident  followed  ;  the 
second  time,  the  left  artery  was  tied  by  M.  Eobert.  "The  result  of  the 
operation  was  as  satisfactory  as  possible ;  there  was  some  mental  excite- 
ment only,  and  the  patient  insisting  on  returning  home,  he  had  to  be  dis- 
charged two  or  three  days  afterwards.  The  joy  he  felt  at  finding  himself 
again  among  his  friends  produced  still  greater  exaltation,  and  brought  on 
delirium,  which  was  soon  followed  by  well-characterized  paralysis  of  the 
right  half  of  the  face  and  the  left  side  of  the  body.  Death  took  place 
shortly  afterwards,  and  a  post-mortem  examination  could  not  be  made." 

In  this  case  Dr.  Gubler  does  not  explain  the  facial  paralysis  by  the  de- 
fective circulation  resulting  from  the  obliteration  of  the  artery,  as  the 
paralysis  involved  the  opposite  side  of  the  face  to  that  on  which  the  artery 
was  tied  ;  but  in  order  to  make  the  facts  fit  in  with  his  theory,  he  says ; 
"After  the  right  common  carotid  had  been  tied,  the  circulation  of  the 
blood  was  re-established  in  the  corresponding  hemisphere,  through  the 
carotid  of  the  opposite  side,  by  means  of  the  communicating  artery  of 
Willis,  and  through  the  vertebral  of  the  same  side,  which  necessarily  in- 
creased in  size  from  the  innominate  retaining  its  capacity  and  from  the  ex- 
pansive force  of  the  blood-current,  which  no  longer  found  a  wide  passage 
through  the  carotid,  tending  of  necessity  to  dilate  the  vertebral  and  the 
subclavian.  Now,  it  may  be  presumed  that  the  vertebral  could  not  be  thus 
distended  without  its  walls  being  at  the  same  time  altered,  or  the  walls  of 
the  basilar,  which  is  its  continuation.  This  is  all  the  more  probablt  that 
aneurismal  dilatation,  or  at  least  atheromatous  and  calcareous  changes  of 
the  coats  of  these  vessels,  are  of  more  frequent  occurrence  than  of  other  in- 
tracranial arteries.  The  nutrition  of  the  substance  of  the  brain  had,  perhaps, 
also  undergone  some  modification,  which  rendered  the  organ  more  Liable  t<> 
he,-,, me  the  <eat  of  hemorrhage.  The  left  carotid  being  tied  under  these 
circumstances,  the  blood  can  only  (low  through  the  two  vertebral  arteries, 
the  wall-  of  which  are  therefore  subjected  to  a  relatively  enormous  pressure. 
The  left  vessel,  which  ha-  healthy  coats  resists  successfully ;  whereas  the 
right  ruptures,  the  rupture  involving  either  the  trunk  of  the  artery,  or  one 
of  its  branches,  on  the  surface  or  in  the  substance  of  the  righl  half  of  the 
pons  near  the  medulla  oblongata.  'Idie  inevitable  resull  of  this,  in  our 
opinion,  is  paralysis  of  the  righl  half  of  the  fac,  and  of  the  upper  and 
lower  Limbs  on  the  left  side."  You  Bee,  gentlemen,  thai  however  ingenious 
these  explanations  may  he,  they  an'  merely  conjectures;  and  that,  instead 
of  drawing  his  conclusions  from  observation,  I  >r.  <  hibler  make-  observation 

tit  iu  with  his  views. 

Of  course  those  cases  alone  are  in  question  in  which  the  cross-paralysis 

of  the  face  and  limbs  is  due  to  one  Lesion  only,  for  it  i-  conceivable  (and 


FACIAL    PARALYSIS,   OR    BELL'S    PARALYSIS.  *('."> 

Dr.  Gubler  has  called  attention  to  the  fact)  that  cross-paralysis  may  be 
caused  by  several  lesions  affecting  different  parts  of  the  brain — a  hemi- 
sphere on  one  side,  and  the  facial  nerve  on  the  opposite  side.  But  Dr. 
Gubler  does  not  apply  the  term  "cross-paralysis"  to  such  cases,  and  con- 
fines it  to  those  in  which  there  is  a  single  lesion.  But  although  I  do  justice 
to  my  colleague's  essay,  and  acknowledge  that  science  is  indebted  to  him 
for  having  been  the  first  to  call  attention  to  interesting  facts,  and  although 
I  admit  also  that  cross-paralysis  is  often  caused  by  a  lesion  of  the  pons 
Varolii,  as  the  cases  which  he  has  published  show,  I  think  that  it  is  carry- 
ing generalization  too  far,  when  this  form  of  hemiplegia  is  regarded  as  an 
absolute  sign  of  a  lesion  of  the  pons.  The  explanation  of  this  singular  form 
of  paralysis  escapes  us  in  some  cases,  and,  after  all,  the  same  thing  happens 
in  a  good  many  cerebral  diseases  which  are  still  so  very  obscure. 


LECTURE  L. 

FACIAL  PARALYSIS,  OR  BELL'S  PARALYSIS. 

Facial  Hemiplegia:  its  Causes  and  Symp>toms. —  Contraction  of  the  Muscles 
consecutive  to  Paralysis  of  one  side  of  the  Face  may  he  mistaken  for 
Paralysis  of  the  opposite  side. — Treatment. — Double  Facial  Paralysis. 

Gentlemen  :  Facial  paralysis  is  an  affection  which  is  often  met  with 
in  practice,  and  although  it  is  in  general  of  no  gravity,  yet  treatment, 
unfortunately,  fails  too  often  to  cure  it.  However  mild  the  disease  may  be 
in  the  majority  of  cases,  it  sometimes  excites  singular  alarm  in  the  patients 
and  those  around  them  ;  and  it  is  all  the  more  important  that  the  physician 
should  know  well  how  to  recognize  it,  that  it  still  pretty  frequently  gives 
rise  to  lamentable  errors  of  diagnosis.  In  order  to  put  you  on  your  guard 
against  such  mistakes,  I  wish,  in  this  conference,  to  call  your  attention  to 
some  special  points  relating  to  this  subject,  apropos  of  two  individuals  suf- 
fering from  this  paralysis,  whom  you  have  seen — one  in  St.  Agnes  Ward, 
and  the  other  in  the  neighboring  ward  of  St.  Louis. 

The  young  man  in  St.  Louis  Ward  is  17  years  old.  He  tells  us  that, 
through  his  being  prevented  from  working  by  a  slight  wound  in  his  hand, 
he  spent  his  time  in  the  streets  and  in  public  promenades ;  that  on  Monday 
last  he  slept  in  the  open  air  on  a  heap  of  pebbles ;  that  he  was  in  a  state  of 
perspiration  at  the  time,  and  got  cold  after  falling  asleep.  He  went  home 
in  the  evening,  feeling  uncomfortable.  The  next  morning,  however,  he 
got  up,  as  usual,  feeling  absolutely  no  disturbance  of  his  health  ;  but  when 
he  began  to  eat,  he  felt  something  peculiar,  and  had  some  difficulty  in 
masticating.  When  his  food  got  between  his  right  cheek  and  his  teeth,  he 
was  compelled  to  squeeze  the  cheek  with  his  hand,  so  as  to  push  the  food 
between  his  teeth  again.  He  was  surprised  at  this,  and  could  not  account 
for  it,  as  it  was  unaccompanied  by  any  painful  sensation.  He  felt  more 
surprised  when  one  of  his  friends,  on  seeing  him,  told  him  that  his  mouth 
was  awry,  and  that  it  became  considerably  more  so  whenever  he  laughed. 
On  then  looking  at  himself  in  a  glass,  he  verified  the  fact,  and  feeling 
frightened,  came  to  the  hospital  to  be  cured. 


896  FACIAL    PARALYSIS,    OR    BELL'S     PARALYSIS. 

The  following  points  I  ascertained  myself:  "When  the  patient's  face  is  at 
rest,  the  right  side  merely  looks  slightly  flatter,  and  more  flaccid  than  the 
left ;  his  right  eye  is  also  more  widely  open  than  the  left,  but  his  physiog- 
nomy, after  all,  does  not  look  strange.  "When  he  speaks,  and  still  more 
when  he  laughs,  the  left  angle  of  his  mouth  is  immediately  drawn  upwards 
and  outwards,  while  the  right  one  is  perfectly  motionless.  As  the  eyelids, 
the  cheek,  and  the  lips  are  motionless  also,  the  face  has  in  consequence  a 
singular  expression,  especially  when  the  patient  tries  to  contract  his  muscles. 
The  eyelids  being  motionless  on  the  right  side,  the  right  eye  cannot  be 
completely  closed;  but  the  globe  of  the  eye  itself  moves  perfectly,  at  the 
patient's  will,  to  the  right  or  to  the  left,  upwards  or  downwards.  Sight  is 
in  nowise  altered.  The  motor  muscles  of  the  eye  are  not  therefore  in  the 
least  at  fault,  and  the  paralysis  (for  there  is  paralysis  present)  affects  ex- 
clusively the  orbicularis  palpebrarum,  without  involving  the  levator  palpe- 
bral superioris. 

When  the  patient  is  asked  to  put  out  his  tongue,  he  does  so  with  perfect 
regularity ;  and  the  difficulty  which  he  has  in  articulating  certain  words 
is  not  owing  to  defective  action  of  the  muscles  of  that  organ,  but  to  the 
immobility  of  the  right  cheek.  On  examining  the  fauces,  it  is  evident 
that  the  double  arch  formed  by  the  pillars  of  the  soft  palate  and  the 
mouth  has  not  on  both  sides  the  regular  form  which  it  normally  has,  for 
the  left  arch  is  narrower  than  the  right,  showing  that  the  uvula  inclines  to 
the  left. 

I  have  told  you  how  the  complaint  originated.  Save  a  few  hours  of 
malaise,  the  patient  has  never  felt  any  general  disturbance,  or  the  slightest 
headache;  nay ,_ more,  he  states  that  he  has  never  felt  better,  and  that  his 
appetite  is  twice  as  good  as  formerly.  I  do  not,  of  course,  attach  great  im- 
portance to  what  he  says,  because  he  is  doubtless  prompted  by  the  fear  of 
being  put  on  too  strict  a  diet.  This  circumstance  is  sufficient,  however,  to 
show  that  there  has  never  been  any  disturbance  of  his  health,  and  that  his 
complaint  consists  merely  in  a  motor  affection  of  the  muscles  of  the  face, 
the  cutaneous  sensibility  of  which  is  in  nowise  perverted.  As  to  other  loco- 
motor apparatus  (the  limbs,  for  example),  their  functions  are  discharged 
perfectly.  The  case,  then,  is  one  of  that  form  of  paralysis  which  has  been 
named  Bell's  parahj.<i«. 

In  the  case  of  the  other  man,  who  occupies  one  of  the  first  beds  in  St. 
Agnes  "Ward,  the  paralysis  of  the  face  occurred  under  different  circum- 
stances. His  health  has  been  generally  good,  and  he  was  smoking  his 
pipe  at  a  window  during  the  heavy  storm  which  burst  over  Paris  a  few 
days  ago.  A  sudden  and  violent  thunderclap  in  the  neighborhood  Bright- 
ened him  very  much,  but  laughing  at  his  terror,  he  soon  resumed  his  place 
at  the  window,  and  went  on  smoking;  but  he  perceived  that  he  had  some 
difficulty  in  spitting  out,  and  a  few  moments  afterwards  lus  wife  noticed 
that  his  face  was  distorted.  As  a  few  days  elapsed  without  this  distortion 
disappearing,  lie  felt  anxious  about  it,  and  came  to  the  Hdtel-Dieu.  In 
this  case,  then,  mental  emotion,  intense  fright,  brought  on  the  same  com- 
plaint as  cold  did  in  the  case  of  the  young  man  in  St.  Louis  Ward.  In 
both  these  men  paralysis  of  one  side  of  the  lace  set  in,  impairing  movement 
alone,  and  involving  exclusively  the  muscles  supplied  by  one  of  the  seventh 
pair  of  nerve-.  These  two  cases  are  instances  of  that  kind  of  facia]  hemi- 
plegia which  has  been  termed  idiopathic,  in  the  language  of  schools  ;  mean- 
ing thereby  that  the  complaint  occurs  independently  of  all  appreciable  ma- 
terial, traumatic  lesion,  whether  inflammatory  or  not,  affecting  the  facial 
nerve  primarily  or  Becondaiily. 


FACIAL    PARALYSIS,    OR    BELL'S    PARALYSIS.  897 

I  shall  dow  rapidly  review  the  different  causes  under  the  influence  of 
which  facial  paralysis  may  occur. 

Cold  is  one  of  the  most  frequent  of  these,  and  it  would  not  he  difficult  to 
collect  a  great  number  of  cases  analogous  to  our  first  one,  for  this  kind  of 
paralysis  has  for  a  long  time  been  spoken  of  by  authors  under  the  name  of 
rheumatic  parqlysis.  The  patient  is  seized  in  the  midst  of  the  most  perfect 
health,  without  there  being  any  disturbance  of  the  general  economy :  a 
mere  draught,  residence  in  a  damp  place,  or  in  a  newly-built  house,  may 
bring  it  on. 

You  have  seen  that  mental  emotion  may  cause  it,  as  in  the  case  of  the 
patient  in  St.  Agnes  Ward,  who  was  greatly  frightened.  In  others,  the 
paralysis  came  on  after  a  violent  fit  of  anger,  and  in  others  again,  after 
some  profound  grief,  caused,  for  instance,  by  the  unexpected  death  of  a 
dear  friend.  Sometimes,  also,  the  disease  cannot  be  ascribed  to  any  ap- 
preciable cause. 

In  all  the  cases  in  which  it  is  not  owing  to  the  presence  of  an  appreci- 
able material  lesion,  the  disease  sets  in  suddenty ;  and  the  same  thing 
happens  when  the  paralysis  results  from  traumatic  lesions  of  the  nerve. 

You  know,  gentlemen,  that  it  is  not  of  uncommon  occurrence  to  meet 
with  facial  paralysis  in  newly-born  children,  and  that  it  is  sometimes  mis- 
taken by  careless  persons  for  a  symptom  of  cerebral  disease.  This  paralysis, 
which  is  due  to  the  compression  by  the  forceps  of  the  facial  nerve  as  it 
emerges  from  the  aqueductus  fallopii,  is  generally  transitory  and  of  no 
gravity  whatever ;  when  the  compression,  however,  has  been  excessive,  it 
may  persist  through  life. 

Your  professors  of  surgery  have  pointed  out  to  you  this  traumatic  cause 
of  facial  hemiplegia,  and  they  have  also  taught  you  that  this  paralysis 
could  be  the  consequence  of  wounds  of  the  seventh  pair,  inflicted  either  by 
accident  or  during  a  surgical  operation. 

This  form  of  paralysis  may  result  also  from  a  fracture  of  the  skull,  involv- 
ing that  part  of  the  temporal  bone  in  which  lies  the  aqueductus  fallopii. 

In  all  these  cases  the  paralysis,  I  repeat,  occurs  suddenly.  But  there 
are  instances  in  which  it  comes  on  slowly  and  by  degrees — namely,  when 
it  is  the  consequence  of  a  lesion  which  affects  the  facial  nerve  secondarily, 
as  when  some  organic  alteration  in  its  neighborhood  after  a  time  compresses 
the  nerve  in  some  part  of  its  course,  or  alters  its  structure. 

You  know  the  course  and  distribution  of  the  seventh  nerve.  You  know 
how,  emerging  from  the  lateral  column  of  the  cord  just  as  this  column 
passes  under  the  pons,  it  enters  the  internal  auditory  meatus,  goes  through 
the  flexuous  canal  of  the  aqueductus  fallopii,  and  comes  out  of  the  skull 
through  the  stylo-mastoid  foramen;  and  how  it  then  gives  off  several  small 
branches — the  posterior  auricular,  stylo-hyoidean,  and  infra-mastoidean — 
and  then  divides  into  two  branches,  the  cervico-facial  and  temporo-facial. 
Now,  before  it  enters  the  temporal  bone,  and  after  it  has  issued  from  it, 
this  nerve  is  sometimes  involved  in  tumors,  which,  whether  they  be  devel- 
oped inside  the  cranial  cavity  or  in  the  region  of  the  parotid,  may  compress 
or  disorganize  it.  It  is  far  from  being  safe  from  all  accident  while  it  trav- 
erses the  temporal  bone ;  necrosis  or  caries,  and  sujjpuration  of  that  portion 
of  the  temporal  bone,  may  bring  on  destruction  of  the  nerve  and,  as  a  con- 
sequence, paralysis  of  the  parts  which  it  supplies.  Several  instances  of  this 
have  come  under  my  notice — one,  among  others,  in  a  boy  seventeen  months 
old,  who  died  in  one  of  my  wards  at  the  Necker  Hospital,  and  whose  case 
was  published  in  the  "Bulletin  General  de  Therapeutique"  for  January, 
1847. 

From  what  I  have  just  told  you,  gentlemen,  you  may  foresee  that  your 
vol.  i. — 57 


898  FACIAL    PARALYSIS,   OR    BELL'S    PARALYSIS. 

prognosis  should  not  be  favorable  in  every  case  of  Bell's  paralysis.  I  will 
add  that,  in  some  very  rare  instances,  this  affection  is  due  to  a  cerebral 
lesion.  Graves  states  that  he  has  twice  seen  paralysis  exclusively  limited  to 
the  face  in  small  cerebral  hemorrhages  ;  and  my  colleague  in  the  hospitals, 
Dr.  Duplay,  has  recorded  several  cases  of  the  same  kind  in  a  very  remark- 
able memoir.  Graves  makes  the  remark  that  paralysis  which  is  thus  local- 
ized is  not  very  extraordinary,  since  cerebral  hemorrhage  pretty  frequently 
manifests  itself  only  by  paralyzing  the  tongue  or  one  arm.  I  have  very 
frequently  met  with  individuals  in  whom  there  had  evidently  been  a  very 
limited  extravasation  of  blood,  and  whose  features  were  considerably  dis- 
torted, although  they  did  not  complain  of  weakness  in  the  limbs  of  the 
same  side.  It  must  be  added,  however,  that  when  such  patients  are  ex- 
amined with  great  care,  when  they  are  asked  to  get  up  and  walk,  there 
may  be  perceived  a  certain  hesitation  in  the  movements  of  their  leg  of 
which  they  are  not  conscious  ;  and  if  their  strength  be  tested  by  means  of 
Burq's  dynamometer,  it  is  found  that  the  pressure  made  on  the  instrument 
by  the  hand  on  the  same  side  as  the  paralysis  of  the  face,  is  evidently  less 
than  that  made  by  the  other  hand.  I  am  therefore  very  much  disposed  to 
believe  that  the  illustrious  Dublin  physician  has  not  had  recourse  to  the 
various  tests  which  I  have  just  mentioned  in  the  case  of  the  two  individuals 
whose  history  he  relates  very  concisely.  As  to  the  instances  recorded  by 
Dr.  Duplay,  they  have  not  convinced  me ;  and  it  seems  to  me  that  in  the 
first  two  cases,  which  he  gives  as  typical  ones,  there  had  been  at  separate 
periods  Bell's  paralysis  and  cerebral  hemorrhage,  diseases  which  by  no 
means  exclude  one  another. 

But  does  it  never  happen  that  a  cerebral  lesion  produces  facial  paralysis 
presenting  the  characters  of  Bell's  paralysis  ?  There  are  cases  of  the  kind, 
as,  for  instance,  in  lesions  of  the  pons  Varolii,  as  M.  Vulpiau's  experiments 
have  conclusively  shown.  He  found  that  a  very  slight  wound  of  the  fourth 
ventricle  produced  paralysis  of  the  face  having  all  the  characters  of  Bell's 
paralysis,  even  those  indicated  by  M.  Duchenne  (de  Boulogne) — namely, 
the  absence  of  all  electric  excitability  of  the  muscles  supplied  by  the 
seventh  pair.  It  is  conceivable,  therefore,  that  if  a  small  hemorrhage 
occurred  in  a  very  limited  spot  of  the  pons,  it  could  give  rise  to  the  symp- 
toms of  Bell's  paratysis  exclusively.  But  such  cases  are  so  very  rare  that, 
in  the  course  of  a  very  long  practice,  I  have  not  yet  met  with  a  single 
instance  of  the  kind.  On  the  contrary,  it  pretty  frequently  happens,  as  I 
was  telling  you  just  now,  that  in  cerebral  hemorrhage  without  lesion  of  the 
pons  Varolii,  there  is  predominating  paralysis  of  the  muscles  of  the  face, 
simulating  Bell's  paralysis.     Let  us  try  then  and  distinguish  them. 

Now,  there  is  a  capital  point  of  distinction,  of  which  I  have  already  told 
you,  and  on  which  I  cannot  insist  too  much — namely,  paralysis  of  the 
orbicularis  palpebrarum.  However  complete  hemiplegia  of  cerebral  origin 
may  be,  I  have  never  seen  complete  paralysis  of  the  orbicularis  palpebrarum; 
the  eye  can  always  be  closed;  whilst  in  Bell's  palsy,  paralysis  of  the  orbicu- 
laris palpebrarum  is  never  absent,  ami  the  eye  cannot  be  completely  closed. 
Dr.  Gazalis,  physician  to  the  Salpetrierc,  has  like  me  paid  attention  t<»  this 
point  of  symptomatology,  and  he  declares  that  he  has  never  seen    a   single 

case  of  cerebral  hemorrhage  or  Boftening,  in  which  the  patient  was  unable 
to  close  his  eye  on  the  affected  side,  however  grave  the  paralysis  mighl  be. 

Yet,  in  -mill'  exceptional  cases,  all  the  branches  of  the  facial  nerve  are  not 
affected  (those,  for  example,  which  supply  the  muscles  of  the  eyelids  may 
escape  i,  so  that  the  symptom  which  I  just  now  pointed  out  to  you  is  some- 
times absent.  In  su<h  cases  One  should  have  recourse  to  the  sign  mentioned 
by  Duchenne,  to  which  I  alluded  just  now,  and  which  has  been  confirmed 


FACIAL    PARALYSIS,    OR    BELL'S    PARALYSIS.  899 

by  Yulpian's  experiments.  In  facial  paralysis  of  cerebral  origin,  the  mus- 
cles respond  normally  to  electric  irritation,  whilst  their  contractility  is  not 
at  all  or  scarcely  at  all  roused  by  an  electric  current,  if  the  paralysis  be 
owing  to  an  injury  to  the  seventh  pair. 

In  cases  of  severe  chronic  otitis,  with  destruction  of  the  tympanum  and 
ossicula,  it  is  not  uncommon  to  find  the  petrous  portion  of  the  temporal 
bone  in  a  great  part  carious,  and  to  see  facial  paralysis  come  on.  Whilst  I 
was  physician  to  the  scrofula  wards  in  the  Hospital  for  Sick  Children,  I 
have  often  pointed  out  to  the  pupils  who  went  round  with  me  the  relations 
between  chronic  diseases  of  the  internal  ear  and  Bell's  paralysis.  But  the 
disease  does  not,  unfortunately,  confine  itself  to  destroying  the  facial  nerve 
in  its  passage  through  the  aqueductus  fallopii ;  it  attacks  the  cranial  surface 
of  the  petrous  portion,  and  on  the  pus  raising  and  then  perforating  the 
dura  mater,  abscesses  are  formed  in  the  base  of  the  skull,  and  purulent 
infiltrations  of  the  arachnoid  result,  to  which  Abercrombie  and  Hamilton 
were  the  first  to  call  the  attention  of  practitioners.  Those  are  terrible  acci- 
dents, which  perhaps  never  spare  life,  as  you  saw  last  year  so  sad  an  in- 
stance in  the  patient  at  jSTo.  30  in  St.  Bernard  Ward. 

In  some  cases  the  pus  makes  its  way  even  into  the  spinal  cavity;  and  I 
cannot  help  quoting  to  you,  in  reference  to  this  point,  the  history  of  a  boy, 
ten  years  old,  who  was  attended  by  Dr.  Graves  (of  Dublin) : 

"A  boy,  about  ten  years  old,  was  admitted  into  the  Meath  Hospital, 
laboring  under  general  dropsy.  He  appeared  of  a  scrofulous  habit,  and 
was  much  worn  down  by  long-continued  diarrhoea.  Under  appropriate 
treatment  his  symptoms  gradually  but  slowly  disappeared,  and  he  was 
restored  to  comparative  health.  We  now  observed  that  the  right  side  of 
the  face  was  affected  with  paralysis,  and  on  examination  found  that  he  had 
been  subject  to  a  discharge  from  the  right  ear  for  seven  years  previously. 
The  paralyzed  cheek  presented  the  phenomena  usually  observed  in  'Bell's 
paralysis.'  He  was  attacked  soon  after  with  acute  pain  in  the  ear,  and  in 
the  left  side  of  the  head  ;  a  fortnight  after,  convulsions  set  in ;  the  pain 
moved  from  the  side  to  the  back  of  the  head,  then  to  the  back  of  the  neck, 
and  ultimately  extended  the  whole  way  down  the  spine,  and  about  this 
period  the  otorrhoea  diminished.  A  few  days  before  death  he  was  attacked 
with  spasms  resembling  those  of  tetanus,  and  the  surface  of  the  body  became 
exquisitely  tender  to  the  touch.  He  never  had  any  loss  of  motion,  and  to  the 
last  his  intellect  was  perfect. 

"  From  the  period  when  the  pain  set  in  to  that  of  his  death,  the  convul- 
sions returned  about  six  times. 

"  Post-mortem. — The  portio  dura  was  dissected  on  the  face,  and  found 
healthy  ;  the  nerve  was  also  healthy,  from  its  origin  at  the  base  of  the  brain 
to  its  entrance  at  the  meatus  auditorius  ;  immediately  above  this  opening 
the  dura  mater  was  of  a  greenish  color,  detached  from  the  bone,  as  if  by 
fluid,  and  perforated  by  a  round  hole,  large  enough  to  admit  a  small  crow- 
quill.  On  dividing  this  part  of  the  membrane,  the  space  between  it  and 
the  bone  was  occupied  by  a  thick,  greenish,  and  offensive  pus,  and  the  open- 
ing in  the  dura  mater  was  observed  to  lie  exactly  opposite  the  foramen  in 
the  petrous  portion  of  the  temporal  bone,  called  the  aqueductus  vestibidi; 
this  opening  was  much  enlarged,  and  the  bone  around  it  was  in  a  carious 
condition.  The  nerves  at  the  base  of  the  brain  were  bathed  in  this  thick 
green  pus,  but  the  organ  itself  was  everywhere  healthy,  and  free  from  any 
excess  of  vascularity.     The  spinal  arachnoid  was  also  filled  with  the  same 

kind  of  matter,  but  the  spinal  cord  itself  presented  no  trace  of  disease."* 

_ \ 

*  Graves's  "Clinical  Lectures,"  vol.  i,  p.  569. 


900  FACIAL    PARALYSIS,    OR    BELL'S    PARALYSIS. 

The  symptoms  of  facial  paralysis  vary  according  as  the  lesion  to  which  it 
is  due  is  seated  at  a  more  or  less  distant  point  from  the  origin  of  the  seventh 
pair.  But,  whatever  be  the  seat  of  the  lesion,  the  patient's  physiognomy 
wears  a  strange  aspect,  which  is  perfectly  characteristic. 

Even  in  the  state  of  repose,  there  is  a  striking  want  of  symmetry  between 
the  two  halves  of  the  face,  owing  to  the  absence  of  antagonism  in  the  muscles, 
which  give  regularity  to  the  features  through  their  co-ordinate  contraction. 
The  sound  cheek  looks  wrinkled  and  shortened ;  the  labial  commissure  on 
that  side  is  drawn  outwards  and  upwards,  and  is  on  a  higher  level  than  the 
opposite  one.  When  the  paralysis  is  very  marked,  the  commissure  on  the 
affected  side  remains  half-open,  and  the  saliVa  escapes  constantly  through  it. 

Moreover,  the  cheek  is  flaccid  from  paralysis  of  the  buccinator  muscle, 
and  yielding  in  forced  expiration  to  the  pressure  of  the  air  exerted  from 
within  outwards,  it  swells  out  and  then  falls  down  flapping,  like  a  curtain 
as  it  were,  in  front  of  the  rows  of  teeth  and  of  the  interval  between  them. 
Breathing  is  badly  performed  through  the  nostril  on  the  affected  side,  from 
its  no  longer  opening  as  it  does  normally,  and  remaining  more  closed  than 
it  should  be  and  than  it  indeed  is  on  the  sound  side,  towards  which  the  tip 
of  the  nose  is  slightly  drawn.  The  eye  is,  on  the  contrary,  more  widely 
open,  although  the  eyebrow  is  lowered,  from  the  corrugator  supercilii  being- 
paralyzed  and  unable  to  keep  it  up :  the  eye  looks  also  larger  and  more 
prominent  than  its  fellow.  The  lower  lid  is  everted  and  depressed,  whilst 
the  upper  lid,  being  now  under  the  influence  of  its  elevator  muscle  alone, 
is  drawn  up  and  maintained  in  that  position.  In  a  pretty  good  number  of 
cases,  there  is  a  constant  flow  of  tears,  and  the  epiphora — which  is  all  the 
more  copious  that  the  irritation  of  the  conjunctiva  causes  the  lachrymal 
gland  to  secrete  more  abundantly — is  due  partly  to  the  fact  that  the  lower 
lid  no  longer  forms  a  canal  for  the  tears,  and  partly  (but  chiefly)  to  pa- 
ralysis of  that  portion  of  the  orbicularis  which  forms  Horner's  muscle.  The 
lachrymal  puncta,  which  it  is  the  office  of  this  muscle  to  pull  inwards  and 
to  make  prominent,  can  no  longer  assume  that  position,  and  therefore  no 
longer  receive  the  tears  which  do  not  find  their  way  into  their  normal 
channels. 

Dangerous  consequences  to  the  organ  of  sight  may  result,  in  facial  paral- 
ysis, from  the  absence  of  winking,  as  sometimes  happens  in  grave  fevers 
from  the  same  cause.  For  you  are  aware  that  three  sets  of  nerves  partici- 
pate in  the  act  of  winking:  (a)  branches  of  the  fifth  pair,  which  are  sen- 
sory, and  give  rise  to  the  sensation  of  the  want  of  winking;  (6)  branches  of 
the  seventh,  which  are  motor  and  preside  over  the  contraction  of  the  orbic- 
ularis muscle,  and  consequently  over  the  closure  of  the  eyelids;  and  in 
lastly,  branches  of  the  third  pair,  the  motor  occuli  communis,  which  pre- 
sides over  the  contraction  of  the  levator  palpebrse  superioris,  the  muscle 
which  opens  the  eyes.  The  use  of  winking  is  to  protect  tin'  globe  of  the 
eye  against  any  external  injury,  and  especially  to  spread  over  its  surface 
the  tears,  which  lubricate  the  membranes  that  enter  into  its  composition 
and  preserve  their  limpidity.  Now,  as  soon  as  a  lesion  of  the  facial  nerve 
brings  on  paralysis  of  the  orbicularis,  the  patient  can  no  longer  wink,  and 
hence  his  tears  are  no  longer  spread  over  the  surface  of  the  globe  of  the 
eye,  or  are  only  imperfectly  spread  :  besides,  from  its  remaining  constantly 
open,  the.  eye  is  exposed  to  (he  irritating  action  of  tin' air,  and  becomes  the 
seat  of  inflammation,  which  increases  more  or  less  rapidly.  The  conjunc- 
tiva is  red  and  injected,  the  cornea  becomes  dry  and  opaque,  ulcerates,  and 
is  then  perforated,  and  the  eye  is  lost,  in  the  same  manner  as  in  grave  con- 
tinued fevers.  Tnese  dreadful  consequences  are  not  common,  however,  in 
eases  of  facial  paralysis,  because,  on  the  one   hand,  winking  is  in   part  sup- 


FACIAL    PARALYSIS,   OR    BELL'S    PARALYSIS.  901 

plied  by  the  movements  of  the  eye,  which  are  performed  by  its  intrinsic 
muscles  ;  and,  on  the  other  hand,  the  patients  instinctively  remedy  the 
absence  of  winking  by  lowering  from  time  to  time  with  their  fingers  the 
palsied  lid,  so  as  to  rub  with  it  the  surface  of  the  eye. 

When  the  patient's  face  gets  animated — when  he  speaks,  laughs,  or  tries 
to  contract  the  muscles  of  his  face,  the  deformity  characteristic  of  facial 
paralysis  becomes  considerably  more  apparent,  from  the  immobility  of 
the  palsied  side  contrasting  singularly  with  the  exaggerated  mobility  of 
the  sound  side.  The  labial  commissure  on  the  sound  side  is  pulled  up- 
wards and  outwards;  the  nostril  rises  and  opens,  the  eye  can  be  closed  at 
will,  and  the  forehead  thrown  into  wrinkles;  whilst  on  the  diseased  side, 
the  labial  commissure  remains  lowered,  the  nostril  closed,  the  forehead 
smooth. 

When  the  patient  speaks,  he  has  some  difficulty  in  pronouncing  labial 
consonants  and  vowels.  The  tongue,  however,  remains  in  general  free,  and 
is  protruded  in  its  normal  direction,  although  it  apparently  deviates,  owing 
to  the  normal  relations  between  the  two  labial  commissures  and  the  median 
line  being  lost,  in  consequence  of  which  the  apex  of  the  organ  seems  to 
point  away  from  the  median  line  on  the  side  corresponding  to  the  paralysis. 
There  are  yet  cases  in  which  the  tongue  is  paralyzed,  and  really  deviates, 
namely,  when  the  branches  which  the  facial  nerve  sends  to  the  stylo- 
glossus and  genioglossus  muscles  are  involved.  In  such  cases  there  exists, 
also,  a  peculiarity  which  several  observers  have  pointed  out,  and  which  I 
noticed  myself  in  the  case  of  the  young  man  in  St.  Louis  Ward ;  I  mean 
paralysis  of  a  portion  of  the  velum  palati  and  uvula,  and  deviation  of  the 
latter.  You  could  see,  when  you  looked  into  the  throat  of  this  patient, 
that  the  uvula  inclined  to  the  left  side  (the  facial  paralysis  was  on  the 
right  side),  so  that  the  semi-arch  comprised  between  it  and  the  pillars  of 
the  soft  palate  was  markedly  much  narrower  than  the  semi-arch  on  the 
right  side. 

Paralysis  of  the  tongue  and  soft  palate  is  an  uncommon  complication  of 
facial  paralysis  after  all,  and  can  only  be  explained  by  admitting  that  the 
lesion  of  the  seventh  nerve  is  seated  near  the  origin  of  the  nerve,  or  at  the 
very  least  before  it  bends  at  the  genu,  iu  the  aqueductus  fallopii ;  for  it  is 
at  that  part  that  the  nerve  gives  off  the  branches  which  go  to  the  spheno- 
palatine ganglion,  from  which  proceed  the  branches  destined  to  the  muscles 
of  the  soft  palate,  to  the  styloglossus,  and  the  genioglossus. 

In  consequence  of  the  paralysis  of  the  orbicularis  oris,  the  patient  can- 
not perform  certain  actions,  such  as  that  of  spitting,  or  at  least  he  has  great 
difficulty  in  spitting  to  a  certain  distance ;  and  you  may  remember  that 
this  was  the  first  symptom  which  made  the  patient  in  St.  Agnes  Ward  no- 
tice the  accident  which  had  happened  to  him.  He  could  no  longer  whistle, 
and  when  he  attempted  to  inflate  his  cheeks,  by  blowing  while  his  mouth 
was  shut,  he  could  not  keep  the  air  in,  and  it  escaped  through  his  half- 
opened  lips. 

Mastication  is  itself  impeded.  The  paralyzed  buccinator  being  unable 
to  push  back  the  food  into  the  cavity  of  the  mouth,  as  it  does  normally, 
the  food  accumulates  outside  the  row  of  teeth,  in  the  sort  of  pouch  formed 
by  the  distended  cheek,  and  the  tongue  must  constantly  go  there  after  it. 
It  frequently  happens  that  the  patient  is  even  obliged  to  use  his  fingers  in 
order  to  get  the  food  back  between  his  teeth,  or  he  supports  with  his  hand 
his  paralyzed  cheek  while  eating,  in  order  to  prevent  it  from  getting  dis- 
tended— thus  instinctively  supplying  the  place  of  the  muscle  which  no 
longer  acts. 

While  motility  is  thus  impaired,  tactile  sensibility  is  perfect  in  the  para- 


902  FACIAL    PARALYSIS,    OR    BELL  '  S    PARALYSIS. 

lyzed  parts,  although  it  occasionally  happens  that  the  sense  of  taste  is  per- 
verted on  the  side  of  the  tongue  which  corresponds  to  the  motor  paralysis. 
On  October  8,  1863,  I  was  consulted  by  a  patient  attended  by  M.  Perate. 
Two  months  previously  he  had  got  wet  through,  while  riding  outside  an 
omnibus.  A  few  days  afterwards  he  went  on  a  railway  journey,  and  the 
window  being  down,  the  left  side  of  his  face  was  exposed  to  the  wind.  On 
the  following  day  it  seemed  to  him,  when  he  ate,  that  his  food  tasted  I  to 
use  his  own  words )  like  "  salt  plaster."  After  another  day,  the  left  side  of 
his  face  was  completely  paralyzed.  The  alteration  of  the  sense  of  taste  was 
still  present  when  I  saw  the  patient,  although  to  a  less  degree. 

Is  this  perversion  of  taste  a  proof  that  the  chorda  tympani  is  a  sensory 
nerve  ?  or  is  taste  modified  only  because  this  nerve  influences  the  secretion 
of  saliva,  as  it  has  been  shown  to  do  by  Claude  Bernard,  and  any  injury 
to  it  causes  modifications  of  that  secretion,  the  utility  of  which  is  indispen- 
sable for  the  regular  action  of  the  sense  of  taste. 

Tactile  sensibility  is  not  only  preserved,  but  there  is  also,  in  some  cases, 
a  sensation  of  pain  in  the  affected  parts,  due  to  the  rheumatic  agency  under 
the  influence  of  which  the  paralysis  set  in. 

It  seems,  gentlemen,  that  there  can  be  no  possibility  of  error  in  a  case  of 
facial  paralysis,  or  that  the  whole  question  of  diagnosis  consists  merely  in 
investigating  the  causes  which  brought  on  the  complaint.  Yet  the  case  of 
a  young  woman,  lying  in  bed  No.  7,  St.  Bernard  Ward,  has  shown  you 
that  this  diagnosis  was  not  always  so  simple  as  one  would  imagine.  You 
remember  how  the  patient  to  whorn  I  allude  was  admitted  into  the  Hotel- 
Dieu  for  a  puerperal  affection,  into  the  history  of  which  I  need  not  go  here, 
and  which  was  besides  of  no  gravity.  From  the  first  day  I  saw  her,  how- 
ever, I  was  struck  Avith  the  deformity  of  her  face,  which,  at  first  sight,  sug- 
gested the  idea  of  paralysis  of  the  left  side  of  the  face ;  for  her  face  was 
distorted,  and  deviated  notably  to  the  right.  The  upper  lip  and  the  ala 
nasi  of  that  side  Avere  drawn  upwards ;  the  labial  commissure  was  pulled 
upwards  and  outwards ;  the  naso-labial  sulcus,  which  was  also  pulled  up- 
wards, was  deeper  than  normal,  whilst  the  corresponding  nostril  was  less 
open  than  the  other.  Yet  the  eye  on  that  side  looked  larger  than  the  left 
eye ;  the  under  lid  was  depressed,  and  slightly  everted  ;  and  the  tears, 
which  were  abundantly  secreted  (especially  when  the  patient  had  looked  at 
some  object),  flowed  over  the  cheek  instead  of  through  their  normal  chan- 
nel :  at  such  times,  also,  the  sight  was  somewhat  obscured. 

On  carefully  examining  the  patient's  face,  one  was  not  long  before  notic- 
ing that  there  occurred,  on  the  right  side,  slight  convulsive  movements, 
analogous  to  those  which  characterize  spasmodic  tic.  Those  movements 
were  spontaneous,  but  could  also  be  induced  by  rubbing  the  cheek  or  the 
upper  lip  with  the  tip  of  the  finger  or  a  penholder,  or  by  gently  tickling 
the  skin  of  those  parts. 

If  left  facial  paralysis  was  thought  of  at  first  sight,  the  depression  of  the 
lower  lid,  and  the  less  marked  expansion  of  the  nostril  on  the  righl  side, 
were  already  sufficient  to  cause  a  modification  of  the  diagnosis.  Bui  when 
the  patient  attempted  to  move  that  side  of  her  face,  there  could  no  longer 
be  any  hesitation,  and  it  became  manifest  that  it  was  the  right  side  which 
was  affected.  When  she  spoke,  and  still  more  when  she  laughed,  her  face 
was  pulled  with  force  to  the  left,  the  upper  lip  and  the  ala  nasi  on  that  side 
going  obliquely  upwards,  and  the  labial  coniiuissiire  being  drawn  with  con- 
siderable energy  upwards  and  outwards.  When  she  attempted  to  blow, 
her  left  cheek  swelled  out,  and  her  mouth  remained  closed  on  that  side; 
whilst  her  right  cheek  was  flaccid,  and  her  mouth  opened  .mt  a  Little  on 


FACIAL    PARALYSIS,    OR    BELL'S    PARALYSIS.  903 

that  side.     Besides,  she  could  not  shut  her  right  eye,  however  much  she 
tried. 

She  gave  us  the  following  account  of  her  case:  She  bad  had  complete 
paralysis  of  the  rigid  side  of  the  face  eight  years  previously.  It  had  sel  in 
suddenly,  subsequently  to  a  cold  caught  during  a  walk  by  the  seaside,  after 
she  had  had  a  tooth  extracted.  For  eight  months  the  application  of 
leeches  and  other  therapeutic  measures  were  vainly  tried  against  this 
affection,  which  was  accompanied  by  violent  pain  in  the  head,  and  which 
yielded  at  last  under  the  influence  of  a  treament  by  localized  electricity 
carried  on  for  four  months.  She  seemed  to  be  radically  cured.  Her  fea- 
tures had  completely  recovered  their  regularity,  when  the  new  change, 
which  attracted  my  attention,  occurred,  and  which  the  patient  stated  she 
had  perceived  of  late  only. 

Several  medical  men,  whom  she  had  consulted  since  then,  mistook,  not 
the  nature  of  the  disease,  but  the  seat  of  the  paralysis,  placing  it  on  the  left, 
whilst  it  was  undoubtedly  on  the  right ;  for  no  one  among  you  can  doubt 
that  we  have,  in  this  case,  to  deal  with  convulsion  and  contraction  of  the 
muscles  of  the  face,  consecutive  to  paralysis. 

We  could  here  suppose,  gentlemen,  but  could  not  affirm,  the  existence  of 
a  relation  between  the  facial  paralysis  and  the  convulsion  of  the  muscles 
supplied  by  the  seventh  pair,  although  this  convulsion  might  well  be  a 
coincidence  only.  Indeed,  what  Graves  has  called  spasm  of  tlie  portio  dura 
of  Bell,  or,  in  other  words,  spasm  of  the  facial  muscles,  occurring  indepen- 
dently of  all  painful  affection  and  of  all  paralysis,  is  pretty  common ;  and 
Graves  relates  a  very  curious  instance  of  it  in  his  thirty-eighth  lecture.  I 
have  often  seen  it  myself — generally,  it  is  true,  in  connection  with  neuralgia 
of  the  fifth  pair,  with  that  variety  of  neuralgia  which  I  have  termed  epi- 
leptiform, and  of  which  I  have  spoken  to  you  at  length. 

Simple  contraction  of  the  muscles  of  the  face  is  very  common  after  Bell's 
paralysis.  In  the  case  of  the  young  woman  to  whom  I  alluded  just  now, 
it  was  partial,  as  it  most  commonly  is ;  the  raised  upper  lip  and  ala  nasi, 
and  the  deviation  of  the  corresponding  labial  commissure,  indicated  that 
the  contraction  only  involved  the  orbicularis  oris,  the  zygomatici,  the  buc- 
cinator, and  the  levator  ala?  nasi  et  labii  superioris ;  whilst  the  depressed 
lower  lid,  the  less  expanded  nostril  on  the  right  side,  showed  also  that  the 
orbicularis  palpebrarum  and  the  dilator  muscle  of  the  nostril  (transversus 
pinna?)  were  still  paralyzed.  The  contraction  was,  besides,  mixed  up  with 
some  degree  of  paralysis,  as  was  shown  by  the  want  of  power  of  contracting 
at  will  the  affected  muscles. 

I  have  often  already,  and  for  a  long  time  past,  called  your  attention  to 
the  contraction  of  the  facial  muscles  which  follows  Bell's  paralysis.  There 
then  occurs  a  process  analogous  to  what  we  observe  in  other  muscles  in  cases 
of  hemiplegia  due  to  cerebral  hemorrhage  or  softening.  As  I  have  had 
occasion  to  tell  you,  when  the  hemiplegia  has  been  such  as  to  abolish  all 
movement  for  several  weeks,  it  rarely  happens  that  the  muscles  of  the  arm 
and  forearm  do  not  become  contracted  irremediably.  If  you  visit  hospitals 
for  the  aged,  you  will  be  struck  with  the  extreme  frequency  of  this  affection. 
The  forearm,  in  such  cases,  is  half-flexed  on  the  arm,  the  hand  on  the  fore- 
arm, and  the  fingers  (more  particularly  the  two  last  phalanges,  and  the 
ungual  phalanx  of  the  thumb)  are  forcibly  bent  into  the  palm  of  the  hand. 
The  contraction  is  sometimes  a  little  painful,  and  attempts  can  never  be 
made  to  overcome  it  without  causing  acute  pain,  and  the  same  result  follows 
when  the  muscular  masses  suffering  from  this  spasm  are  firmly  compressed. 
Contraction,  following  paralysis,  is  therefore  of  extremely  common  occur- 
rence, and  it  is  perfectly  natural  that  it  should  come  on  after  Bell's  paral- 


904  FACIAL    PARALYSIS,    OR    BELL'S    PARALYSIS. 

ysis,  when  this  affection  has  heen  carried  to  an  extreme  degree,  and  has 
lasted  a  long  time. 

There  was  last  year  in  my  wards,  if  you  recollect,  another  very  striking 
instance  of  this.  Of  course  all  the  cases  are  not  exactly  alike — that  is  to 
say,  one  muscle  will  be  at  one  time  contracted,  and  another  muscle  at 
another  time.  In  one  patient,  the  orbicularis  palpebrarum  will  be  affected, 
and  the  consequence  will  be  that  the  eye,  instead  of  being  more  open  than 
the  other,  will  close  and  look  smaller ;  in  another,  as  in  our  young  woman, 
the  buccinator  and  the  zygomatic  will  be  contracted.  It  may  also  happen 
that  the  muscles  become  shorter  in  course  of  time,  in  which  case  there  will 
not  only  be  a  simple  deformity  of  the  face,  but  also  a  considerable  impedi- 
ment in  its  mobility.  This  contraction  of  the  muscles  of  the  face  is,  I 
repeat,  a  frequent  termination  of  the  so-called  rheumatic  paralysis  of  the 
seventh  pair.  Dr.  Duchenne,  in  his  treatise  on  "  Localized  Electrization," 
has  devoted  an  interesting  chapter  to  this  subject.  I  am  the  more  surprised 
at  our  classical  works  making  so  little  mention  of  it,  that  muscular  contrac- 
tion, sequential  to  paralysis  of  the  limbs  or  trunk,  is  a  symptom  which  has 
been  universally  indicated. 

It  was  necessary  to  fill  up  this  omission  in  the  history  of  facial  paralysis, 
in  order  to  put  you  on  your  guard  against  possible  errors  of  diagnosis.  A 
little  care  will  be  sufficient  to  make  you  avoid  them.  As  to  the  differential 
diagnosis  of  the  various  kinds  of  paralysis  from  one  another,  it  should  be 
based  on  a  knowledge  of  the  circumstances  in  which  the  complaint  set  in, 
of  the  course  of  its  development,  and  the  concomitant  phenomena. 

In  one  of  our  previous  conferences,  I  have  dwelt  long  enough  on  the  dif- 
ferential characters  of  Bell's  paralysis,  and  of  facial  paralysis  symptomatic 
of  a  central  affection,  such  as  hemorrhage,  and  I  need  not  return  to  the 
subject  now.  There  are  embarrassing  cases,  however — namely,  when  the 
facial  paralysis  is  due  to  a  tumor  of  the  brain,  developed  either  in  the  men- 
inges, or  in  the  substance  of  the  organ  itself,  or  in  the  petrous  portion  of 
the  temporal  bone,  in  the  neighborhood  of  the  spot  where  the  seventh  nerve 
enters  the  aqueductus  fallopii.  The  cause  of  the  paralysis,  especially  when 
it  sets  in  suddenly,  may  be  mistaken,  and  it  may  be  thought  of  a  rheumatic 
nature.  Such  cases  are,  fortunately,  very  rare ;  and  other  phenomena  enable 
one  besides  to  make,  before  long,  a  correct  diagnosis. 

Idiopathic  facial  paralysis  generally  gets  well,  and  all  the  more  rapidly 
that  it  set  in  suddenly,  and  the  patient  is  young.  There  is  an  important 
point  which  you  must  know,  however — namely,  that  under  certain  circum- 
stances the  complaint  stubbornly  resists  all  treatment,  although  nothing  in 
the  phenomena  which  characterize  it  gives  you  a  clue  to  this;  whilst  in 
other  cases,  presenting  identical  symptoms,  the  disease  yields  with  the  most 
marvellous  facility.  Dr.  Duchenne  (de  Boulogne)  has  shown  that  localized 
electrization  affords  us  a  means  of  distinguishing  such  cases,  abolition  of 
the  electric  contractility  of  the  palsied  muscles  being  regarded  by  him  as  a 
certain  sign  of  the  incurability  of  the  disease. 

Now,  gentlemen,  a  few  words  as  to  treatment.  Above  all,  do  not  forget 
that  facial  paralysis  is  sometimes  such  a  transitory  complaint  that  it  gets 
well  in  24,  15,  and  even  12  hours,  before  medicine  has  had  time  to  interfere. 
Such  cases  are  exceptional,  however.  Antiphlogistics,  Leeches,  and  cupping 
in  front  of  the  ear,  and  on  a  level  with  the  mastoid  process,  are  indicated 
when  the  presence  of  pain,  and  a  certain  amount  of  swelling  of  the  region 

aboul  the  parotid,  seems  to  point  to  an  irritation  of  those  parts. 
When  the  disease  is  of  a  less  acute  character,  remedies  which  stimulate 

the  skin  should  be  had  recourse  to,  and,  of  these,  blisters  rank  first.     If  they 


FACIAL    PARALYSIS,    OR    BELL'S    PARALYSIS.  905 

fail,  more  energetic  measures  are  called  for,  such  as  trauscurrent  cauteriza- 
tion, cauteries,  and  moxas. 

I  have  obtained  pretty  good  results  from  the  use  of  preparations  of 
strychnine  or  of  veratria,  by  the  endermic  method.  I  have  the  raw  surface 
of  a  blister  dressed  with  from  2  to  10  milligrammes  (g^th  to  ith  of  a  grain) 
of  sulphate  of  strychnine  or  of  veratria,  which  are  always  mixed  with  five 
or  six  times  their  weight  of  powdered  sugar.  I  have  also  seen  some  good 
done  by  the  application,  on  the  region  of  the  parotid,  of  compresses  steeped 
in  tincture  of  mix  vomica.  Lastly,  acupuncture,  electropuncture,  or  elec- 
trization simply,  have  been  found  useful ;  but  it  should  be  remembered  that 
faradization  should  be  used  according  to  certain  rules,  well  laid  down  by 
Dr.  Duchenne.  It  is  not  necessary  for  me  to  add,  that  all  I  have  said  on 
treatment  refers  merely  to  the  so-called  rheumatic  paralysis,  for  it  is  self- 
evident  that  the  paralysis  caused  by  an  accidental  division  of  the  nerve,  or 
its  destruction  in  diseases  of  the  petrous  portion  of  the  temporal  bone,  is 
quite  beyond  the  resources  of  art. 

As  yet,  I  have  only  spoken  of  facial  hemiplegia;  but  before  concluding, 
I  will  say  a  few  words  about  double  facial  paralysis,  an  affection  which  is 
not  even  mentioned  in  the  treatises  on  medicine  and  surgery  which  are  in 
your  hands.  Dr.  Davaine,  who  has  the  merit  of  having  brought  together, 
in  a  long  and  important  memoir,  cases  of  this  kind  scattered  through  scien- 
tific records,*  has  summed  up  its  characters.  They  vary  according  as  the 
paralysis  is  general  or  partial,  complete  or  incomplete. 

In  the  general  and  complete  variety  (the  only  one  of  which  I  shall  speak 
here,  for  it  is  the  only  one  which  has  been  observed  in  man,  partial  paral- 
ysis of  both  facial  nerves  having  been  met  with  in  the  lower  animals  alone), 
the  features  have  not  lost  their  regularity,  or,  more  properly  speaking, 
there  is  no  longer  that  want  of  symmetry  which  in  the  hemiplegic  form 
arises  from  the  absence  of  antagonism  between  the  muscles  of  the  affected 
side  and  those  of  the  other.  The  motionless  face  assumes  a  peculiar  aspect, 
and  looks  like  a  lifeless  mask  on  which  the  impressions  of  the  soul  are  no 
longer  expressed  but  by  changes  of  color.  The  forehead  is  smooth,  the 
superciliary  region  lowered ;  the  eyes  are  wide  open  and  cannot  be  closed  ; 
the  lower  lid  is  half-depressed,  and,  as  in  the  hemiplegic  form,  the  tears 
flow  constantly  over  the  cheeks,  while  the  half-opened  lips  allow  the  saliva 
to  run  out  of  the  mouth.  The  nostrils,  already  diminished  in  calibre,  fall 
in  still  more  during  inspiration,  while  in  forced  expiration  the  cheeks  are 
puffed  out,  soon  to  sink  in  again  like  loose  sails.  The  other  symptoms 
which  I  mentioned  to  you  when  speaking  of  facial  hemiplegia — namely, 
the  difficulty  of  mastication,  the  inability  to  spit  out,  to  whistle,  or  to  blow, 
the  difficulty  in  pronouncing  certain  consonants  and  the  labial  vowels — 
are  much  more  marked  in  double  facial  paralysis ;  the  voice,  besides,  has  a 
nasal  twang,  because  the  soft  palate,  which  is  sometimes  involved,  as  we 
have  seen,  in  facial  hemiplegia,  is  generally  much  more  completely  so  in 
the  double  form  of  the  disease.  On  looking  down  into  the  patient's  throat, 
there  is  no  deviation  of  the  uvula  as  in  hemiplegia,  nor  diminution  in  the 
diameter  of  one  of  the  arches  comprised  between  the  uvula  and  the  corre- 
sponding pillars ;  the  two  arches  are  symmetrical.  But  this  complete 
paralysis  of  the  soft  palate  causes,  in  addition  to  the  nasal  twang  of  the 
voice,  difficulty  of  deglutition,  and  the  return  through  the  nose  of  the 
liquids  drunk.     The  difficulty  of  deglutition  is  due  to  other  causes  also — in 

*  Memoire  siir  la  paralysie  generale  ou  partielle  des  deux  nerfs  de  la  septieme 
paire.  (Mem.  de  la  Soci6te  de  Biologie,  1852,  et  Gazette  Medicale  de  Paris,  1852  et 
1853.) 


906  FACIAL    PARALYSIS,    OR    BELL'S    PARALYSIS. 

part  to  the  paralysis  of  the  posterior  belly  of  the  digastric  and  of  the 
stylohyoid  muscles,  which  are  supplied  by  a  branch  of  the  facial  nerve, 
and  the  latter  of  which  raises  the  base  of  the  tongue ;  and  in  part  to  the 
paralysis  of  the  pharynx  itself,  which  is  also  supplied  by  branches  of  the 
seventh  pair  :  lastly,  the  tongue  can  no  longer  be  protruded  out  of  the 
mouth  with  ease,  nor  its  tip  curved  upwards. 

You  understand,  gentlemen,  that  it  is  impossible  to  speak  in  general 
terms  of  the  course,  the  duration,  and  the  termination  of  double  facial 
paralysis,  because  these  are,  in  fact,  necessarily  subordinate  to  the  causes 
which  produce  it. 

These  causes  are  sometimes  lesions  of  the  nervous  centres,  such  as  extrav- 
asations, softening,  &c,  the  symptoms  of  which  are  limited  to  the  muscles 
supplied  by  the  nerves  of  the  seventh  pair,  as  in  one  of  the  cases  recorded 
by  Dr.  Davaine,  although  we  find  it  impossible  to  explain  by  the  anatomi- 
cal lesions  why  the  paralysis  was  so  localized. 

Sometimes  the  cause  is  some  affection  involving  the  two  facial  nerves  in 
their  course  through  the  petrous  portion  of  the  temporal  bone.  Thus,  Dr. 
Davaine  relates  an  instance  of  double  facial  paralysis  resulting  from  a  vio- 
lent concussion,  which  had  fractured  both  temporal  bones  at  the  same 
time.  Now,  in  such  a  case,  the  paralysis  is  explained  by  compression  or 
laceration  of  the  nerves.  But  one  may  conceive  how  a  morbid  influence 
capable  of  acting  on  several  organs  at  the  same  time,  and  especially  on  the 
bones,  such  as  scrofula  and  syphilis,  will  be  more  liable  than  any  other  to 
produce  a  simultaneous  lesion  of  the  two  temporal  bones,  and  thus  to  bring 
on  double  facial  paralysis.  The  author  whom  I  mentioned  just  now,  bor- 
rows from  Sir  C.  Bell  a  case  observed  by  Dupuytren — namely,  that  of  a 
girl,  sixteen  years  of  age,  who  had  double  facial  paralysis,  beginning  on 
the  left  side,  and  involving  the  right  a  week  afterwards,  and  which  disap- 
peared under  the  influence  of  an  anti-syphilitic  treatment  carried  on  for 
eight  months.  I  read,  a  few  days  ago,  in  the  "  France  Medicale,"  a  similar 
case  extracted  from  the  "  Dublin  Quarterly  Journal,"  and  published  by 
Dr.  O'Connor.  The  patient  had  for  a  long  time  exhibited  symptoms  of 
constitutional  syphilis,  and  was  particularly  suffering  from  periostitis  of 
the  cranial  bones.  The  facial  paralysis  in  this  case  also  showed  itself  lii-i 
on  the  left  and  then  on  the  right  side.  Hearing  was  not  impaired,  and 
there  was  no  disturbance  of  the  intellect,  although,  judging  only  from  his 
aspect,  the  patient  looked  a  perfect  idiot.  The  features  were  expressionless. 
The  eyes  were  constantly  staring,  injected,  red,  and  bathed  in  tears,  which 
kept  dropping  on  the  cheeks.  The  flaccid  and  hanging  commissures  of  the 
lips  allowed  the  saliva  to  escape,  as  well  as  any  liquids  which  the  patient 
attempted  to  swallow,  deglutition  being  performed  with  considerable  difli- 
culty  only.  As  the  lips  could  no  longer  be  used  for  articulation,  the  voice 
was  guttural,  and  seemed  to  issue  from  the  bottom  of  the  throat.  As  the 
patient's  life  was  not  in  danger,  the  expression  of  his  face  excited  laughter 
more  than  a  feeling  of  pity,  so  that  the  jokes  of  his  companions  made  him 
leave  the  hospital,  and  Dr.  O'Connor  was  not  able  to  find  out  how  the 
disease  terminated. 

A  third  class  of  causes  of  this  double  facial  paralysis  includes  those  which 
acton  the  nerve  as  it  issues  from  the  stylo-mastoid  foramen  and  on  its 
peripheral  ramifications — such,  for  instance,  as  cold,  and  compression  by 
the  forceps  at  the  time  of  delivery. 

Before  leaving  this  subject  I  must  call  your  attention  to  the  fad  that 

double  facial  paralysis  has  been  confounded  with  another  variety  of  incom- 
plete paralysis  of  the  lace,  which   I  have  called  gbsso-laryngeal  paralysis, 


FACIAL    PARALYSIS,   OR    BELL'S    PARALYSIS.  907 

and  which  1ms  been  described  by  Dr.  Duchenue  (de  Boulogne*  under  the 
name  of  progressvSB  muscular  paralysis  of  the  tongue,  soft  palate,  and  lips. 

You  no  doubt  remember  how  carefully  I  took  notes  of  the  cases  of  five 
individuals  suffering  from  this  affection, and  who  remained  for  several  months 

in  St.  Bernard  and  iSt.  Agnes  Wards.  These  patients  had  paralysis  of  the 
soft  palate,  of  the  tongue  and  the  lips;  the  articulation  of  certain  words 
and  of  certain  letters,  the  deglutition  of  saliva  and  of  food,  had  at  first  been 
difficult  and  then  impossible ;  but  the  paralysis  had  never  spread  to  the 
upper  half  of  the  face.  The  muscles  which  are  concerned  in  the  act  of 
laughing  and  in  the  closure  of  the  eyelids  had  preserved  all  their  con- 
tractility ;  and  even  a  few  moments  before  their  death,  from  asphyxia 
brought  on  by  the  paralysis  of  their  respiratory  muscles,  or  by  the  arrest 
of  a  bolus  of  food  in  the  last  portion  of  their  pharynx,  these  patients  could 
still  sIioav  by  the  expression  of  their  face  their  gratitude  to  those  who  at- 
tended them. 

In  double  facial  paralysis,  on  the  contrary,  the  mask  is  dumb,  and  hence 
the  persistence  of  contractility  in  the  upper  half  of  the  face,  in  cases  of 
glosso-laryngeal  paralysis,  would  alone  be  sufficient  to  save  one  from  an 
error  in  diagnosis.  I  may  add  that  in  Bell's  paralysis  the  tongue  is  never 
paralyzed  to  such  a  degree  as  to  be  incapable  of  being  protruded  out  of  the 
mouth.  And  if  the  patient  speak  with  difficulty,  it  is  less  their  tongue  than 
their  lips  which  fail  in  the  articulation  of  words. 

Dr.  Davaine,  however  (at  a  time,  it  is  true,  when  glosso-laryngeal  pa- 
ralysis had  not  been  yet  described),  mistook  that  affection  for  double  facial 
paralysis,  and  his  memoir  contains  two  cases  of  it  (Cases  VII  and  VIII). 
I  confess  that  a  mistake  may  easily  be  made,  because  in  that  singular  par- 
tial paralysis  the  orbicularis  oris  and  the  tongue  can  scarcely  move ;  and 
as  in  the  act  of  speaking  the  movements  of  the  mouth  are  of  necessity 
most  frequently  repeated,  and  as  most  of  the  facial  muscles  converge  to- 
wards the  mouth,  the  patient  suffering  from  this  complaint  seems  to  wear 
a  motionless  mask,  as  if  he  had  double  facial  paralysis.  On  looking  closely 
at  him,  however,  it  is  ascertained  that  the  orbicularis  palpebrarum  and  the 
other  muscles  of  expression  have  retained  all  their  energy,  while  this  is  not 
the  case  in  Bell's  paralysis.  Moreover,  the  muscles  invariably  retain  their 
electric  excitability,  whilst  in  Bell's  paralysis  this  property  is  abolished  or 
nearly  so. 

Dr.  Davaine  gives,  after  Marshall  Hall,  a  test  by  which  it  may  be  ascer- 
tained whether  the  cause  of  double  facial  paralysis  is  seated  in  the  brain  or 
in  the  course  of  the  nerves.  In  the  former  case  the  conducting  power  of 
the  nerve-trunks  is  retained  for  an  indefinite  period,  so  that  by  galvanizing 
the  trunk  and  the  principal  branches  of  the  facial  nerves,  all  the  muscles 
supplied  by  them  are  thrown  into  contraction,  as  if  the  muscles  themselves 
were  being  galvanized ;  whilst,  when  the  paralyzing  cause  is  in  the  course 
of  the  nerves,  they  very  easily  lose  their  conducting  power.  Moreover,  if 
reflex  movements  be  seen  in  the  paralyzed  muscles,  it  will  be  a  sure  proof 
that  the  cause  of  the  paralysis  is  in  the  nerve-centres. 

When  once  the  seat  of  the  paralysis  has  been  determined,  and  its  cause 
known  or  suspected,  they  will  indicate  the  proper  treatment  which  should 
be  followed,  and  I  need  not  repeat  what  I  have  already  told  you  when 
speaking  of  facial  hemiplegia. 


908  ON    GLOSSO-LARYNGEAL    PARALYSIS. 


LECTURE  LI. 

ON   GLOSSO-LARYNGEAL   PARALYSIS. 

There  is  a  form  of  paralysis  which  is  always  progressive  in  its  course, 
fatal  in  its  termination,  and  which  is  marked,  at  its  onset,  by  a  diminution 
of  motor  power  in  the  tongue,  the  soft  palate  and  the  lips.  I  give  to  this 
affection  the  name  of  glosso-laryngeal  paralysis,  in  order  thereby  to  indicate 
the  principal  symptoms  which  characterize  it. 

This  is  certainly  not  a  new  disease,  and  it  must  have  been  observed  sev- 
eral times  already;  but  as  was  the  case  with  muscular  atrophy,  exophthal- 
mic goitre,  and  locomotor  ataxy,  it  was  confounded  with  other  analogous 
affections.  In  1841,  after  seeing  a  patient,  in  consultation  with  Dr.  Vos- 
seur,  I  wrote  a  memoir  which  Dr.  Vosseur  preserved,  and  communicated 
long  afterwards  to  Dr.  Duchenne  (de  Boulogne),  who  kindly  returned  it 
to  me.  This  memoir  proves  most  peremptorily  that  I  had  well  observed 
this  variety  of  paralysis,  but  that  case,  to  which  I  had  not  been  able  to 
add  another,  had  remained  a  dead  letter  for  me. 

The  memoir  was  as  follows : 

"  We  find  that  Prince  M is  unable  to  speak  and  to  articulate  any 

other  letter  besides  the  letter  a;  moreover  the  extreme  difficulty  which  he 
has  in  swallowing  immediately  drew  our  attention  to  the  organs  of  phona- 
tion  and  deglutition. 

"  We  ascertained,  first,  that  the  soft  palate  is  motionless  and  does  not 
contract  even  when  directly  excited  ;  the  tongue  moves  with  difficulty,  and 
the  patient  cannot  curve  its  tip  upwards,  and  can  scarcely  protrude  it  be- 
tween the  teeth. 

"  When  a  finger  is  passed  down  into  the  throat,  no  swelling  or  tumor  is 
found  at  the  upper  part  of  the  larynx.  The  introduction  of  the  finger 
gives  pain,  but  whilst  the  larynx  is  carried  upwards  spasmodically  by  its 
extrinsic  muscles,  the  pharynx  itself  does  not  contract  very  manifestly. 
AVe  thought  that  there  was  no  laryngeal  phthisis  in  the  sense  usually  un- 
derstood by  this  word. 

"The  preservation  of  the  principal  vocal  sound  a  and  its  extreme  dis- 
tinctness, indicated  that  the  vocal  cords  were  unaffected.  The  inability  to 
pronounce  (lie  four  secondary  vowels  was  solely  and  perfectly  explained  by 
the  lesion  of  the  vocal  apparatus  external  to  the  larynx  ;  just  as  the  ina- 
bility to  pronounce  consonants  was  accounted  for  by  the  affection  of  the 
tongue  and  lips,  parts  which  are  chiefly  concerned  in  the  formation  of  these 
sounds. " 

We  summed  up  our  opinion    by  saying:   "The   undersigned    think    that 

all  these  functional  disorders  are  due  to  weakness  of  the  muscles  of  the 
pharynx,  the  larynx,  the  soft  palate,  the  tongue,  the  lips,  and  the  cheeks. 
"Similar  weakness  exists  in  a  very  marked  degree  in  the  hit  arm;  is  a 
little  more  pronounced  in  the  lefl  than  in  the  righl  side  of  the  face;  con- 
siderably so  in  the  diaphragm,  and  only  slightly  marked  in  the  abdominal 
muscles,  the  bladder,  and  rectum. 

"The  consultants  have  thoughl  that   there  existed  in  the  nerVOUS  centres, 


ON    GLOSSO-LARYNGEAL    PARALYSIS.  909 

and  perhaps  in  the  nerve-trunks,  such  a  modification  that  the  influx  was 
no  longer  normally  and  sufficiently  distributed. 

"  They  have  asked  themselves  what  this  modification  could  he,  and  it 
has  seemed  to  them  easier  to  say  what  it  was  not,  than  to  state  precisely 
what  it  consisted  in.  They  have  thought  that  there  was  neither  chronic 
softening  of  the  nerve-substance,  nor  effusion  of  blood,  nor  a  tumor,  and 
they  have  felt  inclined  to  admit  a  lesion  of  the  same  nature  as  those  which 
si  i  often  give  rise  to  amaurosis,  to  paraplegia,  or  to  facial  paralysis,  lesions 
which  dissection  cannot  always  discover  or  determine." 

Surely,  gentlemen,  we  had  well  seen  that  this  case  was  a  form  of  paral- 
ysis which  had  not  been  described  in  books,  and  this  paralysis  was  the  same 
which,  twenty  years  later,  Duchenne  taught  us  how  to  recognize. 

We  had  noticed  that  the  patient  could  only  pronounce  the  letter  a,  and 
that  the  vowels  o  and  u  could  not  be  articulated  in  consequence  of  the 
feeble  contraction  of  the  orbicularis  oris.  We  had  also  noted  the  paralysis 
of  the  tongue,  the  soft  palate,  and  the  larynx,  as  well  as  the  great  difficulty 
of  deglutition  which  existed,  and  we  summed  up  our  consultation  by  say- 
ing positively  that  the  functional  disorders  were  due  to  weakness  of  the 
muscles  of  the  pharynx,  the  larynx,  soft  palate,  tongue,  lips,  and  cheeks. 

Far  from  me  is  all  idea  of  claiming  any  priority  as  to  the  discovery  of 
this  new  morbid  species.  I  had  seen  it,  but  not  seen  it  with  its  special 
characters,  and  I  had  soon  forgotten  it.  Perhaps  I  might  have  remem- 
bered the  case  of  Prince  M ,  had  other  similar  cases  come  under  my 

observation.     It  is  just,  however,  to  observe  that  in  Prince  M I  had 

noted  symptoms  of  paralysis,  with  progressive  tendencies,  which  have  not 
been  mentioned  in  Dr.  Duchenne's  memoirs,  and  which  subsequent  obser- 
vation has  led  me  to  regard  as  the  fully  developed  expression  of  this  dis- 
ease. Besides,  we  shall  see  by  and  by  that  all  these  symptoms  have  a  com- 
mon bond  of  union,  and  originate  from  the  same  lesion  which  has  certainly 
its  seat  in  a  portion  of  the  nervous  system. 

But  before  I  give  you  a  general  description  of  this  disease,  I  shall  first 
relate  the  cases  the  symptoms  of  which  will,  when  analyzed,  serve  as  the 
basis  of  my  description.  Some  of  you  may  still  remember  that  woman 
who  was  admitted  into  the  St.  Bernard  Ward,  No.  29,  and  whose  progres- 
sive paralysis,  dating  from  October,  1859,  terminated  in  death  in  January, 
1861.  She  was  forty-seven  or  forty-eight  years  old,  and  a  year  before 
coming  under  my  care  she  had  been  treated  by  Dr.  Duchenne.  She  had 
first  noticed  that  she  pronounced  some  words  badly ;  swallowing  next 
became  painful ;  saliva  constantly  dribbled  out  of  her  mouth ;  her  voice 
had  a  nasal  resonance  ;  her  lips  could  no  longer  contract  so  as  to  allow  her 
to  give  a  kiss,  to  whistle,  or  pronounce  the  letters  o  and  u;  aud,  lastly,  a  few 
days  before^ad mission,  aphonia  had  supervened.  When  I  saw  her  for  the 
first  time  in  the  beginning  of  November,  1860,  I  at  once  observed  all  the 
signs  of  the  special  progressive  paralysis  which  Dr.  Duchenne  had  just  de- 
scribed in  the  "  Archives  Generates  de  Medecine."  There  were  almost  com- 
plete aphonia,  considerable  weakness  of  respiration,  and  extreme  difficulty 
of  deglutition :  so  much  so,  that  one  day  the  patient  was  nearly  choked 
through  the  bolus  of  food  stopping  on  a  level  with  her  larynx.  The  pro- 
gressive paralysis  gradually  became  worse,  respiration  grew  feebler  from 
day  to  day,  and  the  patient  apparently  died  of  slow  and  prolonged  asphyxia. 
On  making  a  post-mortem  examination,  no  appreciable  material  lesion 
could  be  detected  in  the  muscles  the  functions  of  which  had  been  princi- 
pally disturbed,  not  even  with  the  aid  of  the  microscope.  But  it  is  to  be 
regretted  that  the  roots  of  the  hypoglossal  nerve,  of  the  spinal  accessory 
and  of  the  spinal  nerves,  were  not  examined  under  the  microscope,  especi- 


910  ON    GLOSSO-LARYNGEAL    PARALYSIS. 

ally  as  we  already  knew  the  researches  of  Dr.  Dumenil  in  a  complicated 
case  of  paralysis  of  the  tongue  and  progressive  muscular  atrophy.  When 
the  post-mortem  examination  was  made,  however,  no  modification  was 
found  in  the  size  and  color  of  the  roots  and  branches  of  the  hypoglossal 
nerve.  Still  I  could  not  help  thinking  that  there  must  have  been  some 
anatomical  lesion  of  the  nervous  system,  since  there  manifestly  was  none 
of  the  muscular  tissue. 

In  September,  1862,  a  compositor,  aged  seventy-two,  was  admitted  into 
St.  Agnes  Ward,  No.  23.  He  was  of  a  robust  constitution,  and  had  always 
enjoyed  good  health  until  March,  1862.  At  that  time  only,  he  first  noticed 
some  defect  in  his  pronunciation  of  certain  words,  his  tongue  felt  embar- 
rassed, his  voice  was  altered,  and  his  speech  was  thick.  Exactly  as  in 
double  facial  paralysis,  the  food  lodged  on  each  side  between  his  cheeks 
and  his  teeth,  and  he  was  obliged  to  use  his  fingers  in  order  to  replace  it  on 
his  tongue ;  occasionally  also  his  voice  had  a  nasal  resonance. 

In  June,  1862,  these  symptoms  having  become  more  distinctly  marked, 
the  patient  requested  to  be  admitted  into  the  Hotel-Dieu.  He  was  at  first 
taken  into  Professor  Rostan's  ward,  where  I  had  occasion  to  see  him  for 
the  first  time.  The  difficulty  he  had  in  answering  my  questions,  as  well  as 
the  evident  paralysis  of  his  tongue  and  lips,  reminded  me  not  of  the  case 

of  Prince  M ,  for  I  had  forgotten  it,  but  of  the  woman  who  had  been 

under  my  care  in  I860.* 

When  this  man  tried  to  speak,  he  uttered  a  sort  of  grunt ;  he  could  not 
pronounce  a  single  word  distinctly,  still  less  construct  the  simplest  sen- 
tence, and  although  his  intelligence  was  unimpaired,  he  answered  only  by 
signs.  His  face  was  expressionless,  owing  to  the  immobility  of  its  lower 
portion  and  to  his  mouth  being  almost  constantly  open. 

On  ascertaining  what  sounds  he  could  utter,  I  found  that  he  could  still 
articulate  the  vowels  a,  e,  i,  but  was  unable  to  say  o  and  u,  for  which  the 
lips  are  indispensable.  ISTor  could  he  articulate  the  consonants  p,  b,  m,  n, 
k,  c,  t,  which  require  more  or  less  the  intervention  of  the  lips  and  tongue, 
as  every  one  may  satisfy  himself  by  slowly  pronouncing  them.  The  other 
letters  of  the  alphabet  could  be  articulated,  only  however  on  the  patient 
making  efforts  and  pinching  his  nose  so  as  to  close  the  external  nares,  and 
send  through  the  mouth  the  whole  column  of  air  expelled  during  expira- 
tion. The  lips,  when  watched  attentively,  were  seen  to  remain  motionless 
during  the  attempts  at  articulation,  at  whistling,  pursing  up  his  mouth,  or 
pronouncing  o  and  u.  The  orbicularis  oris  did  not  contract  any  longer,  so 
that  the  lips  remained  half  open.  Every  moment  the  patient  caught  in  a 
handkerchief  the  saliva  which  he  was  unable  to  swallow,  and  which  his 
lips  could  not  retain  inside  the  cavity  of  the  mouth. 

If  he  was  made  to  laugh,  his  mouth  afterwards  remained  wide  open,  his 
face  looked  like  one  of  those  masks  used  by  the  ancients  in  comedy,  and  lie 
was  obliged  to  bring  his  lips  close  together  again  with  his  fingers  so  as  to 
close  his  mouth,  and  even  then  he  succeeded  imperfectly  only. 

The  tongue  itself  had  in  a  great  measure  lost  its  mobility,  and  was 
lodged  behind  the  lower  row  of  teeth.  It  could  not  be  protruded  outwards, 
nor  moved  sideways,  nor  raised  upwards  to  the  hard  palate;  it  could  not 
be  lengthened  into  a  point,  nor  made  hollow  in  the  centre.  Its  extrinsic 
and  intrinsic  muscles,  therefore,  were  paralyzed,  and  unable  to  aid  in  mas- 
tication, and  assist  in  tasting  the  food  by  pressing  it  againsl  the  roof  of  the 
palate.     This  paralysis  of  the  tongue   must  also  have  had  a  share  in  caUS- 

*  This  case  ia  reported  in  an  Appondix  t<>  the  "  Traitc  d'Electrisation  localises, " 
by  Dr.  Ducbenne  (de  Boulogne).     2<1  edit. 


ON    GLOSSO-LARYNGEAL    PARALYSIS.  911 

ing  the  difficulty  in  the  first  stage  of  deglutition.  As  to  the  paralysis  of 
the  soft  palate,  it  was  proved  by  the  nasal  resonance  of  the  voice  and  by 
the  food  getting  into  the  nasal  fossa?.  The  floor  of  the  mouth  itself  was  no 
longer  tense ;  the  larynx  no  longer  rose  with  the  same  rapidity  during  the 
second  stage  of  deglutition,  so  that  it  was  probable  that  the  mylo-hyoidei, 
stylo-glossi  and  stylo-hyoidei  muscles,  as  well  as  the  levatores  and  tensores 
palati,  were  also  palsied.  Perhaps  were  not  the  constrictors  of  the  pharynx 
themselves  paralyzed  to  the  same  degree,  for  occasionally  the  posterior 
aperture  of  the  mouth  and  the  nasal  fossa?,  remaining  wide  open  through 
the  paralysis  of  the  tongue  and  the  soft  palate,  the  food  was  rejected  with 
violence,  as  if  by  a  spasmodic  contraction  of  the  pharynx.  Let  us  note 
also  that  the  patient  complained  of  a  sense  of  constriction  in  the  pharyn- 
geal region. 

A  fact  well  worth  noticing  is,  that  in  all  the  cases  which  have  come  under 
my  own  observation,  the  paralysis  did  not  remain  confined  to  the  muscles 
of  the  soft  palate,  tongue,  and  lips,  but,  after  a  variable  period,  extended 
to  other  parts  of  the  body,  and  sometimes  showed  manifest  tendencies  to 
become  general.  Thus,  the  compositor  whom  I  mentioned  just  now  suffered 
from  a  marked  diminution  of  contractile  power  in  the  right  arm,  which 
could  not  be  attributed  to  an  old  wound.  Thus,  again,  in  the  case  of  Prince 
M ,  of  the  woman  in  the  St.  Bernard  Ward,  and  of  the  man  whose  his- 
tory I  soon  shall  relate,  the  paralysis  extended  to  the  chest-walls,  the  bladder, 
and  lower  limbs. 

Yet,  amidst  all  these  disorders,  the  intellect  was  not  affected,  and  the 
compositor,  who  could  no  longer  make  himself  understood  by  speech  or 
gesture,  managed,  by  means  of  an  alphabetical  table,  to  compose  words 
expressing  his  thoughts. 

A  good  many  measures  had  been  tried  for  arresting  this  paralysis.  Fara- 
dization of  the  muscles  of  the  tongue,  soft  palate,  and  lips,  alone  succeeded 
in  temporarily  restoring  slight  contractility  to  these  enfeebled  muscles,  so 
that  the  patient  was  constantly  begging  for  electricity  to  be  used. 

During  the  last  month  of  his  existence,  deglutition  became  more  and  more 
difficult.  As  he  could  only  use  his  left  hand,  a  paste  made  with  bread  and 
wine,  of  semi-liquid  consistency,  had  to  be  poured  into  his  mouth.  He 
first  opened  his  mouth,  letting  his  head  fall  backwards  so  as  to  receive  the 
food,  and  then  closing  his  mouth  immediately  with  his  left  hand  in  order 
to  keep  the  paste  in,  he  bent  his  head  forwards,  making  at  the  same  time 
repeated  efforts  to  swallow.  In  spite  of  this  contrivance,  it  sometimes 
happened  that  the  food  came  back  through  the  mouth  and  nostrils.  Subse- 
quently, liquids  alone  could  be  swallowed,  and  the  patient  died  at  last  of 
starvation  fever,  with  rigidity  of  the  limbs  on  the  right  side  and  paralysis 
of  the  bladder  and  rectum. 

At  the  post-mortem  examination,  atrophy  of  the  roots  of  the  hypoglossal 
nerve  was  found,  together  with  increased  consistency  of  the  medulla  ob- 
longata. 

At  Ko.  19,  in  the  same  ward,  we  had  an  opportunity  of  studying  another 
example  of  this  form  of  paralysis. 

B ,  a  gardener,  aged  62,  after  having  enjoyed  excellent  health  pre- 
viously, and  having  never  committed  any  excess,  or  been  exposed  to  any  of 
those  poisonous  influences  which  sometimes  bring  on  paralysis,  fell  ill  in 
February,  1862.  He  was  suddenly  seized  with  fever  and  delirium,  which 
lasted  three  or  four  days  only.  He  was  convalescent  for  a  short  time,  and 
he  seemed  cured,  when  his  attention  was  drawn  by  his  friends  to  a  slight 
nasal  resonance  of  his  voice,  and  he  noticed  himself  that  he  had  some  diffi- 
culty in  pronouncing  words  beginning  with  the  letters  r,  c,  k,  q,  so  that  the 


912  OX    GLOSSO-LAB.YXGEAL    PARALYSIS. 

tongue  was  already  somewhat  embarrassed.  The  following  month,  at  the 
end  of  a  day's  work  in  the  sun,  he  suddenly  felt  weakness  of  the  right  leg 
and  arm,  without  any  impairment  of  intellect.  He  remarked  at  the  same 
time  also,  that  his  food  collected  between  his  teeth  and  cheeks,  and  that  at 
intervals  he  was  obliged  to  wipe  his  lips,  which  were  wet  with  the  escaping 
saliva.  His  appetite  was  good,  and  all  his  functions  were  performed  with 
regularity. 

On  June  12th,  1862,  B was  admitted  into  the  Hotel-Dieu,  under 

Dr.  Empis,  who  was  then  acting  as  Professor  Rostan's  substitute.  He  was 
still  able  to  relate  the  accession  and  the  course  of  his  complaint,  although  his 
lips  were  manifestly  paralyzed.  He  could  not  pronounce  the  letters  o  and  u, 
and  he  dribbled  when  he  talked.  His  face  was  natural  wheu  at  rest ;  but 
when  he  laughed,  the  angles  of  his  mouth  were  strongly  pulled  upwards 
and  outwards,  and  his  mouth  remained  half-open,  so  that  he  was  obliged  to 
use  his  hands  in  order  to  bring  his  lips  together.  The  tongue  seemed  to  be 
fixed  behind  the  lower  row  of  teeth,  by  which  it  was  indented,  and  it  was 
with  great  difficulty  protruded  outwards  and  forwards.  Its  apex,  which 
deviated  a  little  to  the  right,  could  not  be  raised  to  the  upper  incisors,  or 
above  the  lower  molars.  The  articulation  of  certain  words,  however,  and 
deglutition  were  still  possible,  but  with  very  manifest  trouble  and  difficulty. 
The  right  arm  and  leg  were  weak ;  the  left  ankle  could  not  be  flexed,  and 
the  sensibility  of  the  left  side  was  diminished. 

The  progress  of  the  disease  was  rapid  and  continuous.     "When  in  Septem- 
ber, B came  under  my  care,  he  could' no  longer  pronounce  the  letters 

c,  p,  t;  but  he  could  still  articulate  the  consonants  b,  d,  I,  m,  n.  He  swal- 
lowed his  saliva  with  difficulty,  and  he  already  complained  of  a  sense  of 
constriction  in  the  throat.  He  often  passed  his  fingers  down  the  back  of  his 
mouth,  as  if  he  wished  to  extract  some  foreign  body  which  interfered  with 
deglutition.  His  intellect  was  perfectly  clear,  and  if  he  had  great  difficulty 
in  uttering  sounds,  his  physiognomy  showed  that  he  understood  perfectly 
all  the  questions  that  were  put  to  him.  Even  then,  however,  the  lower 
part  of  his  faee  was  not  long  before  it  became  motionless,  whilst  the  upper 
part,  and  more  particularly  the  eyelids  and  forehead,  retained  all  their 
mobility. 

The  feebleness  of  the  sounds  uttered  by  the  patient  was  remarkable. 
Indeed,  Avhen  his  chest  was  exposed,  one  was  struck  with  the  weakni 
his  respiration.  There  was  scarcely  any  oscillation  of  the  walls  of  his  chest 
during  inspiration  and  expiration;  the  lungs  took  in  and  expelled  very 
little  air;  expiration  was  feeble  and  slow.  This  was  one  of  the  reasons  why 
tlic-  Bounds  were  feeble.  Besides,  if  he  was  asked  to  retain  the  air  contained 
in  his  chest,  he  was  unable  to  do  so,  and  the  air  continued  t"  escape  slowly. 
The  glottis  remained  always  open,  so  that  the  air  passed  to  and  fro  through 
the  larynx,  almost  as  through  an  inert  tube.  The  glottis  seemed  to  have 
lost  tin-  greater  part  of  its  active  tension,  and  could  no  Longer,  under  the 
control  of  the  will,  vibrate  like  strings,  or  like  the  membranes  of  a  reed 
instrument.  There  was  oot  only  loss  of  speech,  but  complete  aphonia  also, 
and  it  was  only  by  dint  of  considerable  exertion  that  he  could  feebly  utter 
the  sound  of  «.  The  above  details  have  already  shown  y<m  how  feebly 
respiration  is  carried  on  in  such  cases.  In  tin'  man  at  No.  19  this  diffi- 
culty of  breathing  was  -till  more  increased  on  his  catching  a  cold.  At  such 
time-  in-  could  not  always  cough,  for  he  was  not  strong  enough  to  expel 
rapidly  the  air  contained  within  hi-  chest,  so  that  he  could  nol  easily  clear 
hk<  bronchial  tubes  and  larynx  of  the  accumulating  mucus. 

I  was  very  much  afraid  lest  the  dyspnoea,  which  was  very  marked  already, 
should  go  on  increasing,  in  which  case  the  patient  would  '»•  choked  through 


ON    GLOSSO-LARYNGEAL    PARALYSIS.  913 

accumulation  of  the  bronchial  mucus.  The  muscles  of  the  chest  were  there- 
fore electrified  every  clay,  and,  by  his  gestures,  B expressed  how  much 

better  he  felt  then.  The  dyspnoea  became  less  intense,  and  for  several 
hours  afterwards  the  supplementary  muscles  of  respiration,  the  sterno-inas- 
toidei,  the  trapezii,  and  scaleni,  ceased  their  rhythmical  contractions,  which 
had  assisted  the  intercostal  muscles  and  the  diaphragm.  Every  day,  how- 
ever, until  the  cold  got  well,  electricity  had  to  be  used. 

The  muscles  of  respiration  were  not  the  only  ones  affected,  for  the  mus- 
cles of  the  neck  were  very  feeble  too.     In  fact,  B could  not  touch  his 

chest  sharply  with  his  chin,  or  keep  his  head  forcibly  extended.  The  cer- 
vical muscles,  therefore,  the  trapezii,  and  sterno-mastoidei,  shared  in  the 
weakness  of  the  thoracic  muscles,  and  perhaps  also  were  the  scaleni  and 
the  deep  muscles  of  the  anterior  and  posterior  cervical  regions  similarly 
affected.  The  patient  had  some  difficulty  in  carrying  his  head  up,  and 
he  had  to  pay  a  certain  degree  of  attention  in  order  to  keep  it  in  equilib- 
rium. 

Deglutition  soon  became  still  more  difficult.  The  food,  although  per- 
fectly masticated,  passed  with  great  difficulty,  or  with  feeble  jerks,  from  the 

cavity  of  the  mouth  into  the  pharynx.     B then  applied  his  hands  over 

his  mouth  and  cheeks  in  order  to  assist  the  contractions  of  the  orbicularis 
oris  and  buccinators.  The  movement  of  elevation  of  the  base  of  the  tongue 
seemed  very  limited,  and  when  the  food  reached  the  pharynx  it  was  some- 
times rejected  through  the  nose.  Liquids  also  were  swallowed  badly;  they 
sometimes  got  into  the  larynx,  in  spite  of  the  aryteno-epiglottidean  folds, 
and  brought  on  fits  of  coughing  made  up  of  short  jerks. 

The  circulation,  both  centric  and  peripheral,  presented  no  serious  modi- 
fication. The  pulse  at  the  wrist  was  a  little  more  frequent  than  normal — 
92  in  the  minute ;  the  heart's  action  was  powerful  and  regular. 

Until  then,  there  was  no  paralysis  of  the  bladder  and  rectum.  In  a 
short  time,  however,  the  general  debility  increased  rapidly.  The  patient, 
who  used  to  walk,  although  with  difficulty,  dragging  his  legs  and  resting 
on  the  back  of  a  chair  which  he  pushed  before  him,  found  himself  incapa- 
ble of  leaving  his  bed.  His  breathing  became  slow  and  incomplete,  deglu- 
tition more  and  more  difficult,  his  facies  altered,  and  death  took  place 
quietly  and  without  any  struggles,  the  patient  having  only  a  moment  before 
made  signs  to  thank  the  attendants  for  helping  him  to  place  his  head  down 
on  his  pillow. 

Post-mortem  Examination. — No  fatty  degeneration  of  the  diaphragm, 
although  its  fibres  looked  pale.  No  portion  of  the  muscular  system  pre- 
sented that  beautiful  red  color  which  is  proper  to  it,  and  the  extreme  fria- 
bility of  the  muscles  of  the  right  leg,  especially  of  the  peroneus  longus, 
tibialis  anticus,  and  quadriceps  femoris,  contrasted  with  the  almost  normal 
resistance  of  the  corresponding  muscles  of  the  left  side.  Besides,  the  fria- 
ble, softened  muscles  were  of  a  reddish-yellow  color,  and  manifestly  under- 
going commencing  fatty  degeneration,  a  fact  about  which  microscopical 
examination  left  no  doubt. 

The  muscles  of  the  face  and  the  orbicularis  oris,  although  not  well  de- 
veloped, were  not  altered.  The  intrinsic  and  extrinsic  muscles  of  the  tongue 
were  normal,  as  well  as  the  buccinators,  the  muscles  of  the  soft  palate,  of 
the  pharynx,  the  larynx,  and  the  neck. 

The  calvarium  was  very  thin.  The  dura  mater  looked  thickened ;  the 
pia  mater  was  cedematous  and  injected,  but  could  be  removed  without  tear- 
ing away  the  cerebral  tissue.  The  gray  matter  was  of  good  consistency 
and  unaltered ;  the  white  matter  was  of  a  cafe  au  lait  color,  and  presented 
very  distinct  red  points.  Several  portions  of  the  circumference  of  the  left 
vol.  i. — 58 


914  ON    GLOSSO -LARYNGEAL    PARALYSIS. 

corpus  striatum  were  stained  of  an  amber-red  color,  which  was  apparently 
due  to  small  hemorrhagic  clots  of  old  date.  These  parts,  when  examined 
under  the  microscope  with  a  power  of  250  diameters,  were  seen  to  contain 
hrematin  in  a  state  of  fine  powder,  and  granular  deposits  of  a  brownish-red 
tint. 

The  optic  and  olfactory  nerves  were  of  normal  color  and  consistency. 
The  motor  oculi  had  a  grayish  tint  at  its  origin,  but  the  fourth  nerve  was 
sound.  The  fifth  and  sixth  nerves  could  not  be  examined  at  their  origins. 
The  facial  was  flattened  at  its  origin,  on  both  sides,  but  was  not  affected  in 
other  respects.  The  roots  of  the  pneumogastric  were  atrophied,  but  the 
glossopharyngeal  nerves  were  healthy.  There  was  marked  hyperemia  of 
the  cerebellum.  The  floor  of  the  fourth  ventricle  presented  a  plexiform 
arrangement  of  vessels. 

The  roots  of  the  right  hypoglossal  nerve  were  so  atrophied,  that  they  re- 
sembled filaments  of  congested  cellular  tissue.  When  examined  under  the 
microscope,  they  were  found  to  contain  deposits  of  pink,  brownish-red,  and 
greenish  hamiatin.  The  nerve-tubes  were  few  in  number,  collapsed  in  parts, 
with  a  granular  cylinder-axis,  and  apparently  softening  myeline.  The  roots 
of  the  left  hypoglossal  were  not  examined,  because  they  had  been  torn 
from  the  bulb  when  the  spinal  cord  was  removed. 

The  roots  of  the  spinal  accessory  were  on  both  sides  small.  The  neuri- 
lemma predominated,  especially  on  the  left  side,  and  all  the  roots  of  the 
nerve,  both  those  from  the  medulla  and  those  from  the  spinal  cord  itself, 
were  of  a  grayish  color.  The  microscope  detected  an  increase  of  vessels  in 
them ;  the  capillaries  of  the  neurilemma  were  turgescent,  the  neurilemma 
itself  thickened,  and  consequently  the  nerve-tubes  of  the  roots  were  dis- 
tinguished with  difficulty.  In  the  midst  of  the  elements  of  the  neurilemma 
there  was  seen  a  fatty  substance,  irregularly  scattered  in  granules.  The 
fibres  of  the  connective  tissue  were  markedly  developed,  and  were  mixed 
up  with  a  good  many  elastic  fibres.  The  dura  mater  for  the  upper  third  of 
the  cervical  portion  was  thickened,  congested,  and  of  an  ashy-gray  color. 

The  anterior  spinal  roots  were  atrophied,  especially  on  the  left  side,  near 
the  roots  of  the  spinal  accessory.  In  that  part,  the  roots  of  the  last  nerve 
seemed  to  be  reduced  to  a  band  of  connective  tissue,  whilst  the  antero- 
lateral columns,  in  the  part  which  gives  attachment  to  the  motor  roots, 
were  of  the  same  color  and  had  the  same  congested  appearance  as  the 
posterior  columns  present  in  cases  of  locomotor  ataxy. 

The  roots  of  the  right  spinal  accessory  nerve  were  less  atrophied,  but  had 
to  some  extent  the  same  color,  and  were  as  congested  as  the  roots  of  the 
opposite  side.  A  good  many  of  the  anterior  spinal  roots  presented  a  rela- 
tive diminution  of  size,  and  a  markedly  congested  condition  analogous  to 
what  has  been  noted  in  general  progressive  muscular  atrophy. 

Sections  of  the  spinal  cord,  made  at  different  pail-,  were  examined,  and 
marked  hyperemia  of  the  upper  cervical  portion  was  found.  The  gray 
substance  of  the  cord  was  of  a  deeper  color  and  was  harder  than  natural, 
showing  a  relative  sclerosis  of  the  cord. 

Are  you  not  struck  in  this  case,  gentlemen,  with  the  existence  of  general 
hyperemia  of  the  cerebrospinal  axis,  coupled  with  relative  atrophy  of  the 
greater  number  of  cranial  and  spinal  motor  nerves?  For  these  pathological 
lesions  resemble  thus,,  which  have  been  described  by  Professor  Cruveilhier 
in  progressive  muscular  atrophy,  and  by  Dr.  Dume'nil    de  Rouen)  in  a 

Complex  case  of  paralysis  of  the  tODgue  and  general  muscular  atrophy. 

Let  us  now  proceed  to  analyze  Dr.  Dume'ml's  case,  and  the  one  reported 
in  Dr.  I  tachenne's  memoir. 

Dr.  Duineiiil  reports  hi-  ,;l-,.  under  the  following  heading :  Atrophy  <•( 


ON    GLOSSO-LARYNGEAL    PARALYSIS.  915 

the  hypoglossal,  facia/,  and  spinal  accessory  nerves :  complete  motor  paralysis 
of  the  tongue,  incomplete  of  the  face.  Integrity  of  the  muscles  of  the  tongue 
and  face.  Atrophy  of  the  anterior  spinal  roots :  incomplete  paralysis  of  the 
limbs,  incipient  muscular  atrophy. — That  atrophy  of  motor  nerves  should 
cause  paralysis  of  the  muscles  to  which  they  are  distributed,  is  perfectly 
in  accordance  with  physiological  notions.  But  how  is  it  that  the  atrophy 
of  the  spinal  roots  caused  atrophic  degeneration  of  the  muscles  supplied  by 
them,  whilst  the  atrophy  of  the  cranial  nerves  and  their  roots  did  not  pro- 
duce the  same  effect  on  the  muscles  of  the  tongue  and  face  ?  Dr.  Dumenil 
at  first  thought  that  this  difference  might  be  owing  to  the  fact  "that  motor 
cranial  nerves  do  not  have  the  same  influence  on  the  nutrition  of  muscles 
as  the  anterior  roots  of  spinal  nerves."  But  Dr.  Duchenne  having  reminded 
Dr.  Dumenil  that  in  Professor  Cruveilhier's  case  there  had  been  noted 
atrophic  degeneration  of  the  tongue  as  well  as  atrophy  of  the  hypoglossal 
nerve,  Dr.  Dumenil  had  to  give  up  his  hypothesis,  and,  after  fresh  re- 
searches, he  was  perhaps  the  first  to  express  the  opinion  that  the  impair- 
ment in  the  nutrition  of  the  muscle  was  a  consequence  of  a  lesion  of  the 
sympathetic.  However  this  may  be,  Dr.  Dumenil's  patient  was  afflicted 
with  a  paralysis  of  the  tongue,  the  muscles  of  the  face  and  limbs,  which  was 
due  to  atrophy  of  motor,  cranial,  and  spinal  roots.  How  can  an  individual 
be  said  to  suffer  from  two  associated  diseases,  namely,  progressive  muscular 
atrophy  and  glosso-laryngeal  paralysis,  when  the  anatomical  lesion  is  one 
and  the  same  ?     We  shall  discuss  this  question  by  and  by. 

A  case  communicated  by  Dr.  Costilhes  to  the  Medical  Society  of  Paris, 
in  1860,  suggests  the  same  reflections,  since  there  was  general  muscular  de- 
bility as  well  as  symptoms  of  glosso-laryngeal  paralysis.  However  interest- 
ing that  case  may  be,  I  shall  now  proceed  to  comment  on  the  eighth  case  of 
Dr.  Duchenne's  memoir,  which  he  calls:  Progressive  paralysis  of  the  tongue, 
the  soft  palate  and  lips,  coinciding  with  progressive  fatty  muscular,  atrophy 
limited  to  a  few  muscles  of  the  upper  extremities. 

The  patient  stated  that  the  disease  had  set  in  with  weakness  of  the  move- 
ments of  the  right  arm.  Dr.  Duchenne  found  atrophy  of  the  muscles  of 
the  right  hand,  and  also  commencing  atrophy  of  the  left  hand,  the  trapezii, 
and  many  other  muscles  of  the  trunk  and.  limbs.  Whilst  questioning  the 
patient,  he  noticed  besides  a  marked  defect  of  articulation,  a  circumstance 
which  surprised  him  at  the  onset  of  progressive  muscular  atrophy,  because, 
in  such  cases,  atrophy  of  the  tongue  is  only  observed  at  the  close  of  the 
disease.  Direct  examination  of  the  tongue,  however,  showed  that  the  organ 
was  not  atrophied,  but  merely  paralyzed,  as  were  also  the  orbicularis  oris 
and  the  muscles  of  the  soft  palate.  The  history  of  the  case  could  not  be 
completed,  as  the  patient  left  off  coming  to  Dr.  Duchenne. 

In  this  case,  says  Dr.  Duchenne,  there  were  two  different  diseases,  namely, 
muscular- atrophy  of  the  limbs  without  paralysis,  and  paralysis  of  the 
tongue  without  atrophy.  "  Chance  alone,  a  mere  coincidence,"  adds  the 
learned  investigator,  "  had  brought  together  these  two  distinct  morbid  va- 
rieties," both  in  the  patient  he  saw  himself  in  1858,  and  in  the  one  seen  by 
Dr.  Dumenil  in  1859. 

I  may  be  allowed  to  observe,  however,  that  when  Dr.  Duchenne  made 
this  positive  assertion,  there  was  only  on  record  the  post-mortem  examin- 
ation made  by  Dr.  Dunienil,  which  established  the  existence  of  an  identical 
lesion  in  the  roots  of  the  hypoglossal  nerve  and  the  anterior  spinal  roots. 
Since  then,  a  post-mortem  examination,  made  at  my  request  by  Dr.  Luys 
and  M.  Dumontpallier,  in  presence  of  Dr.  Duchenne  himself,  has  shown 
that  glosso-laryngeal  paralysis  and  progressive  muscular  atrophy  are  at- 
tended with  the  same  nerve-lesions,  namely,  atrophy  of  motor  roots,  both 


916  ON    GLOSSO-LARYNGEAL    PARALYSIS. 

cranial  and  spinal.  Besides,  clinical  observation  has  proved  to  rue,  in  all 
the  cases  which  I  have  seen,  that  in  patients  suffering  from  glosso-laryngeal 
paralysis  there  is  a  tendency  in  the  paralysis  to  become  general.  It  is  very 
probable,  therefore,  that  there  is  moi'e  than  a  mere  chance  coincidence 
in  all  these  cases. 

I  do  not  wish  to  insist  further  on  this  point,  and  I  hasten  to  add  that  Dr. 
Duchenne  was  right  in  giving  a  distinct  description  of  these  two  morbid 
conditions,  because  the  progress  of  the  disease  is  different,  and  the  termin- 
ation always  rapidly  fatal  in  glosso-laryngeal  paralysis.  But  in  my  opinion 
these  morbid  states  are  only  varieties  of  a  paralysis  ^depending  on  an  affec- 
tion of  the  spinal  cord  or  medulla  oblongata,  the  chief  anatomical  expression 
of  which  seems  always  to  consist  in  an  atrophy  of  the  motor  roots. 

Let  us  now  return  to  the  general  study  of  the  four  cases  of  glosso-laryn- 
geal paralysis  which  I  have  related  to  you.  It  is  not  difficult,  if  we  keep 
in  mind  the  principal  symptoms  observed  in  each  of  these  cases,  to  give  a 
broad  sketch  of  this  disease,  the  origin,  progress,  and  termination  of  which 
are  so  very  characteristic,  that  we  meet  with  no  other  identical  affection  in 
the  whole  range  of  nosology. 

When  the  patient  comes  to  us  for  advice,  the  disease  has  already  made 
great  progress,  and  all  its  characters  are  well  marked.  On  carefully  ques- 
tioning him,  however,  it  is  found  that  the  first  circumstance  which  attracted 
his  notice  was  slight  embarrassment  of  speech.  Soon  afterwards,  he  ob- 
served that  his  tongue  was  not  equally  supple,  and  that  his  utterance 
became  thicker  and  thicker.  His  food  then  lodged  at  times  between  his 
teeth  and  cheeks ;  the  tip  of  his  tongue  being  awkward  and  incapable  of 
doing  it,  he  had  to  use  his  fingers  to  replace  the  food  on  his  tongue.  The 
pronunciation  of  certain  words  was  marked  by  a  nasal  resonance ;  the 
vowels  o  and  u  could  not  be  pronounced,  because  the  contractility  of  the 
orbicular,  muscle,  which  is  indispensable  for  this,  had  diminished,  and  there 
was  occasional  dribbling  of  saliva  when  the  head  was  inclined. 

Now,  do  not  these  facts  point  to  an  incipient  paralysis  of  the  tongue,  the 
soft  palate,  and  orbicularis  oris?  By  degrees,  however,  the  paralysis  makes 
continued  progress ;  the  tongue  remains  fixed  as  it  were  behind  the  lower 
teeth  ;  its  apex  and  its  base  are  equally  motionless;  not  a  single  word  can 
be  articulated.  The  first  stage  of  deglutition  has  become  almost  com- 
pletely impossible,  and  the  patient  has  recourse  to  all  kinds  of  stratagems 
for  getting  his  food  into  the  pharynx.  He  tries  to  help  the  orbicularis  oris 
and  the  buccinator  with  his  hands,  and  applying  them  over  his  mouth  and 
cheeks,  he  makes  repeated  and  considerable  efforts  in  order  to  get  his  food 
to  pass  into  the  pharynx,  and  yet  he  takes  great  care  to  chew  well  what  he 
eats,  and  to  facilitate  its  gliding  down  by  drinking  and  throwing  his  head 
backwards.  At  last  he  sometimes  succeeds  in  swallowing,  but  at  other  times 
the  co-ordinate  contraction  of  the  pharyngeal  constrictors  bring  at  fault, 
only  a  small  quantity  of  food  gets  into  the  oesophagus,  whilst  tin'  greater 
portion  is  thrown  up  through  the  mouth  and  nostrils,  the  posterior  aper- 
tures of  the  latter  having  remained  open  through  the  paralysis  of  the  soft, 
palate. 

These  unfortunate  patients  arc  of  course  a  considerable  time  over  their 
meals,  for  their  appetite  remains  excellent.  Liquids  also  are  often  swal- 
lowed with  great  difficulty.  Oftentimes  small  portions  of  food  pass  into 
the  Larynx,  and  then  to  the  horrible  torture  of  nol  being  able  to  swallow  is 

superadded  extreme  difficulty  of  coughing  in  order  to  gel  rid  of  the  food 
which  has  passed  into  the  larynx  and  trachea.  The  anxiety  is  extreme;  at 
last,  aftef  frequent  fits  of  a  small  jerking  cough,  the  patient    gets  calm 


ON    GLOSSO-LARYNflEAL    PARALYSIS.  917 

again.  Hence  it  maybe  seen  that  he  is,  at  every  moment,  in  imminent 
danger  of  death  by  suffocation. 

When  the  paralysis  has  advanced  so  far,  excessive  weakness  of  the  respi- 
ratory movements  may  be  easily  discovered.  The  walls  of  the  chest  scarcely 
move,  and  the  diaphragm  itself  sometimes  shares  in  this  apparent  immo- 
bility. At  this  period  of  the  disease  the  auxiliary  muscles  of  respiration 
have  also  become  powerless,  and  superior  thoracic  breathing  is  impossible. 
If  the  patient  be  asked  to  blow  out  a  candle,  he  collects  all  his  strength, 
and  yet  the  flame  is  scarcely  agitated  as  he  blows  on  it.  This  is  not  only 
owing  to  a  division  of  the  column  of  air  which  is  expired,  and  its  jmssing 
at  the  same  time  through  the  mouth  and  nostrils,  nor  merely  to  the  inability 
of  the  patient  to  contract  the  buccinators  and  orbicularis  oris  in  order  to 
guide  the  column  of  air,  but  it  is  chiefly  due  to  the  small  volume  of  this 
column,  and  to  the  paralysis  of  the  bellows,  namely,  the  walls  of  the  chest. 

If  such  patients  be  attacked  with  bronchitis,  they  are  in  danger  of  quickly 
dying  of  asphyxia,  because  they  can  no  longer  cough  vigorously,  and  thus 
expectorate  the  bronchial  mucus. 

The  pulse  sometimes  becomes  frequent  without  any  fever  supervening, 
and  I  shall  by  and  by  inquire  into  the  physiological  reason  of  this  fre- 
quency of  the  heart's  action. 

As  a  rule,  no  pain  is  complained  of,  but  in  some  cases  pain  is  felt  in  the 
occipital  and  upper  part  of  the  cervical  region.  Sensibility  is  everywhere 
normal :  those  very  muscles  which  are  paralyzed  retain  the  property  of 
contracting  under  the  influence  of  electricity,  and  irritation  of  the  mucous 
membrane  of  the  soft  palate  produces  contraction  of  the  velum  through  a 
reflex  action. 

As  the  general  debility  makes  constant  progress,  however,  the  patients 
drag  themselves  along  with  difficulty,  resting  on  the  arm  or  back  of  a  chair, 
which  they  push  slowdy  before  them.  They  next  refuse  to  get  up,  and 
prefer  to  sit  up  in  bed,  with  the  upper  part  of  their  body  propped  up,  their 
head  resting  on  pillows,  and  inclined  to  one  side,  in  order  to  let  the  saliva 
which  they  are  unable  to  swallow  run  out  of  their  mouth.  Their  sleep  is 
often  disturbed  by  paroxysms  of  suffocation,  probably  clue  to  the  passage 
of  the  saliva  or  of  the  pharyngeal  mucus  into  the  larynx.  If  death  does  not 
take  place  in  one  of  these  paroxysms,  it  seems  to  be  caused  by  an  arrest  of 
the  contractions  of  the  heart,  is  unaccompanied  by  pain  or  any  noise,  and 
occurs  suddenly. 

Such,  gentlemen,  is  the  course  usually  run  by  this  malady,  but  it  is  some- 
times accompanied  by  other  morbid  phenomena — by  paralysis,  for  example, 
either  of  the  upper  and  lower  limbs,  or  of  some  muscles  only  of  these 
different  segments  of  the  body.  Such  cases  are  merely  instances  of  the 
extension  of  the  disease.  But  in  others  you  may  observe  genuine  compli- 
cations, such  as  atrophy  and  fatty  degeneration  of  the  muscles,  hemiplegia 
even,  due  to  there  having  occurred  hemorrhage  or  softening  at  a  period 
anterior  to  the  disease.  In  most  cases,  however,  the  patients  die  without 
presenting  any  other  anatomical  lesions  besides  those  which  are  directly 
dependent  on  the  disease  itself. 

Let  us  now  inquire  whether  the  alterations  found  after  death  can  explain 
the  symptoms  observed  at  the  bedside. 

The  first  post-mortem  examination  which  I  made  was  entirely  negative  as 
regards  the  anatomical  lesion;  perhaps,  however,  because  it  was  incomplete. 
In  the  second  case  there  was  found  very  marked  atrophy  of  the  roots  of 
the  hypoglossal  nerve,  without  any  alteration  of  the  muscular  fibres  them- 
selves. The  medulla  oblongata  was  apparently  also  of  greater  consistency 
than  normal. 


918  ON    &LOSSO -LARYNGEAL    PARALYSIS. 

In  the  third  case,  I  found  well-marked  thickening  and  gray  discoloration 
of  the  dura  mater,  on  a  level  with  the  medulla  oblongata,  and  as  far  down 
as  the  roots  of  the  fourth  cervical  pair.  This  thickening  was  due  to  a  con- 
siderable increase  in  the  amount  of  fibres  of  connective  and  fibro-elastic 
tissue,  and  seemed  to  result  from  a  chronic  congestive  process,  as  shown  by 
the  great  number  of  capillaries  and  of  deposits  of  ha^matin  external  to 
them. 

The  roots  of  the  hypoglossal  and  spinal  accessory  nerves  were  atrophied, 
and  reduced  in  several  places  to  the  neurilemma ;  and  at  the  spot  where 
the  spinal  accessory  was  in  contact  with  the  dura  mater  there  was  adhesion 
of  the  neurilemma  to  the  fibrous  envelope  of  the  cord,  and  a  deposit  of  a 
nucleus  of  connective  tissue  of  the  size  of  a  pea.  A  good  many  motor  roots 
in  the  cervical  region  Avere  thinner  than  natural,  from  partial  disappearance 
of  the  nerve-tubes.  With  the  aid  of  the  microscope,  the  neurilemma  was 
seen  to  preponderate  everywhere  over  the  nerve-tissue  properly  so  called, 
and  notable  hyperemia  could  be  detected  everywhere,  also  together  with 
grayish  discoloration  of  the  neurilemma.  The  cord  itself,  and  the  upper 
part  of  the  anterior  columns,  was  as  congested  and  of  the  same  color  as  the 
posterior  columns  are  found  to  be  in  cases  of  progressive  locomotor  ataxy. 

The  fibres  of  the  palsied  muscles  of  the  tongue,  soft  palate,  lips,  chin, 
and  cheek,  &c.,  were  unaltered.  As  to  the  diminution  in  size  of  the  mus- 
cles of  the  right  leg,  and  their  condition  of  incipient  fatty  degeneration, 
they  need  only  be  mentioned. 

From  the  study  of  these  three  cases  it  follows,  that  in  this  complaint  the 
paralysis  is  due  to  an  alteration  of  the  motor  roots  which  supply  the  affected 
muscles,  these  latter  in  most  cases  presenting  no  change  of  volume  and 
structure. 

The  complete  paralysis  of  the  tongue  is  accounted  for  by  the  general 
atrophy  and  complete  disappearance,  in  some  places,  of  the  roots  of  the  hy- 
poglossal nerve.  In  Dr.  DumeniTs  case,  the  alteration  was  not  confined  to 
the  roots  alone,  for  the  trunk  itself  and  all  the  branches  of  the  nerve  were 
of  a  grayish  color  and  notably  atrophied.  The  lingual  nerve,  on  the  con- 
trary, which  is  a  branch  of  the  sensory  portion  of  the  fifth  cranial  pair,  was 
normal,  as  well  as  the  glosso-pharyngeal,  so  that  the  healthy  condition  of 
these  nerves  accounted  for  the  preservation  of  the  general  and  special  - 
bilitv  of  the  surface  of  the  tongue.  Electro-muscular  sensibility  had  been 
-  at  in  the  beginning,  but  had  diminished  by  degrees,  and  the  nervous 
influence  which  reached  the  muscle  being  feeble  only,  electricity  gave  little 
relief  to  the  patients.  Thus  was  explained,  first  the  difficulty,  and  next  the 
almost  complete  inability  to  swallow. 

The  embarrassment  of  speech  and  the  modifications  in  the  resonanc 
the  voice  are  explained  by  the  paralysis  of  the  muscles  "1"  tin-  tongut 
palate,  lips,  and  chin.  Perhaps  an  alteration  of  the  deep  roots  of  the  facial 
nerve  would  have  been  detected,  had  the  examination  been  carried  bo  for; 
but  in  default  of  this  Dr.  Dumenil  found  structural  alteration-  of  the  trunk 
of  the  facial  and  it-  branches,  which  accounted  for  the  loss  of  contractility 
of  the  orbicularis  oris,  which  is  indispensable  for  the  pronunciation  of  the 
so-called  labials,  and  particularly  of  the  letters  0  and  n.      The  alteration  of 

the  facial  also  ac< ated  for  the  paralysis  of  the  buccinators,  the  muscles  of 

tin    soft  palate  and  chin,  which  are  supplied  by  this  nerve. 

We  found,  a-  you  remember,  grave  lesions  in  the  bulbous  and  spinal  por- 
tion- of  tic'  spinal  accessory.  <  >ur  attention  was  directed  also  to  the  pneii- 
mogastric,  the  roots  of  which  were  atrophied.  The  anatomical  facts  which 
we  have  mentioned  account  perfectly,  therefore,  for  the  principal  phenomena 


ON    GLOSBO -LARYNGEAL    PARALYSIS.  919 

which  have  been  observed,  and  agree  entirely  with  the  results  of  physio- 
logical experiment. 

The  patient,  however,  had  not  only  lost  the  faculty  of  speech,  but  had 
also  become  affected  with  nearly  complete  aphonia.  This  phenomenon  de- 
pended on  two  causes,  namely,  paralysis  of  the  muscles  of  the  larynx  ami 
paralysis  of  the  thoracic  muscles.  Indeed,  physiological  experiments  prove 
that  when  the  spinal  accessory  is  torn  off  at  its  roots,  aphonia  is  brought  on 
through  the  relaxation  of  the  vocal  cords,  which  therefore  become  incapable 
of  producing  vocal  sounds.  On  the  other  hand,  Longet  and  Claude  Ber- 
nard have  shown  that  the  section  of  both  inferior  laryngeal  nerves  causes 
occlusion  of  the  glottis  during  inspiration,  and  consecpaently  death  by 
asphyxia.  This  occlusion  of  the  glottis  can  explain  the  sudden  death  of 
the  patient,  with  this  reservation,  however,  that  in  old  persons  as  well  as  in 
old  animals,  the  complete  occlusion  of  the  glottis  is  not  probable,  on  account 
of  the  considerable  development  of  the  anterior  processes  of  the  arytenoid 
cartilages,  which  leave  between  them  an  interval,  open  at  all  times,  and 
called  by  Longet  the  respiratory  glottis. 

The  absence  of  tension  of  the  glottis  explains  the  feebleness  of  the  voice ; 
whilst,  through  the  spinal  accessory  being  diseased,  there  can  be  no  pro- 
longed voluntary  expiration,  so  as  to  sustain  the  voice,  and  when  the  pa- 
tient, therefore,  makes  a  great  effort  to  utter  a  sound,  he  only  succeeds  in 
producing  a  short  and  low  grunt. 

In  order  to  explain  the  feebleness  of  the  voice,  we  must  also  keep  in 
mind  the  weakness  of  the  thoracic  muscles,  which  scarcely  inspire,  and  have 
consequently  little  to  expire ;  and  if  at  rare  intervals  a  deep  inspiration  is 
made,  perhaps  it  is  to  be  ascribed  to  an  affection  of  the  pneumogastric. 
For  is  it  not  known  that,  whilst  accelerating  the  heart's  action,  division  of 
the  vagus  slackens  respiration,  and  that  the  animal  which  is  the  subject  of 
the  experiment  makes  deeper  inspirations  at  intervals?  The  feeble  con- 
traction of  the  diaphragm  is  explained  by  the  lesion  of  the  motor  spinal 
roots  from  which  the  phrenic  derives  its  nervous  influence. 

\Ve  thus  see  that  physiological  facts  are  in  complete  accordance  with 
pathological  observation  to  account  for  the  symptoms  or  functional  dis- 
turbances met  with  in  this  disease,  namely,  feebleness  of  the  voice,  slacken- 
ing of  the  respiration,  and  death  by  suffocation  or  asphyxia.  All  these 
phenomena  are  the  results  of  disease  of  the  spinal  accessory  nerve. 

The  physiology  of  that  nerve  gives  us  also  an  explanation  of  other  phe- 
nomena. "  If  to  an  animal  in  which  the  spinal  accessory  nerves  have  been 
torn  off,"  says  Claude  Bernard,  "  appropriate  food  be  thrown,  it  rushes  on 
it  voraciously ;  but  it  soon  gets  less  ardent,  and  eating  more  slowly,  stops 
and  lifts  up  its  head  every  time  it  swallows.  If  it  be  suddenly  disturbed  at 
that  instant,  a  sort  of  cough  or  of  sneezing  is  sometimes  produced,  as  if  por- 
tions of  food  had  a  tendency  to  pass  into  the  trachea."  !Note,  gentlemen, 
that  the  first  stage  of  deglutition  was  normal  in  such  cases,  and  that  there 
had  been  no  lesion  of  the  hypoglossal  nerve.  This  impediment  in  the  second 
stage  of  deglutition  is  explained  by  the  paralysis  of  the  pharyngeal  branch 
of  the  spinal  accessory,  but  there  is  no  complete  paralysis  of  the  pharynx, 
because  its  muscles  receive  other  motor  branches  from  the  pharyngeal 
plexus. 

Have  we  not,  indeed,  found  in  our  cases  that  the  food  often  got  into  the 
larynx,  and  that  the  sensibility  of  this  organ,  which  was  unimpaired,  then 
caused  reflex  contractions  of  its  muscles,  often,  however,  insufficient  to  ex- 
pel the  foreign  body  ?  These  phenomena  are  analogous  to  those  observed  in 
animals  after  the  spinal  accessory  nerves  have  been  torn  off,  and  in  whose 


920  ON    GLOSSO-LARYNGEAL    PARALYSIS. 

trachea  and  bronchial  tubes,  and  upper  lobe  of  the  lungs  even,  portions  of 
food  may  be  found. 

Sensibility,  therefore,  is  presei'ved  in  the  larynx  as  well  as  in  the  tongue 
and  palate.  The  sensibility  of  the  larynx,  as  you  well  know,  depends  on 
the  superior  laryngeal  nerve,  which  supplies  only  one  laryngeal  muscle, 
the  crico-thyroid.  The  use  of  this  muscle  is  to  swing  the  thyroid  cartilage 
on  the  cricoid,  and  thus  to  tighten  the  glottis.  The  superior  laryngeal  is, 
therefore,  partly  a  motor  nerve,  and,  indeed,  the  experiments  of  Professor 
Claude  Bernard  have  led  him  to  believe  that,  although  almost  exclusively 
sensitive,  the  pneumogastric  had  still  the  power  of  exciting  contractions. 
This  motor  power  of  the  nerve  is  special,  and  might  be  termed  respiratory ; 
because,  after  the  spinal  accessory  has  been  destroyed,  and  the  functions  of 
the  larynx,  as  the  organ  of  sound,  abolished,  respiration  goes  on  when  the 
animal  is  at  rest ;  but  if  the  pneumogastric  be  torn,  or  the  recurrent  laryn- 
geal nerve  be  divided,  the  dilatation  of  the  glottis  is  immediately  replaced 
by  a  flaccid  condition,  and  the  animal  dies  of  suffocation  brought  on  by  the 
approximation  of  the  lips  of  the  glottis  during  inspiration. 

If  the  spinal  accessory  be  an  undoubted  respiratory  nerve,  acting  volun- 
tarily on  the  muscles  of  the  larynx  and  the  supplementary  muscles  of  res- 
piration, the  pneumogastric  is  an  involuntary  nerve,  a  nerve  of  organic 
life,  which  presides  in  the  larynx  as  in  the  lungs  over  the  maintenance  of 
the  respiratory  functions.  It  is  from  the  pneumogastric,  then,  that  the 
laryngeal,  tracheal,  and  bronchial  mucous  membrane,  as  well  as  the  crico- 
thyroid muscles  and  the  muscular  fibres  of  the  bronchial  tubes,  derive  their 
sensory  and  motor  properties  ;  and  this  fact  explains  how  oxygenation  of 
the  blood  continues  in  cases  of  glosso-laryngeal  paralysis,  in  spite  of  the 
lesiou  of  the  spinal  accessory  nerves  and  the  anterior  roots  of  the  cervical 
and  thoracic  spinal  nerves.  That  the  vocal  is  not  dependent  on  the  respi- 
ratory larynx  is  again  proved  by  comparative  anatomy,  for  birds  have  a 
distinct  vocal  as  well  as  a  respiratory  larynx.  Lastly,  is  it  not  remarkable 
that  in  the  complaint  which  we  are  now  studying,  the  lesions  at  the  onset 
are  almost  exclusively  confined  to  the  muscles  of  the  life  of  relation,  as 
shown  by  an  alteration  of  the  voice,  of  articulation,  of  expression,  and  phys- 
iognomy? while  it  is  only  secondarily  that  the  tongue,  the  soft  palate, 
and  the  pharynx,  become  affected  as  organs  of  deglutition  and  muscles  of 
organic  life.  Later,  however,  and  sometimes  simultaneously  with,  or  even 
before  the  setting  in  of  the  impediment  of  speech,  paralysis  of  some  of  the 
muscles  of  animal  life  is  observed,  as  in  the  cases  recorded  by  Drs.  Du- 
chenne  and  Dumenil,  and  in  the  cases  which  fell  under  my  own  observa- 
tion. 

The  healthy  condition  of  the  pneumogastric  in  some  cases,  and  the  slight 
degree  in  which  it  is  affected  in  others,  explain  how  it  is  that  the  other 
functions  over  which  tins  nerve  presides  remain  nearly  normal.  Thus,  in 
no  case  was  there  paralysis  of  the  oesophagus,  or  of  the  stomach  :  and  se- 
cretion of  thi'  gastric  juice,  and  gastric  absorption,  seemed  to  continue  nor- 
mally. As  to  tin-  genera]  debility  and  the  wasting  occurring  during  the 
lasl  days  of  the  patient's  life,  they  are  sufficiently  accounted  for,  I  believe, 
by  the  inability  to  swallow,  by  the  patient's  confinement  to  bed,  and  per- 
haps by  the  considerable  loss  of  saliva  through  the  opened  mouth. 

I  have  described  to  you,  gentlemen,  the  chief  symptoms  of  glosso-laryn- 
geal paralysis,  the  post-mortem  appearances  mel  with,  and  I  have  attempted 
an  explanation  of  the  symptoms,  thai  is  to  say,  the  pathological  physiology 
of  the  disease,  grounding  my  opinions  on  the  anatomical  lesions  Pound,  and 
on  the  learned  experimental  researches  of  physiologists.  It  now  remains 
for   me,  in   order  to  complete  the   description    of  this   complaint,  to  draw 


ON    GLOSSO-LARYNGEAL    PARALYSIS.  921 

your  attention  to  its  course,  its  modes  of  termination,  and  its  differential 
diagnosis. 

At  the  beginning  of  this  conference  I  told  you  that  glosso-laryngeal 
paralysis  always  terminated  in  death  ;  and  I  do  not  believe  that  a  single 
case  of  this  disease  is  on  record  in  which  its  progress  has  been  arrested 
even  for  a  few  months.  At  the  outset,  however,  the  progress  of  the  malady 
may  be  somewhat  slow.  The  patient  has  an  embarrassment  in  his  speech 
for  three,  four,  five,  or  six  months,  and  he  has  some  difficulty  in  keeping 
his  saliva  in  his  mouth  ;  but  as  soon  as  deglutition  becomes  difficult,  the 
disease  makes  rapid  progress  in  most  cases,  and  life  is  soon  gravely  compro- 
mised. 

The  disease,  which  had  at  first  been  apparently  confined  to  the  inferior 
segment  of  the  face,  and  to  the  tongue,  soon  invades  the  larynx,  the  walls 
of  the  chest,  and  the  diaphragm.  The  respiration,  it  is  true,  seems  to  be 
carried  on  with  regularity  still,  but  each  inspiration  is  feeble,  the  patient 
seeming  then  to  breathe  after  the  manner  of  hibernating  animals;  and  this 
incomplete  respiration  must,  sooner  or  later,  cause  appreciable  modifications 
in  calorification  and  the  oxygenation  of  the  blood.  In  order  to  make  the 
respiratory  feebleness  very  apparent,  it  is  only  necessary  to  ask  the  patient 
to  make  some  effort,  when  not  only  is  feebleness  observed,  but  also  a  want 
of  harmony  in  the  performance  of  the  respiratory  act. 

The  patient  can  no  longer  take  in  air  enough  to  blow  out  a  candle  ;  he 
can  no  longer  keep  up  the  amount  of  effort  necessary  to  allow  him  to  get 
into  bed,  or  to  walk  a  little  briskly  ;  still  less  can  he  go  up  stairs,  for  the 
least  effort  makes  him  pant  for  breath,  and  compels  him  to  stop  suddenly. 
He  is  unable  to  make  an  effort,  because,  owing  to  the  paralysis  of  the  spinal 
accessory,  the  aperture  of  the  glottis  remains  wide  open,  and  because  the 
walls  of  the  chest  being  no  longer  supported  by  the  sterno-mastoid  and 
trapezii  muscles,  which  are  now  powerless,  fall  back  on  the  lungs.  From 
the  inability  of  -the  inspiratory  muscles  to  store  up  air  within  the  lungs 
result  the  feebleness  of  the  voice,  and  the  disorders  which  must  follow  on 
deficient  oxygenation  of  the  blood,  rendered  sometimes  still  more  imperfect 
by  paralysis  of  the  diaphragm. 

Condemned  to  a  nearly  complete  immobility,  the  patient  is  almost  always 
in  bed  or  sitting  in  a  chair.  For  the  same  reason  that  he  cannot  walk,  he 
cannot  make  the  effort  of  coughing  and  expectorating,  that  is  to  say,  he 
cannot  make  with  his  thoracic  bellows  the  sudden  inspiratory  movements 
that  are  requisite  for  detaching  the  mucus  contained  in  his  bronchi  in  order 
to  reject  them  by  a  violent  expiration.  This  impairment  of  the  chest-walls 
is  a  grave  prognostic  sign,  because  the  least  attack  of  bronchitis  may,  by 
causing  engorgement  of  the  lungs,  kill  the  patient  by  asphyxia.  Bronchitis, 
however,  is  not  always  a  proximate  cause  of  death,  and  indeed  you  saw  that 
the  patient  at  No.  19,  in  St.  Agnes  Ward,  did  not  die  of  the  bronchitis 
which  attacked  him.  We  must  admit,  in  such  cases,  that  through  a  special 
organic  contractility,  the  air-passages  gradually  rid  themselves  of  their 
mucus  by  expelling  it  into  the  trachea  and  larynx.  We  almost  have  a  proof 
of  this  hypothesis  in  the  laryngeal  embarrassment  complained  of  by  the 
patient  in  such  cases.  He  is  seen  to  make  feeble  efforts  in  his  attempts  to 
cough  and  clear  his  larynx ;  but  he  is  unable  to  expectorate,  and  if  the 
mucus  be  not  immediately  swallowed,  it  sojourns  a  variable  time  in  the 
pharynx.  In  order  to  clear  his  pharynx,  the  patient  again  tries  to  cough, 
whilst,  by  passing  his  finger  down  to  the  back  of  his  mouth,  he  produces  a 
tendency  to  vomiting,  through  w7hich  the  mucus  is  brought  up  as  far  as  the 
base  of  his  tongue,  where  he  can  seize  it  with  his  fingers. 

In  the  description  which  I  gave  you  of  the  disease,  I  did  not  lay  great 


922  OX    GLOSSO-LARYNGEAL    PARALYSIS. 

stress  on  the  dribbling  of  saliva  out  of  the  mouth,  a  circumstance  which  is 
constantly  observed,  and  which  persists  until  the  death  of  the  patient.  I 
did  not  speak  to  you  either  of  the  grave  consequences  which  had  been  at- 
tributed to  this  prolonged  loss  of  saliva,  because  there  are  on  record  cases 
of  salivary  fistula  which,  in  man,  and  in  horses  also,  did  not  bring  on  failure 
of  strength  or  marked  wasting.  Dr.  Vella,  however,  a  professor  at  the 
University  of  Modena,  and  Dr.  Duchenne,  have  ascribed  to  this  circumstance 
some  share  in  the  general  debility  observed  in  these  cases. 

But  the  progressive  course  of  the  paralysis  of  the  muscles  primarily  at- 
tacked, and  the  implication  of  other  portions  of  the  muscular  system,  taken 
together  with  the  pathological  lesions  observed,  suffice  to  show  the  gravity 
of  such  a  paralysis.  The  almost  complete  dysphagia,  and  the  extreme  fre- 
quency of  attacks  of  choking  caused  by  the  passage  of  food  into  the  larynx, 
give  rise  to  fears  that  the  amount  of  food  taken  will  prove  insufficient,  and 
that  death  bv  asphyxia  is  ever  imminent.  Indeed,  the  patients  die  of  star- 
vation, and  more  frequently  through  being  choked.  Now  when  death  is 
not  preceded  by  any  symptoms  of  pain  or  by  spasms,  has  one  a  right  to 
suppose  that  syncope  was  a  proximate  cause  of  the  fatal  termination  ?  The 
patient  at  Xo.  19,  in  St.  Agnes  Ward,  probably  died  from  a  sudden  arrest 
of  the  heart's  action,  and  the  post-mortem  examination  showed  that  the 
cavities  of  the  heart  were  distended  by  large  clots  of  blood. 

There  is  another  mode  of  fatal  termination,  by  asphyxia,  identical  with 
that  observed  in  cases  of  the  general  paralysis  of  the  insane,  and  which  is 
due  to  an  arrest  of  the  food  on  a  level  with  the  upper  orifice  of  the  oesopha- 
gus. This  accident  scarcely  ever  happens  except  at  a  period  when  the  patient 
'can  still  swallow  semi-solid  substances, whilst  in  the  last  stage  of  the  disease 
he  cannot  accomplish  this.  From  this  observation  may  be  deduced  a  thera- 
peutic indication,  namely,  that  life  may  still  be  prolonged  for  several  days, 
or  months,  if  the  morsel  of  food  be  extracted  in  time.  And,  as  you  may 
recollect,  the  life  of  the  woman  lying  at  Xo.  29,  in  the  St.  Bernard  Ward, 
was  thus  prolonged. 

Xow,  are  we  in  a  position,  with  the  aid  of  the  characters  of  this  disease, 
to  distinguish  it  from  any  other  local  or  general  paralysis? 

The  general  paralysis  of  the  insane  sets  in,  it  is  true,  with  an  embarra>s- 
ment  of  the  tongue  ;  but  there  may  be  noticed,  at  the  same  time,  slight  con- 
vulsive trembling  of  the  lips,  and  in  most  cases  delirium  is  observed  from 
the  beginning,  together  with  a  fixed  stare,  which  is  never  met  with  in  the 
patients  whose  cases  I  related  to  you.  Besides,  in  glosso-laryngeal  paralysis 
the  intellect  is  always  perfectly  clear,  and  the  patieuts  soon  find  out  the 
gravity  of  their  complaint;  whereas  this  is  not  the  case  in  the  paralysis  of 
the  insane.  Again,  in  this  last  affection,  if  sooner  or  later  general  feebleness 
of  the  muscular  contractility  be  observed,  in  no  case  does  this  paralysis  affect 
specially  the  muscles  of  the  soft  palate,  nor  is  there  ever  dribbling  of  the 
saliva,  whilst  from  the  beginning  the  practitioner  is  led,  on  account  of  the 
failure  of  the  intelligence,  to  locate  the  disease  in  the  brain. 

AVu  need  not  stop  to  diagnose  hemiplegia  from  this  form  of  paralysis,  be- 
cause, if  in  our  patients  we  often  Pound  paralysis  of  one  .if  the  upper  or 
lower  limbs,  we  at  the  same  time  discovered  disorders  of  motility  in  the 
muscles  of  the  tongue,  the  soft  palate,  and  the  lips,  which,  taken  as  a  whole, 
ami  from  the  symmetry  of  their  manifestations,  did  not  Buggesl  the  idea  of 
a  cerebral  hemiplegia. 

An    affection    which    is   of   very    rare    occurrence,   namely,   double  facial 

paralysis,  mighl  he  confounded  with  this  form  of  disease,  and  the  mistake 
would  he  excusable,  [ndeed,  in  double  facial  paralysis  the  muscles  of  the 
lips  are  motionless,  and  the  patient  has  consequently  a  difficulty  ill  pro- 


ON    GLOSSO-LARYNGEAL    PARALYSIS.  923 

noimcing  labials.  On  the  other  hand,  if  both  facial  nerves  be  diseased 
high  up  in  the  aqueduetus  fallopii,  the  consequence  will  be  that  the  pa- 
tient's voice  will  have  a  nasal  whine,  owing  to  the  paralysis  of  the  soft 
j)alate.  Let  us  add  again  that,  through  his  inability  to  contract  the  isth- 
inn-  faucium,  he  will  have  some  difficulty  in  swallowing. 

These  symptoms  resemble  very  much  those  of  glosso-laryngeal  paralysis, 
ami  yet  these  two  diseases  may  be  distinguished  from  one  another.  For  in 
the  former  the  hypoglossal  nerve  is  not  affected,  and  the  tongue  therefore 
is  not  impeded  in  its  movements.  In  the  latter,  on  the  contrary,  these 
movements  are  deeply  interfered  with.  Again,  in  double  facial  paralysis 
all  the  muscles  of  the  face  are  paralyzed,  and  whatever  moral  emotions  be 
felt  by  the  patient,  his  face  preserves  the  immobility  of  marble.  It  seems, 
as  Dr.  Duchenne  has  felicitously  expressed  it,  as  if  the  patient  laughed  or 
cried  from  behind  a  mask.  In  glosso-laryngeal  paralysis,  on  the  contrary, 
the  lower  part  of  the  face  alone  remains  motionless,  and  if  the  patient 
laughs,  he  laughs  with  his  eyes,  and  moves  his  zygomatici  and  the  muscles 
of  his  forehead.  If  he  weeps,  on  the  other  hand,  the  upper  part  of  his  face 
is  thrown  into  contraction  and  expresses  true  grief.  In  double  facial  paral- 
ysis, deglutition  is  scarcely  affected,  and  it  is  only  the  articulation  of  the 
letters  o  and  u  which  becomes  difficult. 

Glosso-laryngeal  paralysis  might  possibly,  in  the  beginning,  when  there 
-is  yet  no  great  impairment  of  motility  in  the  tongue  and  the  orbicularis 
oris,  be  confounded  with  diphtheritic  paralysis  restricted  to  the  soft  palate, 
or  implicating  other  muscles  as  well.  But  the  fact  of  there  having  been  a 
previous  attack  of  diphtheritic  angina,  or  a  previous  manifestation  of  diph- 
theria in  some  part  of  the  organism,  suggests  the  nature  of  the  case,  and 
the  diagnosis  will  soon  be  confirmed  by  the  isolated  localization  of  the 
paralysis  in  the  soft  palate,  or  in  cases  when  it  becomes  general,  by  other 
functional  disorders  which  are  never  observed  in  glosso-laryngeal  paralysis, 
namely,  modifications  of  the  general  sensibility  and  special  disorders  of 
vision. 

In  the  cases  when  progressive  muscular  atrophy  begins  in  the  tongue, 
and  next  attacks  the  soft  palate  and  the  orbicularis  oris  simultaneously,  or 
posteriorly  affecting  the  muscles  of  the  limbs  and  trunk,  a  mistake  might 
be  made.  Progressive  muscular  atrophy,  rarely,  however,  begins  in  that 
way  in  the  adult ;  and  even  were  it  to  do  so,  a  careful  examination  would 
soon  disclose  well-marked  muscular  atrophy  of  some  other  part  of  the 
body,  in  most  cases  in  the  thenar  and  hypothenar  eminences,  the  interossei 
muscles  of  the  hand,  &c.  Besides — and  Dr.  Duchenne  lays  great  stress 
on  this  fact — in  glosso-laryngeal  paralysis  the  paralysis  sets  in  at  once,  un- 
accompanied by  atrophy ;  whilst  in  progressive  muscular  atrophy,  the 
atrophy  is  primary,  and  paralysis  supervenes  only  after  the  destruction  of 
the  contractile  fibres. 

There  are  on  record  some  very  interesting  cases,  which  Dr.  Duchenne 
has  termed  cases  of  associated  diseases,  in  which  progressive  fatty  muscular 
atrophy  affecting  the  limbs  is  met  with  concurrently  with  paralysis,  with- 
out atrophy,  of  the  muscles  of  the  tongue,  the  soft  palate,  and  the  lips.* 
Dr.  Duchenne  thinks  that  there  are  two  distinct  diseases  associated  in 
such  cases.  But  must  we  entirely  concur  in  this  opinion  ?  When  in  the 
same  individual  you  find,  on  the  one  hand,  progressive  paralysis  of  the 
tongue  without  any  atrophy  of  the  organ,  and,  on  the  other  hand,  progres- 

*  Vide  Case  VIII  of  Dr.  Duchenne's  memoir,  and  Dr.  Dumenil's  case,  Gaz. 
Hebd.,  1859  and  1861. 


924  ON    GLOSSO-LARYNGEAL    PARALYSIS. 

sive  muscular  atrophy  in  other  parts  of  the  body,  will  you  not  incline  to 
the  opinion  that  these  two  morbid  conditions  are  dependent  on  the  same 
organic  lesion  ?  Lastly,  if  pathological  anatomy  proves  to  you  that  the 
roots  of  the  hypoglossal  and  the  spinal  motor  roots  have  undergone  the 
same  alterations,  can  you  refuse  to  believe  that  the  same  anatomical 
nerve-lesion  has  produced  in  one  part  paralysis  of  the  tongue  without 
atrophy,  and  in  another  part  paralysis  with  fatty  degeneration  of  certain 
muscles  ? 

Dissection  has  sho\vn  that,  in  glosso-laryngeal  paralysis,  the  lesion  was 
primarily  seated  in  the  upper  portion  of  the  cord  and  in  the  motor  roots. 
We  saw  that,  in  that  part  only,  had  the  dura  mater  acquired  considerable 
thickness,  and  that  it  presented  a  highly  vascular  condition,  with  grayish 
discoloration,  pointing  to  congestion  of  ancient  date.  We  saw  the  roots  of 
the  spinal  accessory  nerve  reduced  to  their  neurilemma,  and  we  noted  in- 
cipient atrophy  of  the  cervical  roots. 

These  anatomical  details  sufficiently  indicate  the  gravity  of  glosso-laryn- 
geal paralysis.  But  does  it  follow  that,  in  no  case,  is  the  physician  able 
to  help  the  patient  ?  It  is  plain  that  in  the  two  first  stages  of  the  disease 
the  physician  can,  I  do  not  say  arrest  completely  the  progress  of  the  disease, 
but  at  least  prevent  it  from  being  so  very  rapid,  and  can  relieve  for  some 
time.  He  is  still  able,  with  only  one  remedy,  namely,  faradization  of  the 
affected  muscles,  to  restore  to  them  a  transient  contractility,  and  thus  ob- 
tain that  deglutition  be  accomplished  with  a  little  less  difficulty  and  pain, 
and  consequently  that  food  be  taken  more  regularly  and  effectually.  He 
may,  by  galvanizing  the  auxiliary  muscles  of  respiration,  the  intercostal 
muscles,  and  the  phrenic  nerve,  favor  the  action  of  the  contractile  agents 
of  thoracic  and  diaphragmatic  breathing.  But  the  power  of  the  physician 
does  not  go  beyond  this,  and  little  trust  is  to  be  placed  on  the  passing  of 
probangs  down  the  oesophagus,  and  on  the  administration  of  strychnine. 

Lastly,  does  the  nature  of  the  disease  point  to  a  special  method  of  treat- 
ment? 'Nothing  has  been  or  could  be  tried  on  that  ground,  since  those 
who  studied  the'complaint  having  only  the  interpretation  of  the  symptoms 
to  guide  them,  could  only  conclude  in  the  existence  of  a  paralysis  of  unde- 
termined causation.  An  injury  or  the  rheumatic  diathesis  could  not  be 
invoked  as  the  cause;  nor  could  any  poison  in  the  blood  account  for  the 
phenomena  observed.  So  that  the  symptom  paralysis  could  alone  be  com- 
bated. Let  me  add  that  the  seat  of  the  first  manifestations  of  the  disease, 
and  the  absence  of  all  cerebral  symptom,  did  not  admit  of  the  supposition 
that  the  morbid  cause  was  seated  in  the  brain.  The  pain  in  the  occipital 
and  cervical  region,  as  well  as  the  sensation  of  pharyngeal  constriction, 
could  only  suggest  the  idea  of  an  inflammatory  lesion  of  the  hull)  and  the 
upper  portion  of  the  cord,  in  the  same  way  as  the  functional  disorders  led  one 
to  believe  that  the  hypoglossal,  the  spinal  accessory,  and  the  spinal  oerves 
were  perhaps  diseased  at  their  roots  or  in  some  point  of  their  course.  Hut 
the  oeeipital  and  cervical  pain  was  not  present  in  all  the  eases.  And  even 
if  a  lesion  of  the  nervous  system  could  have  been  almost  affirmed,  the  hy- 
pothesis of  an  anatomical  lesion  could  have  been  expresssed  with  some 
reservation  only. 

Dissection  alone  could  shed  light  on  this  twofold  question  of  morbid 
nature  and  etiology.  The  post-mortem  appearances  found  in  the  patient 
No.  19,  St.  Agnes  Ward,  pointed  to  extensive  lesions,  which,  together  with 
those  which  wo  had  already  found  in  the  patient  No.  '.!•">,  in  St.  kgnes  Ward, 
and  the  distincl  statements  made  by  Dr.  Dum6nil,  constitute  together  an 
amount  of  information  of  considerable  importance. 


ON    GLOSSO-LARYNGEAL    PARALYSIS.  925 

From  all  these  facts  it  follows  that,  in  glosso-laryngeal  paralysis,  anatomi- 
cal lesions  may  be  met  with  characterized  by  the  atrophy  of  the  roots  of 
motor  nerves,  namely,  the  hypoglossal,  spinal  accessory,  and  spinal  nerves. 
This  atrophy,  which  is  thoroughly  identical  with  that  described  by  Profes- 
sor Cruveilhier  and  other  observers,  in  cases  of  progressive  muscular  atro- 
phy, seems  to  be  the  result  of  a  congestion  of  ancient  date,  causing  the 
gradual  disappearance  of  the  nerve-tube,  and  hypergenesis  of  the  connective 
tissue  and  neurilemma  of  the  motor  roots.  The  spinal  cord  itself  partici- 
pates also  in  the  same  congestive  process. 

It  now  remains  to  determine  whether  this  hyperemia  is  of  an  inflamma- 
tory nature ;  and  if  inflammation  be  once  admitted,  the  predisposing  and 
exciting  causes  of  this  inflammatory  process  will  have  to  be  investigated, 
and  the  point  determined  whether  it  does  not  depend  on  a  special  diathesis. 

To  try  and  solve  such  problems  would  be  opening  up  a  vast  field  to 
hypothesis.  We  are  at  present  in  possession  of  no  fact  which  authorizes  us 
to  discuss  any  of  them.  I  prefer  taking  only  into  account  the  hyperemia, 
as  shown  by  an  exaggerated  vascular  condition,  the  deposits  of  hsematin, 
and  the  hyperformation  of  the  connective  tissue.  We  should,  therefore, 
merely  seek  for  remedial  measures  capable  of  combating  this  hypersemia. 
And  even  then  we  can  hope  to  interfere  with  some  degree  of  success  only 
at  the  outset  of  the  disease,  in  the  stage  of  congestion ;  for  when  the  ana- 
tomical alteration  has  been  once  produced,  no  practitioner  could  ever 
think  of  making  fresh  nerve-tubes  and  of  regenerating  a  portion  of  the 
spinal  cord. 


END   OF    VOLUME   ONE. 


CLASSIFIED  INDEX 

(BY  SUBJECTS) 


OF 


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NO.    1012    WALNUT    STREET,    PHILADELPHIA. 

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111 


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Philadelphia,  January  2d,  1882. 

ANNOUNCEMENT.    - 

The  Copartnership  heretofore  existing  between  Robert  Lindsay  and 
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Publishers  and  Booksellers,  is  this  day  dissolved,  by  mutual  consent. 

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P.  BLAKISTON,  SON  &  CO. 


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AMERICAN  HEALTH  PRIMERS. 

Edited  by  W.  W.  Keen,  m.d.     Complete  in  12  volumes,  handsomely  bound  in 

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I.  Hearing  and  How  to  Keep  It.     With  illus- 
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ACTON,  THE  REPRODUCTIVE  ORGANS. 

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ALLEN,  COMMERCIAL  ORGANIC  ANALYSIS. 

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BLACK,  THE  REPRODUCTIVE  AND  RENAL  ORGANS. 

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DISEASES  OF  THE  KIDNEYS. 

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BLOXAM.  CHEMISTRY, Inorganic  and  Organic.  Fourth  Edition. 

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BLOXAM.     LABORATORY  TEACHING.     Fourth  Edition. 

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BRUEN.     PHYSICAL  DIAGNOSIS.    Just  Ready. 

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BENNETT.     NUTRITION  IN  HEALTH  AND  DISEASE. 

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uy  same  author. 

THE     TREATMENT    OF     PULMONARY     CONSUMPTION 
BY  HYGIENE,  CLIMATE  AND  MEDICINE. 

With  an  Appendix  on  the  Sanitaria  of  the  United  States,  Switzerland  and 
the  Balearic  Islands.     Third  Edition  much  Enlarged.  Price  $2.50 

"Any  physician  may  take  it  up  with  every  feeling  of  confidence  that  the  views  enunciated  by  the  author  will  be 
found  to  be  able,  honest  and  orthodox." — Medico-  Ckirurgical  Review. 

BERKART,  ASTHMA. 

The  Pathology  and  Treatment  of  Asthma.  By  Joseph  B.  Berk  art,  m.d. 
8vo.  "  Price  #3.50 


PUBLICATIONS. 


BEALE  ON   SLIGHT  AILMENTS. 

Slight  Ailments,  Their  Nature  and  Treatment.  By  Lionel  S.  Beale,  m.d., 
f.r.s.,  Professor  of  Practice,  King's  Medical  College,  London.    i2mo.    Price  $i. 75 

OUTLINE   OF   CONTENTS. 
Introductory.    The  Tongue  in  Health  and  Slight  Ailments.   Appetite.    Nausea.    Thirst.    Hunger.    Indigestion, 
its  Nature  and  Treatment.     Constipation,  its  Treatment.     Diarrhoea.     Vertigo.     Giddiness.     Biliousness.     Sick 
Headache.     Neuralgia.     Rheumatism.     The  Feverish  and  Inflammatory  State.     Of  the  Actual  Changes  in  Fever 
and  Inflammation.     Common  Forms  of  Slight  Inflammation,  etc.,  etc. 

"  We  venture  to  say  that  among  the  numerous  medical  publications  issued  during  1880  there  has  been  none 
which  will  prove  more  useful  to  the  young  general  practitioner,  for  whom  it  is  really  intended,  than  this  volume, 
while  the  time  of  the  older  physician  might  be  much  more  unprofitably  spent." — American  Journal  0/ Medical 
Science. 

BY   SAME   AUTHOR. 

ON  LIFE  AND  VITAL  ACTION  IN  HEALTH  AND  DISEASE. 
l2mo.  Price  $2.00 

THE  USE  OF  THE  MICROSCOPE  IN  PRACTICAL  MEDI- 
CINE. 

For  Students  and  Practitioners,  with  full  directions  for  examining  the  various 
secretions,  etc.,  in  the  Microscope.  Fourth  Edition.  500  Illustrations.  Much 
enlarged.     8vo.  Price  $7.50 

As  a  microscopical    observer,  and  a  histological 


manipulator,  his  (Dr.  Beale)  skill  and  eminence   are 
generally  conceded." — Popular  Science  Monthly. 


"  We  have  before  us  Prof.  Beale's  work,  The  Micro- 
scope in  Medicine,  a  book  which  it  gives  us  pleasure  to 
recommend  to  every  student  of  microscopy,  whether  he 
be  a  physician  or  naturalist." — Journal  of  the  Frank- 
lin Institute,  Philadelphia. 

HOW  TO  WORK  WITH  THE  MICROSCOPE. 

A  Complete  Manual  of  Microscopical  Manipulation,  containing  a  full  descrip- 
tion of  many  new  processes  of  investigation,  with  directions  for  examining  ob- 
jects under  the  highest  powers,  and  for  taking  photographs  of  microscopic 
objects.  Fifth  Edition.  Containing  over  400  Illustrations,  many  of  them  colored. 
Octavo.  Price  $7.50 

"The  Encyclopaedic  character  of  this  last  edition  of  Dr.  Beale's  well  known  work  on  the  Microscope  renders 
It  impossible  to  present  an  abstract  of  its  contents  ;  suffice  it  to  say,  that  anything  in  his  department  upon  which 
the  physican  can  desire  such  information  will  be  found  here,  and  much  more  in  addition.  It  is,  moreover,  a  store- 
house of  facts,  most  valuable  to  the  physician,  and  is  indispensable  to  every  one  who  uses  the  microscope." — 
American  Journal  of  Medical  Science. 

BIOPLASM. 

A  Contribution  to  the  Physiology  of  Life,  or  an  Introduction  to  the  Study  of 
Physiology  and  Medicine,  for  Students.     With  numerous  Illustrations. 

Price  $2.25 
PROTOPLASM;  or  MATTER  AND  LIFE. 

Third  Edition,  very  much  enlarged.  Nearly  350  pages.  Sixteen  Colored 
Plates.  Part  1.  Dissentient.  Part  11.  Demonstrative.  Part  in.  Suggestive. 
One  volume.  Price  §3.00 

LIFE    THEORIES ;    Their  Influence   upon  Religious    Thought. 

Six  Colored  Plates.  Price  $2.00 

ONE  HUNDRED  URINARY  DEPOSITS, 

On  two  sheets,  for  the  Hospital,  Laboratory,  or  Surgery.  Each  Sheet  $1.00,  or 
on  Rollers,  Price  £1.25 

BERNAY,  CHEMISTRY. 

Notes  for  Students  in  Chemistry.  Compiled  from  Fowne's  and  other  manuals. 
By  Albert  J.  Bernay,  PH.D.     Sixth  Edition,     nrao.  Price  $1.25 

BOCK,  ANATOMY. 

An  Atlas  of  Human  Anatomy.  By  Prof.  C.  E.  Bock,  of  Berlin.  Thirty-seven 
Colored  Plates,  containing  about  200  figures.    Quarto.    Half  Roan.    Price  $  15-00 

This  is  one  of  if  not  the  best  Anatomical  Atlas  now  to  be  had,  and  its  produc- 
tion in  Germany  makes  it  certainly  the  cheapest. 


PPESLE  Y  BLAKISTON'  S 


BEASLEY.  THE  BOOK  OF  PRESCRIPTIONS. 

Containing  over  3100  Prescriptions,  collected  from  the  Practice  of  the  most 
Eminent  Physicians  and  Surgeons — English,  French  and  American ;  a  Com- 
pendious History  of  the  Materia  Medica,  Lists  of  the  Doses  of  all  Officinal  and 
Established  Preparations,  and  an  Index  of  Diseases  and  their  Remedies.  By 
Henry  Beasley.     Fifth  Edition,  Revised  and  Enlarged.  Price  $2.25 

BY    SAME  AUTHOR. 

THE  DRUGGIST'S  GENERAL  RECEIPT-BOOK. 

Comprising  a  copious  Veterinary  Formulary;  numerous  Recipes  in  Patent 
and  Proprietary  Medicines,  Druggists'  Nostrums,  etc. ;  Perfumery  and  Cos- 
metics; Beverages,  Dietetic  Articles  and  Condiments;  Trade  Chemicals,  Scien- 
tific Processes,  and  an  Appendix  of  Useful  Tables.    Eighth  Edition.    Price  $2.25 

THE  POCKET  FORMULARY  and  Synopsis  of  the  British  and 
Foreign  Pharmacopoeias. 

Comprising  Standard  and  Approved  Formulae  for  the  Preparations  and  Com- 
pounds  Employed   in    Medical   Practice.      Tenth    Edition.     511    pp.      i8mo. 

Price  $2*.  2  5 
BENTLEY  AND  TRIMEN'S  MEDICINAL  PLANTS. 

A  New  Illustrated  Work,  containing  full  botanical  descriptions,  with  an  account 
of  the  properties  and  uses  of  the  principal  plants  employed  in  medicine,  especial 
attention  being  paid  to  those  which  are  officinal  in  the  British  and  United  States 
Pharmacopoeias.  The  plants  which  supply  food  and  substances  required  by  the 
sick  and  convalescent  are  also  included.  By  R.  Bentley,  f.r.s.,  Professor  of 
Botany,  King's  College,  London,  and  H.  Trimen,  m.b.,  f.h.s.,  Department  of 
Botany,  British  Museum.  Each  species  illustrated  by  a  colored  plate  drawn 
from  nature.     In  Forty-two  parts.     Eight  colored  plates  in  each  part. 

Price  $2  each,  or  handsomely  bound  in  4  volumes,  Half  Morocco,  $90.00 


"  It  would  be  impossible  to  enumerate  all  the  new 
plants  that  are  here  delineated.  The  result  is  a  work 
which,  from  all  points  ofview,isa  credit  to  the  scientific 
literature  of  the  day." — London  Lancet. 

"It  is  an  indispensable  work  of  reference  to  every  one 
interested  in  pharmaceutical  Botany." — London  Phar- 
maceutical Journal. 


"  This  work  may  be  recommended  as  a  most  useful 
one  to  druggists,  and  all  who  desire  to  be  familiar 
with  the  Botany  of  Medicinal  Plants." — Drug-gists' 
Circular. 

"  The  work  when  complete  (it  is  now  complete) 
will  be  the  most  valuable  compend  of  Medical  Botany 
ever  published." — Boston  "Journal  of  Chemistry. 


Comparative  Anatomy  and  Physiology. 
Illustrations.     Third  Edition. 


BRADLEY,  ANATOMY. 

By  S.  M.  Bradley,  f.r.c.s.    Sixty 
Price  $2.00 

BRUNTON,  ACTION  OF  MEDICINES. 

Experimental  Investigation  of  the  Action  of  Medicines.  Part  I,  Circulation. 
By  T.  Lauder  Brunton,  m.d.,  f.r.s.     Second  Edition.  [Preparing. 

BYFORD.     DISEASES  OF  WOMEN.     New  Revised  Edition. 

The  Practice  of  Medicine  and  Surgery,  as  applied  to  the  Diseases  of  Womeft. 
By  W.  H.  Byford,  a.m.,  m.d.,  Professor  of  Obstetrics  and  The  Diseases  of  Wo- 
men and  Children,  in  the  Chicago  Medical  College.  Third  Edition.  Revised 
and  Enlarged,  much  of  it  rewritten,    with  numerous  additional  illustrations. 

Price,  in  Cloth  $5.00;  Leather,  $6.00 

"  The  author  is  an  experienced  writer,  an  able  teach- 
er  in  his  department,  and  has  embodied  in  the  present 
work  the  results  of  a  wide  field  of  practical  observa- 
tion. We  have  not  had  time  to  read  its  pages  critically, 
but  freely  commend  it  to  all  our  readers,  as  one  of  the 
most  valuable  practical  works  issued  from  the  Ameri- 
can press." — Chicago  Medical  Examiner. 

BY    SAME   AUTHOR. 

ON  THE  UTERUS.     The  Chronic  Inflammation  and  Displace- 
ment of  the  Unimpregnated  Uterus. 

An  Enlarged  Edition,  with  Illustrations.     8vo.  Price  52.50 

"A  good  book  from  a  good  man." — American  Journal  Medical  Science. 

"  It  i9  ft  sensible,  practical  work,  and  cannot  fail  to  be  read  with  interest  and  profit."— Boston  Medical  and 
Surgical  Journal. 


"  The  treatise  is  as  complete  a  one  as  the  present 
state  of  our  science  will  admit  of  being  written.  We 
commend  it  to  the  diligent  study  of  every  practitioner 
and  student,  as  a  work  calculated  to  inculcate  sound 
principles  and  lead  to  enlightened  practice. — New 
York  Medical  Record. 


PUBLICA  TIONS. 


BRAUNE,  TOPOGRAPHICAL  ANATOMY. 

An  Atlas  of  Topographical  Anatomy.  Thirty-four  Full-page  Plates,  Photo- 
graphed on  Stone,  from  Plane  Sections  of  Frozen  Bodies,  with  many  other  illus- 
trations. By  Wilhelm  Braune,  Professor  of  Anatomy  at  Leipzig.  Translated 
and  Edited  by  Edward  Bellamy,  f.r.c.s.,  Lecturer  on  Anatomy,  Charing 
Cross  Hospital,  London.     Quarto.     Price,  Cloth,  $10.00;  Half  Morocco,  $12.00 

"As  a  whole  the  work  cannot  fail  to  meet  with  a  hearty  reception  by  every  progressive  student  of  the  human 
body.  To  the  surgeon  it  is  a  contribution  to  the  study  of  topographical  anatomy  which  needs  to  be  known  to  be 
properly  appreciated  To  such  practitioners  who  reside  in  large  cities,  where  anatomy  can  be  studied  upon  the 
cadaver,  it  will  afford  a  valuable  aid,  while  to  those  who  are  without  such  means  of  study  it  is  an  almost  indis- 
pensable addition  to  a  working  library." — New  York  Medical  Record. 

"  We  commend  the  book  most  heartily  to  the  Profession." — American  your  nal  of  Medical  Science. 

BUCKNILL  AND  TUKE  ON  INSANITY. 

A  Manual  of  Pyschological  Medicine :  containing  the  Lunacy  Laws,  the 
Nosology,  (Etiology,  Statistics,  Description,  Diagnosis,  Pathology  (including 
morbid  Histology),  and  Treatment  of  Insanity.  By  John  Charles  Bucknill, 
m.d.,  f.r.s.,  and  Daniel  Hack  Tuke,  m.d.,  f.r.c.p.  Fourth  Edition,  much 
enlarged,  with  twelve  lithographic  plates,  and  numerous  illustrations.     Octavo. 

Price  $8.00 

"  We  have  read  no  book  in  any  language,  and  certainly  none  in  English,  which   ought  to  be  preferred  to    this 
for  a  text  book,  by  those  who  wish  to  make  a  thorough  study  of  the  subject. — Edinburgh  Medical  Journal. 
"  We  can  heartily  commend  the  work. — American  Journal  of  Insanity. 

BURDETT,  HOSPITALS. 

Pay  Hospitals  and  Paying  Wards  throughout  the  World.  Facts  in  support 
of  a  rearrangement  of  the  system  of  Medical  Relief.  By  Henry  C.  Burdett. 
8vo.  Price  $2.25 

"  Mr.  Burdett  displays  and  discusses  the  whole  scheme  of  Hospital  accommodation  with  a  comprehensive 
understanding  of  its  nature  and  extent. — American  Practitioner. 

BY  SAME  AUTHOR. 

COTTAGE  HOSPITALS. 

General,  Fever,  and  Convalescent :  their  Progress,  Management,  and  Work. 
Second  Edition,  rewritten  and  much  Enlarged,  with  many  Plans  and  Illustra- 
tions.    Crown  8vo.  Price  $4.50 

Contents. — Chap. — 1.  Origin  and  Growth  of  the  Cottage  Hospital  System.  2.  Comparative  Success  of 
Treatment  in  large  and  small  Hospitals.  3.  Finance.  4.  Cottage  Hospital  Construction  and  Sanitary  Arrange- 
msnts.  5.  The  Medical  and  Nursing  Departments.  6.  Domestic  Supervision  and  General  Management.  7. 
Cottage  Hospital  Appliances  and  Fittings.  8.  Cottage  Fever  Hospitals.  9.  Midwifery  in  Cottage  Hospitals.  10. 
Remunerative  Paying  Patients.  11.  Convalescent  Cottages .  12.  Cottage  Hospitals  in  America.  13.  Mortu- 
aries. 14.  A  more  Detailed  Account  of  certain  Cottage  Hospitals,  with  Plans  and  Elevations.  15.  Selected  and 
Model  Plans  criticised  and  compared,  with  a  detailed  description  of  various  Hospitals.  16.  Peculiarities  and 
Special  Features  in  the  Working  of  Cottage  Hospitals.  With  an  Appendix  containing  much  statistical  and  useful 
information. 

"  Mr.  Burdett's  book  contains  a  mass  of  information,  statistical,  financial,  architectural,  and  hygienic,  which  has 
already  proved  of  great  practical  utility  to  those  interested  in  cottage  hospitals,  and  we  can  confidently  recom- 
mend this  second  edition  to  all  who  are  in  search  of  the  kind  of  information  which  it  contains." — Lancet. 

BUZZARD,  SYPHILITIC  NERVOUS  AFFECTIONS. 

Clinical  Aspects  of  Syphilitic  Nervous  Affections.  By  Thos.  Buzzard,  m.d. 
i2mo.  Price  $1.75 

CARPENTER,  THE  MICROSCOPE.     Sixth  Edition. 

The  Microscope  and  its  Revelations.  By  W.  B.  Carpenter,  m.d.,  f.r.s. 
Sixth  Edition.     Revised  and  Enlarged,  with  over  500  Illustrations.     Price  $5.50 


"  Not  only  the  student  of  medicine,  but  amateurs, 
and  others  interested  in  the  study  of  natural  history, 
will  find  this  volume  one  of  great  practical  value." — 
New  York  Medical  Journal. 

"  It  is  by  far  the  most  complete  and  useful  treatise 
now  accessible  to  the  student." — The  Technologist. 


"As  a  text  book  of  Microscopy  in  its  special  relation 
to  natural  history  and  general  science,  the  work  before 
us  stands  confessedly  nrst(  and  is  alone  sufficient  to 
supply  the  wants  of  the  ordinary  student." — American 
Journal  of  Microscopy. 


PRESLEY  B  LA  KIS  TON'S 


Oazeaux's  Great  Work  on  Obstetrics. 

THE  MOST  COMPLETE  TEXT-BOOK  NOW  PUBLISHED. 
GREATLY    ENLARGED    AND    IMPROVED. 

CONTAINING   175    ILLUSTRATIONS. 

k  Theoretical  and  Practical  Treatise  on  Midwifery,  including  the  Disease* 
of  Pregnancy  and  Parturition,  by  P.  Cazeaux,  Member  of  the  Imperial 
Academy  of  Medicine ;  Adjunct  Professor  in  the  Faculty  of  Medicine  of 
Paris,  etc.,  etc.  Revised  and  Annotated  by  S.  Tarnibb,  Adjunct  Pro- 
fessor in  the  Faculty  of  Medicine  of  Paris ;  Former  Clinical  Chief  of  the 
Lying-in-Hospital,  etc.,  etc.  Sixth  American  from  the  Seventh  French  Edi- 
tion. Translated  by  Wm.  R.  Bullock,  M.  D.  In  one  volume  Royal  Oc- 
tavo, of  over  1100  pages,  with  numerous  Lithographic  and  other  Illustra- 
tions on  Wood. 

Price,  bound  in  Cloth,  bevelled  boards,                     .        .        .        $6.00 
"    '         "        Leather,  .  7.00 

M.  Cazeaux's  Great  Work  on  Obstetrics  has  become  classical  in  its  character,  and 
almost  an  Encyclopaedia  in  its  fulness.  "Written  expressly  for  the  use  of  students  of 
medicine,  and  those  of  midwifery  especially,  its  teachings  are  plain  and  explicit,  present- 
ing a  condensed  summary  of  the  leading  principles  established  by  the  masters  of  the 
obstetric  art,  and  such  clear,  practical  directions  for  the  management  of  the  pregnant, 
parturient,  and  puerperal  states,  as  have  been  sanctioned  by  the  most  authoritative 
practitioners,  and  confirmed  by  the  author's  own  experience.  Collecting  his'  materials 
from  the  writings  of  the  entire  body  of  antecedent  writers,  carefully  testing  their  correct- 
ness and  value  by  his  own  daily  experience,  and  rejecting  all  such  as  were  falsified  by 
the  numerous  cases  brought  under  his  own  immediate  observation,  he  has  formed  out  of 
them  a  body  of  doctrine,  and  a  system  of  practical  rules,  which  he  illustrates  and  enforces 
in  the  clearest  and  most  simple  manner  possible. 

OPINIONS  OF  THE  PRESS. 

"  It  is  unquestionably  a  work  of  the  highest  excellence,  rich  in  information,  and  perhaps  fuller  in  detail  t 
than  any  text-book  with  which  we  are  acquainted.  The  author  has  not  merely  treated  of  every  ques- 
tion which  relates  to  the  business  of  parturition,  but  he  has  done  so  with  judgment  and  ability." 
British  and  Foreign  Medico- Chirurgical  Review. 

"  The  translation  of  Dr.  Bullock  is  remarkably  well  done.  We  can  reoommend  this  work  to  those 
especially  interested  in  the  subjects  treated,  and  can  especially  recommend  the  American  edition." 
Medical  Timet  and  Gazette. 

"  The  edition  before  us  is  one  of  unquestionable  excellence.  Every  portion  of  it  has  undergone  a 
thorough  revision,  and  no  little  modification  ;  while  copious  anchimportant  additions  have  boen  made  to 
nearly  every  part  of  it.  It  is  well  aDd  beautifully  illustrated  by  numerous  wood  and  lithographie 
engravings,  and,  in  typographical  execution,  will  bear  a  favorable  comparison  with  othor  works  of  the 
same  class." — American  Medical  Journal. 

"  In  the  multitudinous  collection  of  works  devoted  to  the  propagation  of  human  beings,  and  to  t-ht 
Jetailfi  of  parturition,  none,  in  our  estimation,  bears  any  comparison  to  the  work  of  Cazeaux,  in  itf 
entire  perfectness;  and  if  we  were  called  upon  to  rely  alone  on  one  work  on  accouchments,  our  ohoiov 
would  fall  upon  the  book  before  us  without  any  kind  of  hesitation." —  West.  Jour,  of  Med.  aud  Surgery 

"  We  do  not  hesitate  to  say,  that  it  is  now  the  most  complete  and  best  treatise  on  the  suhjpet  in  th» 
English  language." —  Buffalo  Medical  Journal. 

"We  know  of  no  work  on  this  all-important  branoh  of  our  profession  that  we  can  reoommend  to  th» 
rtudent  or  practitioner  as  a  safe  guide  bofore  this." — Chicago  Medical  Journal. 


PUBLICA  TIONS. 


CHARTERIS,  PRACTICE  OF  MEDICINE. 

Hand-Book  of  the  Practice  of  Medicine.  By  M.  Charteris,  m.d.,  Member 
of  Hospital  Staff  and  Professor  in  University  of  Glasgow.  With  Microscopic  and 
other  illustrations.  Price  $2.00 

"  We  have  not  often  met  with  a  book  whieii  can  be  so  confidently  recommended  to  physicians  or  men  in  general 
practice . ' ' — Lancet. 

"  The  style  in  which  it  is  written  is  clear  and  attractive.  The  illustrations  are  a  marked  feature  in  it.  It  can 
be  recommended  as  a  very  reliable,  handy  book,  well  adapted  for  ready  reference." — New  Remedies. 

CHAVASSE  ON  CHILDREN. 

The  Mental  Culture  and  Training  of  Children.     By  Pye  Henry  Chavasse. 

iamo.  Price  $1.00 

The  mental  culture  and  training  of  children  is  of  immense  importance.     Many 

children  are  so  wretchedly  trained,  or  rather  not  trained  at  all,  and  so  mismanaged, 

that  a  few  thoughts  on  this  subject  cannot  be  thrown  away,  even  upon  the  most 

careful. 

CLAY  ON  OBSTETRIC  SURGERY.     Third  Edition. 

A  complete  Hand-Book  of  Obstetric  Surgery,  with  Rules  for  every  Emergency 
and  Descriptions  of  the  more  difficult  as  well  as  the  every  day  operations.  By 
Charles  Clay,  m.d.,  with  numerous  illustrations.  From  the  Third  London  Edi- 
tion.    i2mo.  Price  $2.00 

"  It  is  a  useful  and  convenient  book  of  reference ;  the  illustrations  are  good,  and  the  book  will  be  found  of  value 
to  the  student  and  young  practitioner,  as  well  as  to  the  skilled  Obstetrician." — American  Journal  of  Obstetrics. 

CLEVELAND,  POCKET  DICTIONARY. 

A  Pronouncing  Medical  Lexicon,  containing  correct  Pronunciation  and  Defi- 
nition of  terms  used  in  medicine  and  the  collateral  sciences.  By  C.  H.  Cleve- 
land, m.d.     Twenty-sixth  Edition.     i6mo. 

Price,  Cloth,  75  cents  ;  Tucks  with  Pocket,  $1.00 
This  is  a  most  convenient  size  for  the  pocket,  and  contains  all  the  principal  words 
in  use,  together  with  rules  for  pronunciation,  abbreviations  used  in  prescriptions,  list 
of  poisons,  their  antidotes,  etc. 

COHEN,  INHALATION.     Enlarged  Edition. 

Inhalation,  its  Therapeutics  and  Practice,  including  a  Description  of  the  Ap- 
paratus Employed,  etc.  By  J.  Solis  Cohen,  m.d.  With  cases  and  Illustrations. 
A  New  Enlarged  Edition.     8vo.  Price  $2.50 

"  The  book  has  the  merit  of  containing  much  information  that  cannot  be  found  elsewhere." — N.  Y.  Medical 
Journal. 

"  One  of  the  best  treatises  we  have  seen  on  this  subject." — Medical  Times  and  Gazette. 

BY   SAME  AUTHOR. 

CROUP, 

In  its  Relation  to  Tracheotomy.     8vo.  Price  $1.00 

CLARKE,  SURGERY. 

Outlines  of  Surgery  and  Surgical  Pathology,  including  the  Diagnosis  and 
Treatment  of  Obscure  and  Urgent  Cases.  By  F.  LeGross  Clarke,  f.r.s. 
Second  Edition.     8vo.  -  Price  $2.00 

COBBOLD,  PARASITES. 

A  Treatise  on  the  Entozoa  of  Man  and  Animals,  including  some  account  of 
the  Ectozoa.  By  T.  Spencer  Cobbold,  m.d.,  f.r.s.  With  85  illustrations. 
8vo.  Price  $5.00 


PRESLEY  BLAKISTON'S 


DAY  ON    CHILDREN. 

A  SECOND  EDITION.    JUST  READY. 

The  Diseases  of  Children.  A  Practical  and  Systematic  Treatise,  for  Practitioners 
and  Students.  By  Wm.  Henry  Day,  m.d.  Second  Edition.  Enlarged.  8vo. 
752  pp.  Price,  Cloth,  $5. 00;  Sheep,  $6.<y 

What  Prominent  Professors  Say  of  It. 


"  The  more  I  read  Dr.  Day's  book,  the  more  I  like 
it.  I  shall  recommend  it  to  the  students  of  George- 
town College." — Prof.  J.  Tabeb  Johnson,  Washington, 

d.  c. 

"  I  pronounce  the  book  a  good  one,  and  one  that 
promises  to  be  useful  to  both  practitioners  and  stu- 
dents."— Prof.  W.  A.  Edmunds,  St.  Louis. 

"  I  think  it  admirably  adapted  to  the  uses  of  practi- 
tioners and  students  of  medicine." — Prof.  Hannah  T. 
Ceoasdale,  Woman's  Medical  College,  Philadelphia. 

"  Believing  the  work  well  adapted  to  meet  the  wants 
of  the  student  as  well  as  the  practitioner,  it  will  give 
me  pleasure  to  recommend  it  to  the  classes  of  Kueh 
Medical  College." — Prof.  De  Lf.skie  Milleb,  Cliicago. 

"  It  is  the  work  for  which  we  have  so  long  felt  tho 
want  and  need.  I  take  pleasurein  recommending  it." 
—Prof.  C.  T.  Bedfoed,  Indianapolis,  Ind. 

u  The  practitioner  can  confidently  rely  upon  finding 
in  Its  pages  the  very  best  and  latest  knowledge  con- 


cerning the  diseases  of  children." — Prof.  W.  J.  Conv 
LIN,  Dayton,  0. 

"  It  is  just  what  a  student  and  a  busy  practitioner 
needs.  I  can  heartily  recommend  it." — Prof.  J.  M. 
Dunham,  Columbus,  0. 

"  It  is,  in  my  judgment,  the  most  satisfactorily  ar- 
ranged and  eminently  practical  work  upon  the  eil- 
ment3  of  infancy  and  childhood  yet  published  in  the 
English  language." — Prof.  E.  L.  Sim,  Memphis,  Tenn. 

"  It  is  especially  to  be  recommended  for  judicious 
comments  on  infant  feeding,  etc." — Prof.  H.  6.  Ljln- 
dis,  Columbus,  0. 

"  An  excellent  practical  treatise,  superior  to  any  of 
the  reprints  in  the  department  of  Diseases  of  Children 
that  I  have  seen." — Prof.  E.  0.  F.  Eoleb,  Chicago. 

"  It  is  fairly  entitled  to  the  highest  rank  among  the 
text-books  on  Diseases  of  Children,"— Prof.  J3.  Kings- 
ley,  St.  Louis. 


PRESS  OPINIONS. 


*'  A  careful  examination  of  this  boot  leads  us  to 
characterize  it  as  a  plain,  straightforward  treatise  on 
the  subject  upon  which  it  treats,  ....  giving 
sound  practical  advice." — Philadelphia  Medical  Times. 

"  We  heartily  recommend  this  book  to  the  profession 
as  a  safe  and  reliable  guide  in  the  department  of  which 
it  treats." — Medical  and  Surgical  Reporter. 

"The book  is  wonderfully  readable." — British  Medi- 
cal Journal. 

"  The  article  on  the  true  diseases  of  children,  those 
of  the  pulmonary,  circulatory  and  renal  apparatus,  and 
the  nervous  system,  are  in  many  parts  exhaustive.  . 
.  .  The  writing  is  clear  and  forcible,  and  to  the 
point." — American  Journal  of  Medical  Sciences. 

"We  have  no  doubt  it  will  be  read  with  interest, 
which  its  style,  as  well  as  its  matter,  deserves." — Dub- 
lin Medical  Journal. 

"  Taking  the  book  as  a  whole,  its  correct  classifica- 
tion, its  perfect  style,  and  its  comprehensiveness  place 
it  in  advance  of  nil  othor  books  upon  tho  same  sub- 
ject."—  Walsh's  Retrospect. 
,"  A  safe  guide  for  the  student  and  practitioner." — 
College  and  Clinical  Reaord. 

"  One  ef  the  most  useful  and  valuable  additions  to 
tho  medical  literature  of  the  present  day.  No  medical 
library  should  be  without  this  book  on  its  shelves." — 
Medical  Bulletin. 

"Dr.  Day  brings  to  his  task  a  largo  experience,  and 
evidences  a  very  thorough  knowledge*  of  tho  litera- 
ture, native  and  foreign,  pertaining  to  this  special 
branch  of  medicine.  Tho  book  has  been  written  with 
great  care,  and  tho  author  is  a  good  writer.  Tho  pub- 
lisher's part  of  tho  task  has  also  been  excellently  per- 
formed."— Boston  Medical  and  Surgical  Journal. 

"  We  advise  every  physician  to  havo  a  copy." — 
BraitliwaMs  Quarterly  Epitome. 


"Altogether  we  can  heartily  commend  this  volume 
to  any  students  of  this  subject  that  desire  to  obtain  the 
latest  and  most  judicious  compend  of  our  knowledge 
of  Children's  Diseases." — Detroit  Lancet. 

"  Ono  of  tho  most  satisfactory  guides  in  the  diagnosis 
and  treatment  of  diseases  peculiar  to  children  to  be  had 
in  the  language." — New  Remedies. 

"  This  volume,  from  tho  title-page  to  the  end  of  the 
last  chapter,  abounds  in  just  such  practical  and  well- 
put  information  as  every  man,  in  tho  courso  of  his 
treatment  of  children's  diseases,  must  oftentimes  feel 
the  need." — Medical  Herald,  Louisville. 

"  We  commend  it  particularly  for  its  practical  worth, 
being  full  of  valuable  hints  in  regard  to  diagnosis  and 
treatment." — Medical  Annals,  Albany,  N.  Y. 

"It should  bo  in  the  library  of  every  medical  stu- 
dent atKl  practitioner." — Southern  Medical  Record. 

"  It  is  full  of  valuable  facts  and  suggestions  that  will 
make  a  welcome  addition  to  tho  working  library  of 
every  practitioner." — Ohio  Medical  Journal. 

"  Plain,  full  and  eminently  practical." — Southern 
Clinic. 

"The  book  is  up  to  tho  times,  and  wo  cordially  com- 
mend it  to  those  for  whom  it  is  written,  but  especial- 
ly tho  studeat." — Therapcutio  Gaxettc. 

"  A  safe  guide  In  practice." — Pacifio  Medical  and  Sur- 
gical Journal. 

"It  is  not  too  much  to  say  of  it  that  It  is  probably 
not  equaled,  and  certainly  not  excelled  by  My  other 
book  on  its  subject." — Michigan  Medical  M  W 

"  A  thoroughly  practical  work." — Independent  I\ac- 
tiiioncr. 

"It  is  just  such  a  book  as  Is  wanted  by  tho  goneral 
practitioner." — Medical  Brief. 


Price:  Cloth,  $5.00 ;  Leather,  $6.00.   For  sale  by  all  booksellers, 
or  sent  to  any  address,  postpaid,  on  receipt  of  price. 


PUBLICATIONS.  13 


COULSON,  THE  BLADDER.     Sixth  Edition. 

Diseases  of  the  Bladder  and  Prostate  Gland.     By  Walter  J.  Coulson,  f.r.c.S. 
Sixth  Edition.     Revised  and  Enlarged,  with  22  Engravings.     8vo.      Price  56.40 

CRIPPS,  THE  RECTUM. 

Cancer  of  the    Rectum.     Its  Pathology,  Diagnosis  and  Treatment.     By.  W. 
Harrison  Cripps,  f.r.c.s.     Illustrated  by  Plates.     8vo.  Price  $2.40 

CORMACK.     CLINICAL  STUDIES. 

Illustrated   by  Cases  Observed   in  Hospital  and   Private  Practice.      By  Sir 
John  Rose  Cormack,  m.d.,  k.b.,  etc.    Illustrated.    2vols.    1127  pp.    Price$5.oo 

Contents. — Vol.  i. — Chapter  i.  Relapsing  Fever,  n.  Cholera,  in.  Scarlatinous  Nephritis,  rv.  Puerperal 
Convulsions,  v.  Glandular  Degeneration  of  the  Kidney,  and  Its  Relation  to  Scrofula.  VI.  Infantile  Remittent 
Fever,  vn.  Labor  Complicated  with  Cauliflower  Excrescence  of  the  Uterus,  vm.  Value  of  the  Dark  Abdominal 
Line  as  a  Test  of  Recent  Delivery,  ix.  Dystocia  from  Cystous  Kidney  in  the  Mature  Foetus,  x.  Hernia  of  the 
Uterus. 

Vol.  11. — Chapter  I.  Air  in  the  Organs  of  Circulation.  II.  Reflex  Convulsions  in  Infancy,  in.  Pharyngo- 
Laryngo-Tracheal  Diphtheria,  iv.  Diphtheria,  v.  Paralytic  Affections,  vi.  Paralytic  Affections  in  Enteric 
Fever,  vn.  Treatment  of  Paralytic  Affections,  vm.  Non- Venereal  Discharges  from  the  Urethra,  ix.  Scarla- 
tinal Vaginitis,  x.  Congenital  Syphilis,  xi.  Chronic  Poisoning  by  Chloroform,  xn.  Resection  of  the  Shoulder 
Joint,     xin.  Concussion  of  the  Brain,     xiv.  General  Paralysis  with  Insanity,     xv.  Short  Attacks  of  Insanity. 

DAY  ON  HEADACHES. 

The  Nature,  Causes,  and  Treatment  of  Headaches.     Third  Edition.     Illus- 
trated.    By  Wm.  Henry  Day,  m.d.  Price  52.00 

Summary  of  Contents. — Headache  from  Cerebral  Anaemia,  Cerebral  Hyperxmia,  Sympathetic,  Congestive, 
Dyspeptic  or  Bilious  Headaches,  Headache  from  Plethora,  from  Exhaustion,  from  Change  in  Cerebral  Tissue, 
from  Affections  of  the  Periosteum,  Nervous  and  Nervo-Hyperamic  Headache,  Toxaemic,  Rheumatic,  Arthritic 
or  Gouty  Headache,  Neuralgic  Headache,  and  Headaches  of  Childhood,  Early  and  Advanced  Life. 

"  Well  worth  reading.     The  remarks  on  treatment  are  very  sensible." — Boston  Medical  and  Surg:  Journal. 

DALBY,  ON  THE  EAR. 

The  Diseases  and  Injuries  of  the  Ear.     By  W.  B.  Dalby,  m.d.,  Surgeon  and 
Lecturer  on  Aural  Surgery,  St.  George's  Hospital.     With  Illustrations.     i2mo. 

Price  $1.50 


'A  safe  and  readable  introduction  to  aural  surgery." 
Medical  Press  and  Circular. 

"  Dr.  Dalby  has  presented  us  with  a  very  readable 
little  book,  which  is  destined  to  render  much  service  in 
the  saving  of  ears." — N.  Y.  Medical  Journal. 


"The  lectures  occupy  226  pages,  are  clearly  and 
consisely  written,  contain  a  number  of  good  illustrations, 
and  are  well  worth  the  careful  study  of  both  student 
and  practitioner.  To  aurists  the  work  will  be  most 
welcome  and  valuable." — Specialist. 


DILLINGBERGER,     WOMEN     AND     CHILDREN'S     DIS- 
EASES. 

A  Hand-Book  of  the  Treatment  of  the  Diseases  Peculiar  to  Women  and  Chil- 
dren.    By  Dr.  Emil  Dillingberger.     i2mo.  Price  $1.50 

"It  is  a  magnum  in  parvo.     The  style  is  simple,  clear,  lucid,  and  free  from  theoretical  discussion.     No  one  will 
regret  the  small  outlay  for  this  volume. — Richmond  and  Louisville  Medical  Journal. 

DUNGLISON,  THE  PHYSICIAN'S  REFERENCE  BOOK. 

The  Practitioner's  Reference  Book,  containing  Therapeutical  and  Practical 
Hints,  Dietetic  Rules,  and  General  Information.  By  Richard  J.  Dunglison, 
m.d.     Second  Edition.     8vo.  Price  $3.50 


"  We  can  heartily  commend  this  book  as  one  that 
must  prove  very  useful  to  the  general  practitioner." — 
The  Medical  Record. 


"  The  demand  for  a  second  edition  so  soon  after  the 
publication  of  the  first  volume  shows  that  this  work  is 
appreciated  by  the  profession." — Canada  Lancet. 


DURKEE,  VENEREAL  DISEASES.     Sixth  Edition. 

Gonorrhoea  and  Syphilis.     By  Silas  Durkee,  m.d.     Sixth  Edition.     Revised 
and  Enlarged,  with  Portrait  and  Eight  Colored  Illustrations.     8vo.     Price  $3.50 

"  We  may,  finally,  recommend  Dr.  Durkee's  book  as  eminently  practical,  well  written,  full  of  excellent  counsel, 
and  worthy  of  being  consulted  by  every  member  of  the  profession.  A  late  number  of  the  London  Medical  Times 
and  Gazette  also  speaks  of  the  book  in  terms  of  the  highest  approval."— .Boston  Medical  and  Surgical  Journal. 


14  PRESLEY  BLAKISTON'S 

DAGUENET,  OPHTHALMOSCOPY. 

A  Manual  of  Ophthalmoscopy,  for  the  Use  of  Students.  By  Dr.  Daguenet. 
Translated  from  the  French,  by  Dr.  C.  S.  Jeaffreson,  f.r.c.s.e.  Illustrated. 
l2mo.  Price  $1.50 

"Its  portable  size,  the  condensed  nature  of  its  text,  and  the  admirably  systematic  arrangement  of  its  contents, 
render  it  extremely  useful  as  a  pocket  manual  for  Students. —  Translator's  Pre/ace. 

DOBELL,  WINTER  COUGH  AND  CATARRH. 

On  Winter  Cough,  Catarrh,  Bronchitis,  Emphysema,  Asthma,  etc.  By 
Horace  Dobell,  m.d.,  Lecturer  at  the  Royal  Hospital  for  Diseases  of  the 
Chest.     Third  Edition.     With  Colored  Plates.     8vo.  Price  $3.50 

BY    SAME   AUTHOR. 

ON  LOSS  OF  WEIGHT.     Revised  Edition. 

Blood  Spitting  and  Lung  Disease.  Colored  Frontispiece  of  Lung.  Tabular 
Map,  etc.     Second  Edition  Enlarged.     8vo.  Price  S4.00 

DOMVILLE,  ON  NURSING. 

A  Manual  for  Hospital  Nurses  and  others  engaged  in  attending  to  the  sick. 
4th  Edition.     With  Recipes  for  Sick  Room  Cookery,  etc.  Price  $1. 00 

DRUITT'S  MODERN  SURGERY.     Eleventh  Edition. 

The  Surgeon's  Vade  Mecum;  a  Manual  of  Modern  Surgery.  By  Robert 
Druitt,  f.r.c.s.  Eleventh  Enlarged  Edition,  with  369  Illustrations.  S64  pp. 
1878.  Price  $5.00 

This  is  a  most  complete,  accurate,  and  trustworthy  Hand,  or  Text-Book  of  Sur- 
gery. Unrivaled  as  a  book  for  the  Student.  Fully  illustrated,  and  brought  up  to 
the  present  state  of  the  science.     In  use  in  many  Medical  Colleges. 

DULLES,  ACCIDENTS. 

What  to  do  First,  in  Accidents  and  Poisoning.  By  C.  W.  Dulles,  m.d.  Il- 
lustrated.    i6mo.  Price  .50 

"  Its  usefulness  entitles  it  to  a  wide  and  permanent  I        "  So  plain  and  sensible  that  it  ought  to  be  introduced 

circulation." — Boston  Gazette.  into    every    female     seminary. — Evening    Chronicle , 

"  A  complete  guide  for  sudden  emergencies. — Phila-  Pittsburgh, 
delphia  Ledger. 

EDWARDS,  BRIGHT'S  DISEASE.     New  Edition. 

How  a  Person  Affected  with  Bright's  Disease  Ought  to  Live.  By  Jos.  F.  Ed- 
wards, m.d.     Second  Edition.     i2mo.  Price  .75 

BY   SAME   AUTHOR. 

DYSPEPSIA.    Just  Ready. 

How  to  Avoid  It.     i2mo.  .75 

Contents. — Chap.  i. — Food.     11.  Digestion,     in.  How  to  Cook  Food.    iv.  How  and  What  We  Ought  to  Eat. 

CONSTIPATION.     New  Edition. 

Plainly  Treated  and  Relieved  Without  the  Use  of  Drugs.  Second  Edition. 
i2mo.  Price  .75 

MALARIA. 

Malaria:  What  It  Means;  How  to  Escape  It;  Its  Symptoms;  When  and 
Where  to  Look  for  It.     i2mo.  Wee  .75 

These  are  invaluable  little  treatises  upon  subjects  that  enter  painfully  into  the 
life  experiences  of  a  large  majority  of  the  human  family.  Dr.  Edwards  shows  not 
only  how  they  may  be  avoided,  but  in  plain  and  simple  language  he  tells  those 
already  afflicted  with  them  how  they  may  find  relief.  Many  learned  works  have  been 
written  upon  their  treament;  but  the  authors  have,  in  nearly  every  case,  neglected 
to  show  to  the  public  how  to  avoid  them. 


PUBLICA  TIONS. 


EKIN,  WATER  ANALYSIS. 

Potable  Water.  How  to  Form  a  Judgment  on  the  Suitableness  of  Water  for 
Drinking  Purposes.     By  Charles  Ekin.     Second  Edition.     i2mo.        Price  .75 

ELLIS,  DISEASES  OF  CHILDREN. 

A  Practical  Manual  of  the  Diseases  of  Children,  with  a  Formulary.  By  Ed- 
ward Ellis,  m.d.  Late  Physician  to  the  Victoria  Hospital  for  Children, 
London.     Fourth  Edition  Enlarged.     Now  Ready.  Price  §3.50 

BY   SAME   AUTHOR. 

WHAT  EVERY  MOTHER  SHOULD  KNOW. 

i2mo.  Price  .75 

"  It  is  only  too  true  that  our  children  have  to  dodge  through  the  early  part  of  life  as  through  a  labyrinth.  We 
must  be  thankful  to  meet  with  such  a  sensible  guide  for  them  as  Dr.  Ellis." — Pall  Mall  Gazette. 

FENNER,  ON  VISION. 

Vision;  Its  Optical  Defects,  the- Adaptation  of  Spectacles,  Defects  of  Accommo- 
dation, etc.  By  C.  S.  Fenner,  m.d.  With  Test  Types  and  74  Illustrations. 
8vo.  Price  §3.50 

FENWICK,  THE  PRACTICE  OF  MEDICINE. 

Outlines  of  the  Practice  of  Medicine.  With  Appropriate  Formulae  and  Illus- 
trations.    By  Samuel  Fenwick,  m.d.,  Physician  to  the  London  Hospital.    i2mo. 

Price  $2.00 

"  This  little  work  displays  a  sound  judgment  in  the  arrangement  of  its  subject  matter,  and  an  intimate  acquaint- 
ance with  the  practice  of  medicine  possessed  by  but  few  writers,  and  should  have  been  elaborated  into  a  more 
comprehensive  work.     Of  all  the  hand-books  we  have  seen,  this  is  certainly  one  of  the  best." — Medical  Herald. 

"  It  is  an  eminently  practical  little  treatise,  pervaded  with  much  common  sense,  and  will  doubtless  be  found 
useful,  particularly  by  advanced  students." — Boston  Medical  and  Surgical  Journal. 

BY  SAME   AUTHOR. 

ON  THE  STOMACH. 

The  Morbid  State  of  the  Stomach  and  Duodenum,  and  Their  Relations  to 
Diseases  of  Other  Organs.     With  10  Plates.     8vo.  Price  $4.25 

Atrophy  of  the  Stomach  and  Its  Effect  on  the  Nervous  Affections  of  the  Digest- 
ive Organs.     8vo.  Price  $3.20 

FOTHERGILL,  ON  THE  HEART.     Second  Edition. 

The  Heart  and  Its  Diseases.  With  Their  Treatment.  Including  the  Gouty 
Heart.  By  J.  Milner  Fothergill,  m.d.,  Associate  Fellow  of  the  College  of 
Physicians  of  Philadelphia.      Second  Edition,    Entirely   Re-written.     Octavo. 

Price  $3.50 


"  It  is  the  best,  as  well  as  the  most  recent  work  on 
the  subject  in  the  English  language." — Medical  Press 
and  Circular. 

"  The  most  interesting  chapter  is  undoubtedly  that 
on  the  gouty  heart,  a  subject  -which  Dr.  Fothergill  has 
specially  studied,  and  on  which  he  entertains  views 
such  as  are  likely,  we  think,  to  be  generally  accepted 


"  To  many  an  earnest  student  it  will  prove  a  right  in 
darkness ;  to  many  a  practitioner  cast  down  with  a 
sense  of  his  powerlessness  to  cope  with  the  rout  and 
demoralization  of  Nature's  forces,  a  present  help  in 
time  of  trouble." — Philadelphia  Medical  Times. 

"  The  work  throughout  is  a  masterpiece  of  graphic, 
lucid  writing,  full  of  good,  sound  teaching,  which  will 


by  clinical  physicians,  although  they  have  not  before        be  appreciated  alike  by   the  practitioner  and  the  stu 
been  stated,  so  far   as  we  are   aware,  with  the  same        dent." — Students'  Journal. 


been  stated,  so  far  as  we  are  aware,  with  the  same 
breadth  of  view  and  extended  illustration." — British 
Medical  Journal. 


FULTON,  ON  PHYSIOLOGY. 

A    Text-Book   of   Physiology.     By   J.   Fulton,   m.d.,  Professor  at    Trinity 
Medical   College,   Toronto.     Second   Edition,  Illustrated  and   Revised.     8vo. 

Price  $4.00 


i6  PRESLEY  BLAKISTON'S 

FLOWER,  DIAGRAMS  OF  THE  NERVES. 

Diagrams  of  the  Nerves  of  the  Human  Body.  Exhibiting  their  Origin, 
Divisions,  and  Connections,  with  their  Distribution  to  the  various  Regions  of  the 
Cutaneous  Surface,  and  to  all  the  Muscles.  By  William  H.  Flower,  f.r.c.s., 
f.r.s.,  Hunterian  Professor  of  Comparative  Anatomy,  and  Conservator  of  the 
Museum  of  the  Royal  College  of  Surgeons.  Third  Edition,  thoroughly  revised. 
With  six  Large  Folio  Maps,  or  Diagrams.     Royal  Quarto.  Price  $3.50 

"Admirably  arranged,  and  will  be  of  incalculable  aid  to  the  student  of  anatomy.  Each  of  the  large  and 
beautiful  plates  is  accompanied  with  explanatory  text." — N.  Y.  Medical  Record. 

"  The  nerves  and  ganglia  are  clearly  represented.  The  impressions  are  well  made,  and  no  doubt  the  diagrams 
will  prove  useful." — Medical  and  Surgical  Reporter. 

FLAGG,  PLASTIC  FILLING. 

Plastics  and  Plastic  Filling;  As  Pertaining  to  the  Filling  of  all  Cavities  of  De- 
cay in  Teeth  below  Medium  in  Structure,  and  to  Difficult  and  Inaccessible 
Cavities  in  Teeth  of  all  Grades  of  Structure.  With  some  beautifully  executed 
Illustrations.  By  J.  Foster  Flagg,  d.d.s.,  Professor  of  Dental  Pathology  and 
Therapeutics  in  Philadelphia  Dental  College.     Octavo.  Price  $3.00 

Contents. — Introductory.  Article  i.  Plastic  Filling.  2.  Amalgam.  3.  Amalgam  continued.  4.  Amalgam 
continued.  5.  Attributes  of  Metals  used  for  Amalgam  Alloys.  6.  The  Making  of  Amalgam  Alloys.  7.  Tests 
for  Amalgam.  8.  Preparation  of  Cavities.  9.  The  Making  of  Amalgam.  10.  Instrument  for  the  Insertion  of 
Amalgam  Fillings.  11.  The  Insertion  of  Amalgam  Fillings.  12.  General  Considerations  Pertaining  to  Amalgam. 
13.  Gutta-percha.  14.  Oxy-chloride  of  Zinc.  15.  Oxy -sulphate  of  Zinc.  16.  Zinc  Phosphate.  17.  Temporary 
Stopping.     18.  Technicalities.     Conclusion. 

FOSTER,  CLINICAL  MEDICINE. 

Lectures  and  Essays  on  Clinical  Medicine.  By  Balthazar  Foster,  m.d. 
Illustrated.     8vo.  Price  $3.00 

"No  one  can  peruse  the  thoughtful  comments  of  our  I  "It  is  the  record  of  honest  work,  such  as  Dr.  Foster 
author  upon  every  subject  he  considers,  without  feeling  maybe  proud  of;  we  can  recommend  it  to  the  profession; 
himself  a  wiser  man  for  his  pains." — N.   Y.  Medical         it  may  be  read  with  profit  and  advantage  by  both  prac- 

Journal.  i     titioner  and  student. — Edinburgh  Medical  journal. 

FOX,  ATLAS  OF  SKIN  DISEASES. 

Complete  in  Eighteen  Parts,  each  containing  Four  Chromo-Lithographic  Plates, 
with  Descriptive  Text  and  Notes  upon  Treatment.  In  all  72  large  colored  Plates. 
By  Tilbury  Fox,  m.d.,f.r.c.p.,  Physician  to  the  Department  for  Skin  Diseases 
in  University  College  Hospital.     Folio  Size. 

Price  $2.00  each,  or  complete,  bound  in  cloth,  $30.00 

No  Atlas  of  Skin  Diseases  has  been  issued  in  this  country  for  many  years,  and  no 
complete  work  of  the  kind  is  now  procurable  by  the  Profession.  This  one,  brought 
out  under  the  editorial  supervision  and  care  of  Dr.  Tilbury  Fox  (the  most  distin- 
guished writer  on  Cutaneous  Medicine  now  in  the  English  language),  is  partly  based 
upon  the  classical  work  of  Willan  and  Bateman  (now  entirely  out  of  print),  but  com- 
pletely remodeled,  so  as  to  represent  fully  the  Dermatology  of  the  present  day. 

"  Preference  will  be  given  to  this  work  over  Hebra ;  not  simply,  however,  because  it  is  a  home  production,  but 
bv  reason  of  the  manner  of  its  execution,  the  excellent  delineation  of  disease,  and  the  natural  coloring  of  the  plates. 
The  letter-press  is  entirely  new.     In  the  accuracy  of  the  latter  the  subscriber  may  have  the  fullest  conn- 
dencei  since  it  is  from  the  pen  of  Dr.  Tilbury  Vox.-— British  and  Foreign  Medico- Chirurgicat  Review. 

FRANKLAND,  WATER  ANALYSIS. 

Water  Analysis,  For  Sanitary  Purposes,  with  Hints  for  the  Interpretation  of 
Results.     By  E.  Frankland,  m.d.-,  f.r.s.     Illustrated,     nmo.  Price  51.00 

"The  author's  world-wide  reputation  will  commend  I       "The  work  is  one  which  physicians  practicing  i> 

this  manual  to  all  sanitarians,  and  they  will  not  be  dis-  the  country  and   ,n    v.llagcs   and  town^ ^  remo e from 

appointed   in  finding  all  the  essentials  of  the  important  medical  centres  cannot. afford  to  be  without.    -Medical 

subject  of  which  it  treats."—  The  Sanitarian.  \    and  Surgical  Reporter. 

BY  SAME  AUTHOR. 

CHEMISTRY. 

How  to  Teach  Chemistry;  being  Six  Lectures  to  Science  Teachers.  Edited 
by  G.  George  Chaloi<ier,  f.c.s.     Illustrated.     i2mo.  Price  51.25 


PUB LIC A  TIONS.  i7 


FOX,  WATER,  AIR  AND  FOOD. 

Sanitary  Examinations  of  Water,  Air  and  Food.      By  Cornelius  B.  Fox, 
m.D.     94  Engravings.     8vo.  Price  $4.00 

GALLABIN,  DISEASES  OF  WOMEN. 

The  Student's  Guide  to  the  Diseases  of  Women.     By  A.  Lewis  Gallabin,  m.a., 
m.d.,  f.r.c.p.     Illustrated  with  63  Engravings.      i2mo.  Price  $2.00 


"Among  all  the  various  works  on  diseases  of  women 
with  which  we  are  acquainted,  there  is  none  which  so 
nearly  approaches  the  perfection  of  what  a  student's 
text-book  should  be  .  .  .  The  work  is  well  illustrated." 
— Students'  "Journal. 

"Though  the  book  is  a  small  one  and  the  subject  ex- 
tensive, yet  so  admirable  is  the  style  of  the  writer,  and 
so  careful  his  selection  of  words,  that  each  disease  is 
thoroughly  treated  of." — Philadelphia  Medical  Times. 


"  Its  style  is  clear,  elegant,  and  concise.  It  contains 
agreat  amount  of  information  ;  indeed,  we  do  not  think 
the  student  or  practitioner  will  find  any  book  which 
will  convey  to  him  in  so  small  a  compass  so  much  accu- 
rate knowledge  about  the  pathology  and  diagnosis  of 
the  diseases  peculiar  to  women." — Medical  Times  and 
Gazette. 


GROSS,  BIOGRAPHY  OF  JOHN  HUNTER. 

John  Hunter  and  His  Pupils.  By  S.  D.  Gross,  m.d.,  Professor  of  Surgery  in 
Jefferson  Medical  College,  Philadelphia.  With  a  beautifully  executed  full  length 
Portrait  of  the  Author  in  his  Study.  A  Handsome  Octavo  volume.  Bound  in 
Beveled  Cloth.  Price  $1.50 

"  It  is  refreshing  to  read  the  story  of  a  life  so  fully  devoted  to  science,  and  the  reader  will  readily  appreciate 
Professor  Gross's  enthusiasm  for  his  subject,  which  led  him  to  extend  what  was  originally  intended  for  an  essay  to 
its  present  size. 

"  The  phototype  of  Sharp's  well-known  engraving  of  Sir  Joshua  Reynold's  portrait  is  an  excellent  reproduction, 
and  forms  a  fitting  and  handsome  frontispiece. 

"  The  volume  will  prove  an  ornament  to  the  study  table,  where  it  will  be  a  constant  incentive  to  whatever  is 
best  and  noblest  in  a  noble  profession." — Boston  Med.  and  Surgical  Journal. 

BY  SAME  AUTHOR. 

AMERICAN  MEDICAL  MEN. 

American  Medical  Biography  of  the  Nineteenth  Century,  with  portrait  of  Dr. 
Benjamin  Rush.     Large  8vo.  Price  $3.50 

GANT,  A  SYSTEM  OF  SURGERY.     Enlarged  Edition. 

The  Science  and  Practice  of  Surgery,  including  Special  Chapters  by  different 
Authors.  By  Frederick.  James  Gant,  f.r.c.s.,  Senior  Surgeon  to  the  Royal 
Free  Hospital.  Second  Edition,  rewritten  and  much  enlarged  throughout. 
Illustrated  by  969  wood  engravings.     In  two  Octavo  volumes. 

Price,  Cloth  $11.00;  Leather  $  13.00 

"  After  the  most  patient  analysis  our  limited  time  '  "  This  new  and  magnificent  work  on  surgery  sup- 
has  permitted,  we  f«el  compelled  to  say  that  this  book  I  plies  all  that  can  be  required,  whether  for  the  most  com- 
is  a  valuable  and  comprehensive  addition  to  the  surgical  |  plete  study  or  for  constant  reference  in  practice." — 
literature  of  the  profession  and  a  monument  to  the  care-  London  Medical  Press  and  Circular. 
fill,  conscientious  and  painstaking  industry  of  the  "  The  reader  has  the  advantage  of  mature  experience 
author.   -Cincinnati  Lancet  and  Observer.  ;„  treating  of  special  subjects7that  are  either  omitted 

or  very  lightly  referred  to  in   ordinary  works   on  sur- 

I  gery." — London  Lancet. 

BY  SAME  AUTHOR. 

ON  THE  BLADDER  AND  PROSTATE. 

Diseases  of  the  Bladder  and  Prostate  Gland  and  Urethra,  including  a  Practical 
View  of  Urinary  Diseases,  Deposits  and  Calculi.  Fourth  Edition,  Revised  and 
Enlarged,  with  New  Illustrations.     i2mo.  Price  $3.00 

GIBBES,  STUDENT'S  PATHOLOGY. 

Practical  Histology  and  Pathology.  By  Heneage  Gibbes,  m.b.  i2rno. 
Cloth.  Price  $1.00 

Chap.  i.  Introduction.  2.  On  Preparing  Tissues  for  Examination.  3.  On  Cutting  Sections.  4.  On  Staining. 
5.  On  Double  Staining.  6.  On  Mounting.  7.  Method  of  Obtaining  Animal  Tissues,  etc.  Practical  Histology, 
Pathology,  Memoranda  and  Formulae. 

"  This  excellent  little  work  is  admirably  adapted  to  fulfill  the  purpose  for  which  it  has  been  written.  It  is 
short,  clear,  and  eminently  practical.  The  author  is  evidently  an  accomplished  histologist,  and  his  book  conveys 
the  impression  that  it  is  based  upon  his  own  personal  experience." — The  London  Medical  Record. 


18  PRESLEY  B LA KIS TON'S 

GODLEE'S  ATLAS  OF  HUMAN  ANATOMY. 

Illustrating  most  of  the  Ordinary  Dissections  and  many  not  usually  practiced 
by  the  Student.  Accompanied  by  References  and  an  Explanatory  Text.  Com- 
plete. Folio  Size.  48  Colored  Plates.  By  Rickman  John  Godlee,  m.d., 
f.r.c.S.  Forming  a  large  Folio  Volume,  with  References,  and  an  Octavo 
Volume  of  Letter-press. 

Price  of  the  two  Volumes,  Atlas  and  Letter-press,  Cloth,  $30.00 


"  It  is  likely  to  prove  as  useful  to  the  physician  and 
surgeon  as  to  the  anatomist." — Medical  Times  and 
Gazette. 


"  The  explanatory  text  is  concise,  well  written,  and 
contains  many  valuable  suggestions  for  the  surgeon." 
— London  Lancet. 


GOWERS,  SPINAL  CORD. 

Diagnosis  of  Diseases  of  the  Spinal  Cord.  With  Colored  Plates  and  Engrav- 
ings. A  Second  Edition,  Revised  and  Enlarged.  By  William  R.  Gowers, 
m.d.,  Assistant  Professor  Clinical  Medicine,  University  College,  London.     8vo. 

Price  $1.50 

BY  SAME  AUTHOR. 

OPHTHALMOSCOPY. 

A  Manual  and  Atlas  of  Medical  Ophthalmoscopy.  With  16  Colored  Auto" 
type  and  Lithographic  Plates  and  26  WTood  Cuts,  comprising  112  Original  Illus- 
trations of  the  Changes  in  the  Eye  in  Diseases  of  the  Brain,  Kidneys,  etc.   8vo. 

Price  S6  00 
GREENHOW,  BRONCHITIS. 

On  Chronic  Bronchitis,  especially  as  connected  with  Gout,  Emphysema,  and 
Diseases  of  the  Heart.     By  E.  Headlam  Greenhow,  m.d.   i2mo.      Price  $1.50 

BY    SAME   AUTHOR. 

ADDISON'S  DISEASE. 

Being  the  Croonian  Lectures,  delivered  before  the  Royal  College  of  Physi- 
cians, London.     Revised  and  Illustrated  by  Plates  and  Reports  of  Cases.     8vo. 

Price  $3.00 

"The  book  forms  a  most  interesting  and  valuable   monograph,  comprehensive  and   exhaustive." — British 
Medical  Journal. 

GLISAN,  TEXT-BOOK  OF  MODERN  MIDWIFERY. 

A  Text-Book  of  Modern  Midwifery.  By  Rodney  Glisan,  m.d.,  Emeritus 
Professor  of  Midwifery  and  Diseases  of  Women  and  Children  in  the  Medical 
Department  of  Willamette  University,  Portland,  Oregon,  and  Late  President 
of  the  Oregon  State  Medical  Society.  With  129  Illustrations.  One  Volume, 
octavo,  624  pp.  Price,  in  Cloth  $4.00;  in  Leather  $500 

Many  years  have  elapsed  since  the  appearance  of  an  original  American  text-book 
of  obstetrics.  The  author  of  this  one,  believing  that  there  is  a  demand  for  a  work 
thoroughly  representing  American  obstetrical  practice,  ventures  to  present  this  con- 
densed treatise  to  the  medical  students  and  practitioners  of  his  own  country.  Many 
years'  experience  as  a  practitioner  and  several  as  a  teacher  of  midwifery,  warrants 
this  effort  to  supply  the  demand  for  a  book  fully  brought  up  to  the  present  time, 
faithfully  representing  the  peculiarities  of  American  practice,  and  adapted  to  the  wants 
of  obstetric  teachers  and  busy  practitioners. 

The  book  is  freely  illustrated  wherever  its  value  and  usefulness  can  be  thus  en- 
hanced, and  being  brought  out — owing  to  the  unavoidable  absence  of  the  author — 
under  the  supervision  of  the  well-known  obstetrician,  Dr.  Robert  P.  Harris,  of 
Philadelphia,  the    publishers  very  confidently  anticipate  for  it  a  favorable  reception. 

GILL,  ON  INDIGESTION.     Second  Edition. 

Indigestion;  What  It  Is;  What  It  Leads  To  ;  and  a  New  Method  of  Treating 
It.     By  John  Beadnell  Gill,  m.d.     Second  Edition.     i2mo.  Price  $1.25 


PUB LIC A  TIONS.  19 


HABERSHON,  ON  THE  STOMACH. 

On  Diseases  of  the  Stomach — The  Varieties  of  Dyspepsia — Their  Diagnosis 
and  Treatment.  By  S.  O.  Habershon,  m.d.,  f.r.C.p.,  Senior  Physician  to,  and 
Late  Lecturer  on,  the  Principles  and  Practice  of  Medicine  at  Guy's  Hospital. 
Third  Edition,  Revised.     Crown  8vo.  Price  $1.75 

"  As  an  expression  of  the  results  of  long  personal  experience  in  both  hospital  and  private  practice,  conveyed  in 
agreeable  though  not  always  perspicuous  diction,  this  contribution  of  Dr.  Habershon's  has  special  value  of  its 
own,  and  is  so  f.ir  entitled  to  the  favorable  consideration  of  the  practitioner,  as  is  already  testified  by  a  demand  for 
a  third  edition." — American  "Journal  of  Medical  Sciences. 

"  It  is  divided  into  twenty  chapters,  fifteen  of  which  are  devoted  to  a  consideration  of  the  different  forms  of 
Dyspepsia,  while  the  remaining  treat  of  Degeneration,  Ulceration,  Cancerous  Diseases,  and  Spasms  of  the 
Stomach."     We  can  cordially  recommend  this  book  of  Dr.  Habershon's  to  the  profession." — Medical  Record. 

HALE,  ON  CHILDREN. 

The  Management  of  Children  in  Health  and  Disease.  A  Book  for  Mothers. 
By  Mrs.  Amie  M.  Hale,  m.d.  Abounding  in  valuable  information  and  com- 
mon-sense advice.     New  Enlarged  Edition.     i2mo.  Price  .75 

"  We  shall  use  our  influence  in  the  introduction  of  this  work  to  families  under  our  care,  and  we  urge  the  profession 
generally  to  follow  our  example." — Buffalo  Medical  and  Surgical  Journal. 

HARDWICH  AND  DAWSON,  PHOTOGRAPHIC   CHEMIS- 
TRY. 

Hardwich's  Manual  of  Photographic  Chemistry.  Illustrated.  Eighth  Edition . 
Rearranged  by  G.  Dawson.     i2mo.  Price  $2.00 

HARDWICKE,  MEDICAL  EDUCATION. 

Medical  Education  and  Practice  in  All  Parts  of  the  World.  Containing 
Regulations  for  Graduation  at  the  Various  Universities  throughout  the  World. 
By  Herbert  Junius  Hardwicke,  m.d.,  m.r.c.p.     8vo.  Price  $3.00 

"  Dr.  Hardwicke's  book  will  prove  a  valuable  source  of  information  to  those  who  may  desire  to  know  the 
conditions  upon  which  medical  practice  is  or  may  be  pursued  in  any  or  every  country  of  the  world,  even  to  the 
remotest  corners  of  the  earth.  The  work  has  been  compiled  with  great  care,  and  must  have  required  a  vast 
amount  of  labor  and  perseverance  on  the  part  of  its  author." — Dublin  Medical  Journal. 

HARRISON,  STRICTURE  OF  THE  URETHRA. 

On  Stricture  and  Other  Diseases  of  the  Urinary  Organs.  By  Renegall 
Harrison,  f.r.c.S.     With  numerous  Illustrations.     8vo.  Price  $2.75 

HAYDEN,  ON  THE  HEART. 

The  Diseases  of  the  Heart  and  Aorta.  By  Thomas  Hayden,  m.d.  With  81 
Illustrations.     2  vols.     1232  pp.     8vo.  Price  $6.00 

"  The  author  evidently  has  had  a  very  wide  and  well  used  experience  in  that  of  which  he  writes  ;  is  well  versed 
in  modern  physiology  and  pathology,  and  holds  a  fluent  pen,  consequently  the  book  is  an  excellent  one,  and  as 
the  teachings  of  the  text  are  abundantly  illustrated  by  the  reports  of  one  hundred  and  fifty  cases,  Dr.  Hayden's 
effort  will  probably  attain  the  popularity  it  deserves." — Philadelphia  Medical  Times. 

"  There  is  not  an  unnecessary  page  in  Dr.  Hayden's  work." — N.  Y.  Medical  Record. 

HOLDEN,  HUMAN  OSTEOLOGY.     Sixth  Edition. 

Comprising  a  Description  of  the  Bones,  with  Colored  Delineations  of  the  At- 
tachments of  the  Muscles.  The  General  and  Microscopical  Structure  of  Bone 
and  its  Development.  By  the  Author  and  A.  Doran,  f.r.c.S.,  with  Lithographic 
Plates,  etc.  By  Luther  Holden,  f.r.c.s.  Numerous  Illustrations.  Sixth 
Edition,  carefully  Revised.  Price  $5.50 

BY   SAME   AUTHOR. 

ANATOMY. 

Manual  of  Dissections  of  the  Human  Body.  Fourth  London  Edition.  With 
170  Illustrations.  Price  #5.50 

LANDMARKS. 

Landmarks,  Medical  and  Surgical.  Third  London  Edition.  Revised  and 
Enlarged.  Price  #1.25 

"  Mr.  Holden  is  the  happy  possessor  of  the  faculty  of  writing  interesting  works  on  Anatomy.  A  part  of  the 
charm  consists  in  the  frequent  references  to  practical  points,  and  in  the  explanation  of  the  advantages  and  objects 
of  details  of  structures." — Boston  Medical  and  Surgical  Journal. 


20  PRESLEY  BLAKISTON'S 

HEATH'S  OPERATIVE  SURGERY. 

A  Course  of  Operative  Surgery,  consisting  of  a  Series  of  Plates,  each  plate 
containing  Numerous  Figures,  Drawn  from  Nature  by  the  Celebrated  Anatomi- 
cal Artist,  M.  Leveille,  of  Paris,  Engraved  on  Steel  and  Colored  by  Hand, 
under  his  immediate  superintendence,  with  Descriptive  Text  of  Each  Operation. 
By  Christopher  Heath,  f.r.c.s.,  Surgeon  to  University  College  Hospital,  and 
Holme  Professor  of  Clinical  Surgery  in  University  College,  London.  One  Large 
Quarto  Volume.  Price  $14.00 

The  author  has  embodied  in  this  work  the  experience  gained  by  him  during 
twenty  years  of  surgical  teaching.  It  comprises  all  the  operations  that  are  required 
in  ordinary  surgical  practice.  He  has  selected  for  illustration  and  description  those 
methods  which  appear  to  give  the  best  results  in  practice,  referring  to  the  errors 
likely  to  occur  and  the  best  methods  of  avoiding  them. 

BY    SAME   AUTHOR. 

THE   STUDENT'S  GUIDE  TO   SURGICAL   DIAGNOSIS. 

i2mo.  Price  $1.50 

"Mr.  Heath  is  so  well  known,  both  as  a  practical  surgeon,  teacher  and  writer,  that  anything  from  his  pen  re- 
quires no  introduction  from  the  hands  of  reviewers,  and  scarcely  any  notice  but  the  announcement  of  the  fact  that 
he  has  written  a  book." — Medical  Record. 

A  MANUAL  OF    MINOR    SURGERY   AND  BANDAGING. 

Sixth    Edition,    Revised    and   Enlarged.      With    115    Illustrations.       i2mo. 

Price  $2.00 

"This  excellent  work  should  not  be  termed  a  '  Minor'  Surgery,  but  it  really  consists  of  the  sum  and  substance 
of  Practical  surgery.     We  would  not  exchange  it  for  any  book  in  our  possession." — Southern  Clinic. 

HEATH'S  PRACTICAL  ANATOMY.     Fifth  London  Edition. 

Practical  Anatomy.  A  Manual  of  Dissections.  Fifth  London  Edition.  24 
Colored  Plates,  and  nearly  300  other  Illustrations.     Just  Ready.  Price  $5.00 

INJURIES  AND  DISEASES  OF  THE  JAWS. 

The  Jacksonian  Prize  Essay  of  the  Royal  College  of  Surgeons  of  England, 
1867.     Second  Edition,  Revised,  with   over   150  Illustrations.     Octavo. 

Price  $4.25 
HOOD,  ON  GOUT  AND  RHEUMATISM. 

A  Treatise  on  Gout,  Rheumatism,  and  the  Allied  Affections.  Their  Treat- 
ment, Complications,  and  Prevention.  By  Peter  Hood,  m.d.  Second  Edi- 
tion, Revised  and  Enlarged.     With  some  Considerations  on  Longevity.  Octavo. 

Price  $3.50 

"  The  Observations  on  Treatment  are  specially  to  be  commended."— London  Lancet. 

HOLDEN,  THE  SPHYGMOGRAPH. 

The  Sphygmograph.  Tts  Physiological  and  Pathological  Indications.  By 
Edgar  Holden,  m.d.  Illustrated  by  Three  Hundred  Engravings  on  Wood. 
8vo.  Pnce  $2-°° 

HOLMES,  THE  LARYNGOSCOPE. 

A  Guide  to  the  Use  of  the  Laryngoscope  in  General  Practice.  By  Gordon 
Holmes,  m.d.,  Physician  to  the  Throat  and  Ear  Infirmary.     i2mo.     Price  ;?i.oo 

BY   SAME   AUTHOR. 

VOCAL  PHYSIOLOGY. 

Vocal  Physiology  and  Hygiene.  With  reference  to  the  Cultivation  and 
Preservation  of  the  Voice.     Illustrated.     i2mo.  Fncc  $2.00 

HOFF,  ON  HEMATURIA. 

Haematuria  as  a  Symptom  of  the  Diseases  of  the  Gcnito-Unnary  Organs.  By 
O.  Hoff,  M.D.     Illustrated.     i2ino.  Pnce  -75 


PUBLICATIONS.  21 

HUNTER,  MECHANICAL  DENTISTRY. 

A  Practical  Treatise  on  the  Construction  of  the  Various  kinds  of  Artifici^ 
Dentures,  with  Formulae,  Receipts,  etc.  By  Charles  Hunter,  d.d.s.  100 
Illustrations.     i2mo.  Price  $2.25 

"  It  is  the  outcome  of  his  own  experience  of  some  twenty  years  as  a  Mechanical  Dentist,  and  contains,  moreover, 
much  derived  from  practical  knowledge  of  other  dentists.  The  value  of  the  book  is  also  much  added  to  by  illus- 
trations. It  will  be  very  useful  to  the  Dental  Student,  and  to  all  Mechanical  Dentists." — London  Medical  Times 
*nd  Gazette. 

HUTCHINSON'S    ILLUSTRATIONS    OF    CLINICAL   SUR- 
GERY.    First  Volume  Complete. 

Consisting  of  Plates,  Photographs,  Woodcuts,  Diagrams,  etc.  Illustrating 
Surgical  Diseases,  Symptoms,  and  Accidents;  also  Operations  and  other 
Methods  of  Treatment.  With  Descriptive  Letter-press.  By  Jonathan  Hutch- 
inson, f.r.c.S.,  Senior  Surgeon  to  the  London  Hospital,  Surgeon  to  the  Moor- 
fields  Ophthalmic  Hospital,  and  to  the  Hospital  for  Diseases  of  the  Skin,  Black- 
friars.  In  Quarterly  Fasciculi.  Imperial  4to.  Volume  1.  (Ten  Fasciculi)  bound 
complete  in  itself.  Price  $25.00.  Parts  Eleven,  Twelve,  Thirteen,  and  Fourteen 
of  Volume  2,  Now  Ready.  Each  $2.50 

HEWITT,  DISEASES  OF  WOMEN.     Third  Edition. 

The  Diagnosis,  Pathology,  and  Treatment  of  Diseases  of  Women,  Including 
the  Diagnosis  of  Pregnancy.  Founded  on  a  Course  of  Lectures  Delivered  at  St. 
Mary's  Hospital  Medical  School.  By  Graily  Hewitt,  m.d.,  Lond.,  m.r.c.p., 
Physician  to  the  British  Lying-in  Hospital ;  Lecturer  on  Midwifery  and  Diseases 
of  Women  and  Children  at  St.  Mary's  Hospital  Medical  School;  Honorary 
Secretary  to  the  Obstetrical  Society  of  London,  etc.  The  Third  Edition.  Re- 
vised and  Enlarged,  with  New  Illustrations.     Octavo. 

Price,  Cloth  $4.00;  Leather  $5.00 

"  The  excellent  work  of  Dr.  Hewitt  presents — in  a 
form  well  adapted  to  conduct  the  student  to  a  knowledge 
of  the  Diseases  of  Women,  and  to  assist  the  young 
practitioner  in  his  study  of  these  diseases  at  the  bedside 
of  the  patient — a  very  full  and  clear  exposition  of  the 
views  entertained  by  the  most  authoritative  teachers  as 
to  their  pathological  treatment  and  their  correct  Diag- 
nosis. "—Amer.  Med.  "Journal. 

HAY,  SARCOMATOUS  TUMOR. 

History  of  a  Case  of  Recurring  Sarcomatous  Tumor  of  the  Orbit  in  a  Child. 
By  Thomas  Hay,  m.d.     Illustrated.     Paper.  Price  .50 

HEWSON,  EARTH  IN  SURGERY. 

Earth  as  a  Topical  Application  in  Surgery,  Being  a  Full  Exposition  of  its  Use 
in  Cases  Requiring  Topical  Applications.  By  Addinell  Hewson,  m.d.  Illus- 
trated.   8vo.  Price  $2.50 

HODGE,  ON  ABORTION. 

On  Foeticide  or  Criminal  Abortion.     By  Hugh  L.  Hodge,  m.d. 

Price,  Paper,  .30;  Cloth,  .50 
HODGE,  CASE-BOOK. 

Note-Book  for  Cases  of  Ovarian  Tumors.  By  H.  Lennox  Hodge,  m.d.  With 
Diagrams.  Price,  Paper,  .50 

HIGGINS,  DISEASES  OF  THE  EYE. 

A  Hand-Book  of  Ophthalmic  Practice.  By  Charles  Higgins,  f.r.c.s. 
Ophthalmic  Assistant  Surgeon    at  Guy's  Hospital.      Second  Edition.      i6mo. 

Price  .60 

Contents. — Section  i.  Discharge  from  the  Eyes.  n.  Intolerance  of  Light,  in.  Iritis  and  Glaucoma,  rv. 
Diseases  of  the  Eyelids,  v.  Watering  of  the  Eye.  VI.  Acuteness  of  Vision,  Field  of  Vision,  Anomalies  of  Re- 
fraction,  Astigmatism,  Accommodation,  Presbyopia,  vn.  Disturbance  of  Vision,  Use  of  the  Ophthalmoscope, 
Normal  and  Morbid  Appearances.     VIM.  Injuries. 

"  We  have  rarely  seen  so  much  important  information  condensed  in  so  short  a  space." — American  Medical 
Journal. 


"  Readers  of  the  former  editions  will  not  require  to 
be  told  that  the  additions  now  made  are  of  the  highest 
possible  excellence." — Times  and  Gazette. 

"  It  is  one  of  the  most  useful,  practical,  and  compre- 
hensive works  upon  the  subject  in  the  English  language, 
a  true  guide  to  the  student,  and  an  invaluable  means  of 
reference  for  the  teacher." — N.  Y.  Medical  Record. 


22  PRESLEY  BLAKISTON'S 

HARRIS,  THE  PRACTICE  OF  DENTISTRY.     Tenth  Edition. 

•  The  Principles  and  Practice  of  Dentistry.  Tenth  Revised  Edition.  In  great 
part  Rewritten,  Rearranged,  and  with  many  new  and  important  Illustrations. 
By  Chapin  A.  Harris,  m.d.,  d.d.s.  Edited  by  P.  H.  Austen,  m.d.,  Professor 
of  Dental  Science  and  Mechanism  in  the  Baltimore  College  of  Dental  Surgery. 
With  nearly  400  Illustrations.     Royal  Octavo.    Price,  Cloth,  $6.50 ;  Leather,  $7.50 

This  new  edition  of  Dr.  Harris'  work  has  been  thoroughly  revised  in  all  its  parts, 
more  so  than  any  previous  edition.  So  great  have  been  the  advances  in  many 
branches  of  dentistry  that  it  was  found  necessary  to  rewrite  the  articles  or  subjects, 
and  this  has  been  done  in  the  most  efficient  manner  by  Professor  Austen,  for  many 
years  an  associate  and  friend  of  Dr.  Harris,  assisted  by  Professor  Gorgas  and  Thomas 
S.  Latimer,  m.d.  The  publishers  feel  assured  that  it  will  now  be  found  the  most 
complete  text-book  for  the  student,  and  guide  for  the  practitioner  in  the  English 
language. 

BY    SAME  AUTHOR. 

MEDICAL  AND  DENTAL  DICTIONARY.     Fourth  Edition. 

A  Dictionary  of  Medical  Terminology,  Dental  Surgery,  and  the  Collateral 
Sciences.  Fourth  Edition,  Carefully  Revised  and  Enlarged.  By  Ferdinand 
J.  S.  Gorgas,  m.d.,  d.d.s.,  Professor  of  Dental  Surgery  in  the  Baltimore  College, 
etc.     Royal  Octavo.  Price,  Cloth,  $6.50;  Leather,  $7.50 

This  Dictionary,  having  passed  through  three  editions,  and  been  for  some  time 
out  of  print,  has  been  again  carefully  revised  by  F.  J.  S.  Gorgas,  M.D.,  Dr.  Harris' 
successor  as  Professor  of  Dental  Surgery  in  the  Baltimore  College  of  Dental  Surgery. 
In  his  preface  to  this  new  edition,  the  editor  says  : — 

"  The  object  of  the  reviser  has  been  to  bring  the  book  thoroughly  up  to  the  pres- 
ent requirements  of  the  profession,  the  Medical  portion  having  been  as  carefully  re- 
vised and  added  to  as  that  devoted  more  especially  to  Dental  Science,  while  a 
number  of  obsolete  terms  and  methods  have  been  omitted.  In  nearly  every  one  of 
the  seven  hundred  and  forty-three  pages  of  the  former  edition  corrections  and  addi- 
tions have  been  made,  and  many  new  processes,  terms  and  appliances  described, 
some  of  which  are  not  found  in  any  other  work  published." 

HANDY,  ANATOMY. 

Text-Book  of  Anatomy  and  Guide  to  Dissections.  For  the  Use  of  Students. 
By  W.  R.  Handy,  m.d.     312  Illustrations.  Price  S3.00 

HILLIER,  DISEASES  OF  CHILDREN. 

A  Clinical  Treatise  on  the  Diseases  of  Children.  By  Thomas  Hillier,  m.d. 
8vo.  Price  $2.00 

HUFELAND,  LONG  LIFE. 

The  Art  of  Prolonging  Life.  By  C.  W.  Hufeland.  Edited  by  Erasmus 
Wilson,  m.d.     i2mo.  Price  ?i.oo 

*'  We  wish  all  doctors  and  all  their  intelligent  clients  would  read  it,  for  surely  its  perusal  would  be  attended 
with  pleasure  and  benefit." — American  Practitioner, 

"  It  certainly  should  be  in  the  library  of  every  physician." — Medical  Brief. 

HUNTER,  PORTRAIT  OF. 

Portrait  of  John  Hunter.  From  Sharp's  well  known  Engraving;  a  copy  of 
Sir  Joshua  Reynold's  Portrait.  For  Framing.  Large  size,  9  x  1 1  ;  sheet  16  x  20. 
Price,  in  the  Sheet,    sent  free  by   mail,   50   cents  ;    or,   Handsomely    Framed( 

Price  $2.00 


PUB  LIC A  TIONS.  23 


HEADLAND,  THE  ACTION  OF  MEDICINES.    Sixth  Edition. 

On  the   Action  of  Medicines   in  the   System.     By  F.  W.  Headland,  m.d. 

Sixth  American  Edition,  Revised  and  Enlarged.     8vo.  Price  #3.00 

"  It  displays  in  every  page  the  evidence  of  extensive  knowledge  and  of  sound  reasoning;  it  will  be  useful  alike 
to  those  who  are  just  commencing  their  studies,  and  to  those  who  are  engaged  in  the  active  pursuits  of  pro- 
fessional life."— Medical  Times. 

"  The  very  favorable  opinion  which  we  were  amongst  the  first  to  pronounce  upon  this  essay  has  been  fully 
confirmed  by  the  general  voice  of  the  profession,  and  Dr.  Headland  may  now  be  congratulated  on  having  pro- 
duced a  treatise  which  has  been  weighed  in  the  balance,  and  found  worthy  of  being  ranked  with  our  standard 
medical  works." — London  Lancet. 

JAMES,  SORE  THROAT. 

On  Sore  Throat,  Its  Nature,  Varieties  and  Treatment,  Including  its  Con- 
nection with  other  Diseases.  By  Prosser  James,  m.r.c.P.  Fourth  Edition, 
Revised  and  Enlarged..    With  Colored  Plates  and  Numerous  Wood-cuts.     i2mo. 

Price  $2.25. 

""We  can  confidently  recommend  his  therapeutic  teachings  as  well  worthy  of  the  careful  consideration  of  the 
Profession,  for  they  set  forth  the  practice  of  an  enthusiastic  worker,  whose  special  experience  has  been  large  and 
lengthened." — British  Medical   "Journal. 

"  The  practitioner  who  buys  Dr.  James'  unpretending  little  book  will  provide  himself  with  a  wise  and  practical 
clinical  commentary,  and  with  a  well  arranged  digest  of  long  and  varied  experience." —  Westminster  Review. 

BY   SAME   AUTHOR. 

LARYNGOSCOPY  AND  RHINOSCOPY. 

Including  the  Diagnosis  of  Diseases  of  the  Throat  and  Nose.  Third  Edition. 
With  Colored  Plates.     i8mo.  Price  $2.00. 

"  It  gives  in  a  succinct  form  the  approved  methods  of  examination  and  treatment  of  diseases  of  the  nose,  throat, 
and  larynx.  The  plan  pursued  is  one  well  adapted  to  the  needs  of  the  general  practitioner." — American  Medical 
Journal. 

JONES,  AURAL  ATLAS. 

An  Atlas  of  Diseases  of  the  Membrana  Tympani.  Being  a  Series  of  Colored 
Plates,  containing  62  Figures.  With  appropriate  Letter-press  and  Explanatory 
Text.  By  H.  Macnaughton  Jones,  m.d.,  Surgeon  to  the  Cork  Ophthalmic  and 
Aural  Hospital.     4to.  Price  $6.00. 

"  The  cases  are  well  selected,  the  drawings  executed  from  life,  highly  artistic  and  very  conscientious,  and  the 
commentaries  indicate  familiarity  with  the  subject  and  good  judgment  in  dealing  with  it." — British  Medical 
Journal. 

BY   SAME    AUTHOR. 

AURAL  SURGERY. 

A  Practical  Hand-Book  on  Aural  Surgery.     Illustrated.     i2mo.      Price  $1.50. 

JONES,  SIEVEKING  AND  PAYNE,  PATHOLOGICAL  AN- 
ATOMY. 

A  Manual  of  Pathological  Anatomy.  By  C.  Handfield  Jones,  m.d.,  and 
Edward  H.  Sieveking,  m.d.,  Physician  to  St.  Mary's  Hospital.  A  New  En- 
larged Edition.  Edited  by  J.  F.  Payne,  m.d.,  Lecturer  on  Morbid  Anatomy  at 
St.  Thomas'  Hospital.     With  Numerous  Illustrations.     Demi  8vo.     Price  $5.50. 

JONES,  ON  SIGHT  AND  HEARING. 

The  Defects  of  Sight  and  Hearing,  their  Nature,  Causes,  and  Prevention.  By 
T.  Wharton  Jones,  m.d.     Second  Edition.     i6mo.  Price  .50. 

KIRBY,  ON  PHOSPHORUS.     Fifth  Edition. 

Phosphorus  as  a  Remedy  for  Functional  Diseases  of  the  Nervous  System. 
By  E.  A.  Kirby,  m.d.     Fifth  Edition.     8vo.  Price  $1.00 

KOLLMEYER,  KEY  TO  CHEMISTRY. 

Chemia  Coartata,  or  Key  to  Modern  Chemistry.  By  A.  H.  Kollmeyer,  m.d. 
With  Numerous  Tables,  Tests,  etc.  Price  $2.25 

KIRKE,   PHYSIOLOGY.     Revised  up  to  1881. 

A  Hand-book  of  Physiology.  By  Kirke.  Tenth  London  Edition.  By  W. 
Morrant  Baker,  m.d.     420  Illustrations.  Price  $5.00 


24  PRESLE Y  BLAKISTON'S 

KANE,  THE  OPIUM,  MORPHINE  AND  SIMILAR  HABITS. 

Drugs  that  Enslave.  The  Opium,  Morphine,  Chloral,  Hashisch  and  Similar 
Habits.     By  H.  H.  Kane,  m.d.,  of  New  York.     With  Illustrations.     Price  $1.50 

"  It  contains  a  large  amount  of  information  collected  with  much  labor  and  presented  in  a  systematic  manner. 
The  subject  of  the  chloral  habit  has  not  been  investigated  by  any  one,  we  believe,  so  thoroughly  as  Dy  Dr.  Kane." 
— Medical  Record. 

"  It  deserves  to  be  read  by  those  who  feel  an  interest  in  discouraging  the  use  of  these  dangerous  drugs.  The 
book  is  embellished  by  an  excellent  phototype  frontispiece  of  Laocoon." — American  your  nai  of  Pharmacy. 

"  A  work  of  more  than  ordinary  ability  and  careful  research.  .  ...  For  the  first  time,  reliable  statistics  on 
the  use  of  chloral  are  classified  and  published,  .  .  .  and  it  is  shown  that  the  use  of  chloral  causes  a  tnore 
comj/lete  and  rapid  ruin  of  mind  and  body  than  either  opium  or  morphine." — Druggists'  Circular  and  Gazette. 

KIDD,  THERAPEUTICS. 

The  Laws  of  Therapeutics  ;  or,  the  Science  and  Art  of  Medicine.  By  Joseph 
Kidd,  m.d.     i2mo.     Cloth.  Price  #1.25. 

Dr.  Joseph  Kidd,  who,  "by  the  way,  was  Lord  Beaconsfield's  medical  adviser,  and 
an  eminent  physician  of  the  regular  school,  briefly  but  clearly  sketches  the  history  of 
medicine  from  the  earliest  period.  He  shows  that  the  chief  mistakes  have  been 
made  through  deference  to  theory  and  negligence  of  the  teachings  of  facts.  Thence 
he  passes  to  an  assertion  of  the  value  of  the  homceopathic  principle  of  similia  simili- 
bus  in  the  treatment  of  many  diseases.  He  is  not  a  follower  of  Hahnemann,  and 
does  not  believe  in  infinitessimal  doses,  but  he  claims,  and  enforces  his  position  by 
the  citation  of  cases  in  his  own  practice,  that  the  homceopathic  principle  has  performed 
wonders  where  that  of  his  own  school  was  much  less  successful. 

"  Dr.  Kidd  acknowledges  two  laws — that  of  contraria  contrariis  and  similia  similibus  ;  but  the  cases  he  gives 
in  his  chapter  on  ars  medica  show  that,  like  a  sensible  practitioner,  he  does  not  allow  himself  blindly  to  follow 
either  the  one  or  the  other,  but  seeks  out  the  cause  of  disease,  and  tries  by  rational  measures  to  remove  it.  The 
cases  are  the  most  valuable  part  of  the  book." — London  Practitioner. 

LEGG,  ON  THE  URINE. 

Practical  Guide  to  the  Examination  of  the  Urine,  for  Practitioner  and  Student. 
By  J.  Wickham  Legg,  m.d.     Fifth  Edition,  Enlarged.     Illustrated.     i2mo. 

Price  .75 

This  little  work  is  intended  to  supply  the  Physician  or  Student  with  a  concise  guide 

to  the  recognition  of  the  different  characteristics  of  the  urine,  and  though  small  and 

well  adapted  to  the  pocket,  contains,  probably,   everything  that  could  be  gleaned 

from  a  larger  work. 

LEARED,  IMPERFECT  DIGESTION. 

The  Causes  and  Treatment  of  Imperfect  Digestion.  By  Arthur  Leared,  m.d. 
The  Sixth  Edition.     Revised  and  Enlarged.     i2mo.  Price  $1. 50 

LIEBREICH,  ATLAS  OF  OPHTHALMOSCOPY. 

An  Atlas  of  Ophthalmoscopy,  containing  12  Full-page  Chromo-Lithographic 
Plates,  with  59  Figures.  By  R.  Liebreich,  m.d.  Second  Edition,  Enlarged. 
Large  Quarto.  *  Price  $12.00 

LIVEING,  ON  SICK  HEADACHE. 

Megrim,  or  Sick  Headache  and  Some  Allied  Disorders.  By  Edward  Live- 
ing,  m.d.     With  Plates,  Tables,  etc.     8vo.  Price  $5.50 

LEBER  AND  ROTTENSTEIN,  DENTAL  CARIES. 

Dental  Caries  and  Its  Causes.  An  Investigation  into  the  Influence  of  Fungi 
in  the  Destruction  of  the  Teeth.   By  Drs.  Leber  and  Rottenstein.    Illustrated. 

8vo.  Price  #1.25 

*'  The  work  gives  the  result  of  patient  observation,  presents  the  deductions  of  its  authors  with  a  perspicuity  and 
modesty  calculated  to  secure  for  its  positions  a  thoughtful  consideration.  Wc  heartily  commend  it  as  an  educa- 
tional work." — Dental  Cosmos. 


PUBLICA  TIONS. 


*5 


LEWIN,  ON   SYPHILIS. 

The  Treatment  of  Syphilis.  By  Dr.  George  Lewin,  of  Berlin.  Translated 
by  Carl  Proegler,  m.d.,  and  E.  H.  Gale,  m.d.,  Surgeons  U.  S.  Army.  Illus- 
trated.    i2mo.  Price  $1.50 

"  When  such  authorities  as  Dr.  Drysdale  (as  we  quoted  a  few  weeks  ago)  condemn  the  use  of  mercury  in  syphilis 
as  "  too  dangerous,"  while,  on  the  other  hand,  eminent  surgeons,  such  as  Professor  Gross,  will  not  treat  a  case 
without  that  drug,  general  practitioners  will  gladly  welcome  any  media  via  which  gives  us  all  the  good  effects  of 
mercurials  without  any  danger  of  their  ill  results  appearing.  This  is  what  is  accomplished  by  Dr.  L«win." — 
Philadelphia  Medical  and  Surgical  Reporter. 


LIZARS,  ON  TOBACCO. 

The  Use  and  Abuse  of  Tobacco. 


By  John  Lizars,  m.d.  i2mo.         Price  .50 


LONGLEY,   POCKET  MEDICAL  LEXICON. 

Students'  Pocket  Medical  Dictionary,  Giving  the  Correct  Definition  and  Pro- 
nunciation of  all  Words  and  Terms  in  General  Use  in  Medicine  and  the  Collate- 
ral Sciences,  with  an  Appendix,  containing  Poisons  and  their  Antidotes,  Abbre- 
viations Used  in  Prescriptions,  and  a  Metric  Scale  of  Doses.  By  Elias  Longley. 
24mo.  Price,  Cloth,  $1.00;  Tucks  and  Pocket  $1.25 

This  is  an  entirely  new  Medical  Dictionary,  containing  some  300  compactly 
printed  24mo  pages,  very  carefully  prepared  by  the  author,  who  has  had  much  ex- 
perience in  the  preparation  of  similar  works,  assisted  by  the  Professors  of  Chemistry 
and  of  Botany  in  one  of  our  leading  medical  colleges. 

"  This  little  book  will  be  welcomed  by  students  in 
medicine  and  pharmacy  as  a  convenient  pocket  com- 
panion, giving  the  pronunciation,  acceptation,  and 
definition  of  medical,  pharmaceutical,  chemical  and 
botanical  terms." — American  Jour  ?ial  of  Pharmacy. 

"  It  would  seem  to  be  just  the  book  for  dental  and 
medical  students." — Dental  Advertiser. 


"  It  is,  we  believe,  also  the  only  lexicon  in  existence 
in  which  the  pronunciation  of  words  is  fully  and  dis- 
tinctly marked." — Canada  Medical  Review. 

"This  is  a  very  compact  and  complete  little  diction- 
ary. We  commend  it  as  particularly  useful  to  students." 
— New  York  Medical  journal. 


MARTIN,  ATLAS  OF  GYNAECOLOGY. 

An  Atlas  of  Obstetrics  and  Gynaecology.  By  Prof.  A.  Martin,  of  Berlin. 
Translated  and  edited  from  the  Second  German  Edition,  with  additions,  by  Fan- 
court  Barnes,  m.d.,  m.r.c.p.  With  98  Full-page  Lithographic  Plates,  con- 
taining over  400  figures,  many  being  colored.  With  full  letter-press  references 
to  and  explanations  of  each  figure  ;  forming  a  thick  quarto  volume.  Bound  in 
heavy  beveled  boards.     Sold  only  by  subscription.  Price  $12.00 

"  This  valuable  and  classic  series  of  illustrations 
includes  98  pages  of  plates,  with  an  average  of  5  illus- 
trations on  each,  many  of  which  are  colored,  and  some 
drawn  on  a  large  scale,  so  as  to  occupy  the  whole  page. 
The  subjects  treated  range  through  the  whole  of  mid- 
wifery and  gynaecology,  beginning  with  normal  and  ab- 
normal pelvis,  and  ending  with  illustrations  of  some  of 
the  most  important  obstetric  gynaecologic  instruments 
used  in  Germany  and  in  this  country.  .  .  The  de- 
scriptive letter-press  is  very  full  and  accurate,  and  the 
whole  makes  an  extremely  handsome  volume." — Brit- 
ish Medical  Journal,  July  10th,  1880. 


"  The  atlas  is  the  most  complete  and  comprehensive 
work  of  its  kind.  .  .  Nearly  every  point,  anatomi- 
cal, physiological,  obstetrical,  and  gynaecological,  is 
illustrated  in  the  best  way,  by  well  known  authors, 
from  whose  works  the  late  Dr.  Martin  culled  his  illus- 
trations. As  a  work  of  reference,  to  the  practitioner, 
the  atlas  is  invaluable;  while  to  the  student  who  wishes 
to  refresh  his  memory  in  the  readiest  way  and  in  the 
shortest  time,  it  will  be  very  useful." — London  Medi- 
cal Record,  July  15th,  1880. 


MACDONALD, 

WATER. 

A  Guide  to  the 
Macdonald,  M.'D. 
Tables,  etc.     8vo. 


MICROSCOPICAL      EXAMINATION      OF 

Microscopical  Examination  of  Drinking  Water.     By  J.  D. 
With   Twenty  Full-page   Lithographic  Plates,  Reference 

Price  $2.75 


"  The  volume  is  an  excellent  hand-book  and  will  greatly  facilitate  the  study  of  the  subject." — Popular  Science 

Monthly. 

MACEWEN,  ON  OSTEOTOMY. 

An  Inquiry  into  the  ^Etiology  and  Pathology  of  Knock-knee,  Bow-leg  and 
other  Osseous  Deformities  of  the  Lower  Limbs.  By  Wm.  Macewen,  m.d.  Il- 
lustrated.    8vo.  Price  $3.00 


a6  PRESLEY  BLAKISTON'S 


MACKENZIE,  ON  THE  THROAT  AND  NOSE. 

Including  the  Pharynx,  Larynx,  Trachea,  (Esophagus,  Nasal  Cavities,  and 
Neck.  By  Morell  Mackenzie,  m.d.,  London,  Senior  Physician  to  the  Hos- 
pital for  Diseases  of  the  Chest  and  Throat,  Lecturer  on  Diseases  of  the  Throat 
at  London  Hospital  Medical  College,  etc.,  etc.  Vol.  i,  containing  the  Pharynx, 
Larynx  and  Trachea,  with  112  Illustrations.     Now  ready. 

Price,  Cloth,  $4.00;  Sheep,  $5.00 

B@° Author's  Edition,  with  the  Original  Illustrations.  Published  from  early 
sheets,  by  arrangement  with  Dr.  Mackenzie.     Vol.  2  in  preparation. 

"We  have  long  felt  the  want  of  a  thoroughly  practical  and  systematic  treatise  on  diseases  of  the  throat 
and  nasal  passages.  Admirable  essays  have  from  time  to  time  appeared  ;  no  standard  work  has  been  written. 
Any  one  familiar  with  laryngoscopic  work  must  appreciate  the  valuable  addition  now  made  to  this  special 
department  in  the  work  before  us.  The  entire  work  will  include  the  consideration  of  affections  of  the  pharynx, 
larynx,  trachea,  oesophagus,  nasal  cavities,  and  neck.  The  matter  now  presented  complete  for  the  first  time  is 
the  result  of  the  author's  large  and  unrivaled  experience,  both  in  hospital  and  private  practice,  extending  over 
a  period  of  twenty  years.  There  can  be  but  one  verdict  of  the  profession  on  this  manual — it  stands  without  any 
competitor  in  medical  literature,  as  a  standard  work  on  the  organs  it  professes  to  treat  of." — Dublin  Journal. 

"  It  is  both  practical  and  learned  ;  abundantly  and  well  illustrated  ;  its  descriptions  of  disease  are  graphic,  and 
the  diagnoses  the  best  we  have  anywhere  seen.  To  give  examples  of  the  thoroughness  of  Dr.  Mackenzie's  book, 
we  may  cite  the  chapter  on  diphtheria,  which  embraces  47  pages.  The  chapter  on  non-malignant  tumors  of  the 
larynx  would  appear  to  be  absolutely  exhaustive.  Nowhere  else  have  we  seen  so  elaborate  a  statement  of  the  sub- 
ject. We  can  predict  for  this  work  a  high  position,  and  congratulate  its  distinguished  author  upon  its  appear- 
ance."— Philadelphia  Medical  Times. 

BY   SAME  AUTHOR. 

THE  PHARMACOPOEIA  of  the   Hospital  for  Diseases   of  the 
Throat  and  Nose. 

The  Fourth  Edition,  much  enlarged,  containing  250  Formulae,  with  Directions 
for  their  Preparation  and  Use.     i6mo.  Price  $1.25 

DIPHTHERIA.     ITS  NATURE  AND  TREATMENT. 

i2mo.  Price  .7 5 

Contents.— 1.  The  Definition  and  History.  2.  The  Etiology.  3.  The  Symptoms.  4.  The  Paralyses.  5. 
The  Diagnosis.  6.  The  Pathology.  7.  The  Prognosis.  8.  The  Treatment.  9.  Laryngo-Tracheal  Diphtheria. 
10.  Nasal  Diphtheria,     n.     Secondary  Diphtheria. 

"The  terse  remarks  on  prognosis  are  excellent;  and  what  the  Author  says  of  treatment,  general  and  local,  and 
tracheotomy,  we  commend  most  cordially." — New  York  Medical  Journal. 

GROWTHS  IN  THE  LARYNX. 

Their  History,  Causes,  Symptoms,  etc.  With  Reports  and  Analysis  of  one 
Hundred  Cases.     With  Colored  and  Other  Illustrations.     8vo.  Price  $2.00 

MACNAMARA,  DISEASES  OF  THE  EYE. 

A  Manual  of  the  Diseases  of  the  Eye.  By  C.  Macnamara,  m.d.  Third 
Edition,  Carefully  Revised;  with  Additions  and  Numerous  Colored  Plates,  Dia- 
grams of  Eye,  Wood-cuts,  and  Test  Types.     Demi  8vo.  Price  S4.00 

"As  a  book  of  ready  reference  on  diseases  of  the  eye  it  has  no  superior,  and  we  may  safely  say,  no  equal  in  our 
language." — Cincinnati  Lancet  and  Observer. 

BY  SAME*  AUTHOR. 

ON  THE  BONES  AND  JOINTS. 

Lectures  on  Diseases  of  the  Bones  and  Joints.     Second  Edition.      Demi  8vo. 

Price  5425 

MADDEN,   HEALTH    RESORTS. 

Health  Resorts  for  the  Treatment  of  Chronic  Diseases.  A  Hand-Book,  the 
result  of  the  author's  own  observations  during  several  years  of  health  travel  in 
many  lands,  containing  also  remarks  on  climatology  and  the  use  of  mineral 
waters.     By  T.  M.  Madden,  m.d.     8vo.  Price  $2.50 

"  Rarely  have  we  encountered  a  book  containing  so  much  information  for  both  invalids  and  pleasure  seekers." 
—  Tin  Sanitarian. 


PUBLICA  TIONS.  27 


MARSHALL  &  SMITH,  ON  THE  URINE. 

The  Chemical  Analysis  of  the  Urine.  By  John  Marshall,  m.d.,  and  Edgar 
F.  Smith,  m.d.,  of  the  Chemical  Laboratory,  Medical  Department,  University  of 
Pennsylvania.     Illustrated  by  Phototype  Plates.  121110.  Price  $1.00 

MARSHALL,  ANATOMICAL  PLATES; 

Or  Physiological  Diagrams.     Life  Size  (7  by  4  feet)  and  Beautifully  Colored. 
By  John  Marshall,  f.r.s.     An  Entirely  New  Edition,  Revised  and  Improved, 
Illustrating  the  Whole  Human  Body. 
The  Set,  Eleven  Maps,  in  Sheets,  Price  $50.00 

handsomely  Mounted  on  Canvas,  with 

Rollers,  and  Varnished,  Price  $80.00 
An  Explanatory  Key  to  the  Diagrams,  Price  .50 

Dr.  Marshall's  Plates,  from  their  size  and  perfection  of  drawing  and  coloring,  excel 
any  diagrams  that  have  been  published.  They  have  proved  invaluable  in  Medical 
Schools  and  Lecture  Rooms.  The  low  price  at  which  they  are  offered  brings  them 
within  reach  of  all. 

No.  1.  The  Skeleton  and  Ligaments.  No.  2.  The  Muscles,  Joints,  and  Animal  Mechanics.  No.  3.  The  Vis- 
cera in  Position — The  Structure  of  the  Lungs.  No.  4.  The  Organs  of  Circulation.  No.  5.  The  Lymphatics  or 
Absorbents.  No.  6.  The  Digestive  Organs.  No.  7.  The  Brain  and  Nerves.  No.  8.  The  Organs  of  the  Senses 
and  Organs  of  the  Voice,  Plate  1.  No.  9.  The  Organs  of  the  Senses,  Plate  2.  No.  10.  The  Microscopic 
Structure  of  the  Textures,  Plate  1.     No.  11.  The  Microscopic  Structure  of  the  Textures,  Plate  2. 

MARSDEN,  ON  CANCER. 

A  New  and  Successful  Mode  of  Treating  Certain  Forms  of  Cancer.  By  Alex- 
ander Marsden,  m.d.     Second  Edition.     Colored  Plates.     8vo.        Price  $3.00 

MARTIN,  MICROSCOPIC  MOUNTING. 

A  Manual  of  Microscopic  Mounting.  With  Notes  on  the  Collection  and  Ex- 
amination of  Objects,  and  upwards  of  150  Illustrations.  By  John  H.  Martin. 
Second  Edition,  Enlarged.     8vo.  Price  $2.75 

MORRIS,  ON  THE  JOINTS. 

The  Anatomy  of  the  Joints  of  Man.  Comprising  a  Description  of  the  Liga  • 
ments,  Cartilages,  and  Synovial  Membranes;  of  the  Articular  Parts  of  Bones, 
etc.  By  Henry  Morris,  f.r.c.s.  Illustrated  by  44  Large  Plates  and  Numerous 
Figures,  many  of  which  are  Colored.     8vo.  Price  $5.50 

MUTER,  MEDICAL   AND    PHARMACEUTICAL   CHEMIS- 
TRY. 

An  Introduction  to  Pharmaceutical  and  Medical  Chemistry.  Part  One. — 
Theoretical  and  Descriptive.  Part  Two. — Practical  and  Analytical.  Arranged 
on  the  principle  of  the  Course  of  Lectures  on  Chemistry  as  delivered  at,  and  the 
Instruction  given  in  the  Laboratories  of,  the  South  London  School  of  Pharmacy. 
By  John  Muter,  m.d.,  President  of  the  Society  of  Public  Analysts.  A  Second 
Edition,  Enlarged  and  Rearranged.  The  Two  Parts  bound  in  one  large  octavo 
volume.  Price  $6.00 

Part  Two.— Practical  and  Analytical.  Bound  Separately,  for  the  Special  Con- 
venience of  Students.     Large  8vo.     Cloth.  Price  $2.50 

MAC  MUNN,  THE  SPECTROSCOPE. 

The  Spectroscope  in  Medicine.  By  Chas.  A.  Mac  Munn,  m.d.  With  3 
Chromo-lithographic  Plates  of  Physiological  and  Pathological  Spectra,  and  13 
Wood  Cuts.     8vo.  Price  #3.00 

'*  This  book  is,  without  question,  the  best  that  has  yet  been  published  on  the  subject ;  to  those  not  familiar  with 
Physiological  Spectroscopy  it  will  prove  interesting,  while  to  those  who  are  worfcng  in  this  field  it  is  a  neces/ 
sity." — New  York  Medical  Journal. 


28  PRESLEY  BLAKISTON'S 

It  is  eminently  a  book  which  -will  teach  the  Student. — Practitioner. 
It  forms  one  of  the  most   convenient,  practical,  and  concise  books  ye* 
published  on  the  subject.  —  London  Lancet. 

MEADOWS'  MANUAL  OF  OBSTETRICS. 

THE  THIKD  EEVISED  AND  ENLAKGED  EDITION,  NOW  KEADY; 

WITH  ONE  HUNDRED  AND  FORTY-FIVE  ILLUSTRATIONS. 

INCLUDING  THE  SIGNS  AND  SYMPTOMS  OF  PREGNANCY, 
Obstetric  Operations,  Diseases  of  the  Puerperal  State,  &c,  &c.  By 
Alfred  Meadows,  M.  D.,  Physician  to  the  Hospital  for  Women,  to 
the  General  Lying-in  Hospital,  Sec,  &c.  Revised  and  Enlarged  Edi- 
tion.    With  numerous  Illustrations.  Price  $2.00 

In  this  new  edition, ..  .not  merely  is  the  practical  treatment  of  Labor,  and  also  of  the  Dis* 
eases  and  Accidents  of  Pregnancy,  well  and  clearly  taught,  hut  the  anatomical  machinery 
of  parturition  is  more  effectively  explained  than  in  any  other  treatise  that  we  remember ; 
besides  this,  the  book  is  honorably  distinguished  among  manuals  of  Midwifery  by  the  fub 
ness  with  which  it  goes  into  the  subject  of  the  structure  and  development  of  the  ovum.  On 
all  questions  of  treatment,  whether  by  medicines,  by  hygienic  regimen,  or  by  mechanical  or 
operative  appliances,  this  treatise  is  as  satisfactory  as  a  work  of  manual  size  could  be ;  student* 
and  practitioners  can  hardly  do  better  than  adopt  it  as  their  vade-mecum. — TJie  Practitioner. 

Upwards  of  ninety  new  engravings  have  been  inserted  in  this  edition,  and,  with  a  view  to 
facilitate  reference,  the  author  has  furnished  it  with  a  very  full  and  complete  table  of  contents 
and  index.  We  can  cordially  recommend  this  mamxal  as  accurate  and  practical,  and  as  con- 
taining in  a  small  compass  a  large  amount  of  the  kind  of  information  suitable  alike  to  the 
student  and  practitioner. — London  Lancet. 

It  is  concise,  well  arranged,  and  remarkably  complete,  as  a  guide  to  the  student  during  his 
lecture  term ;  and  as  a  ready  reference  to  the  Physician,  no  work  of  similar  character  equals 
it  in  value. — Buffalo  Medical  Journal. 

The  systematic  arrangement  of  subjects,  and  the  concise,  practical  style  in  which  it  is 
written,  make  the  work  especially  valuable  as  a  student's  manual,  while  a  very  full  table 
of  contents  and  index  renders  it  easily  accessible  as  a  work  of  reference. —  Chicago  Medical 
Examiner. 

There  can  be  no  doubt  that  this  manual  will  be  generally  accepted  as  a  brief,  convenient, 
and  compendious  guide  to  the  study  and  practice  of  the  Obstetric  Art. — Richmond  and 
Louisville  Medical  Journal. 

We  cannot  but  feel  that  every  teacher  of  obstetrics  has  good  cause  to  congratulate  himself 
on  being  able  to  put  in  the  hands  of  the  student  a  book  which  contains  so  much  valuable 
and  reliable  information  in  so  condensed  a  form. — Philadelphia  Medical  Timet. 

It  is  concisely  and  clearly  written,  and  the  information  is  on  the  whole  on  a  level  with  the 
most  recent  knowledge  of  the  day. — British  and  Foreign  Medical  A'<  view, 

A  work  which  embodies  a  larger  amount  of  practical  information  than  any  other  bttok  on 
the  subject. — Pacific  Medical  and  Surgical  Journal. 

It  is  with  great  gratification  that  we  are  enabled  to  class  Dr.  Meadows'  Manual  as  a  rare 
exception,  and  to  pronounce  it  an  accurate,  practical,  and  creditable  work,  ami  to  unheal- 
tatingly  recommend  it  to  both  student  and  practitioner. — American  Journal  <>/  Obstetric* 

It  is  a  book  of  decided  merit :  every  page  teems  with  sound,  practical  common  sense,  advice 
and  suggestions. — Kansas  City  Medical  Journal. 


PUBLIC  A  TIONS. 


MENDENHALL,  VADE  MECUM. 

The  Medical  Student's  Vade  Mecum.  A  Compend  of  Anatomy,  Physiology, 
Chemistry,  The  Practice  of  Medicine,  Surgery,  Obstetrics,  etc.  By  George 
Mexdexhall,  m.d.     Eleventh  Edition.     224  Illustrations.     8vo.        Price  §2.00 

MEIGS  AND  PEPPER,  DISEASES  OF  CHILDREN. 

A  Practical  Treatise  on  the  Diseases  of  Children.  By  J.  Forsyth  Meigs,  m.d., 
Fellow  of  the  College  of  Physicians  of  Philadelphia,  etc.,  etc.,  and  William 
Pepper,  m.d.,  Physician  to  the  Philadelphia  Hospital,  Provost  University  of 
Pennsylvania.  Seventh  Edition,  thoroughly  Revised  and  Enlarged.  A  Royal 
Octavo  Volume  of  over  1000  pages.  Price,  Cloth,  $6.00;  Leather,  $7.00 

"  With  the  recent  additions  it  may  safely  be  pronounced  one  of  the  best  and  most  comprehensive  works  on  Dis- 
eases of  Children." — New  York  Medical  Journal. 

"  Must  be  regarded  as  the  most  complete  work  on  Diseases  of  Children  in  our  language." — Edinburgh  Medical 
Journal. 

"  We  have  seldom  met  with  a  text-book  so  complete,  so  just  and  so  readable  as  the  one  before  us." — American 
Journal  of  Obstetrics. 

MATHIAS,  LEGISLATIVE  MANUAL. 

A  Rule  for  Conducting  Business  in  Meetings  of  Societies,  Legislative  Bodies, 
Town  and  Ward  Meetings,  etc.  By  Benj.  Mathias,  a.m.  Sixteenth  Edition. 
i6mo.  Price  .50 

MORTON,  REFRACTION  OF  EYE. 

The  Refraction  of  the  Eye.  Its  Diagnosis  and  the  Correction  of  its  Errors. 
With  Chapter  on  Keratoscopy.     By  A.  Staxford  Mortox,  m.b.,  f.r.c.s.     i2mo. 

Price  $1.00 

"  The  author  has  not  only  given  very  thorough  rules  for  the  objective  and  subjective  examinations  of  the  eye  in 
the  various  conditions  of  refraction  which  present  themselves,  but  has  entered  into  an  explanation  of  the  phenom- 
ena observed,  which  is  at  once  scientific  and  elementary." — Edinburgh  Medical  Journal. 

MEARS,  PRACTICAL  SURGERY. 

Practical  Surgery.  Including:  Part  1. — Surgical  Dressings  ;  Part  11. — Band- 
aging ;  Part  in. — Ligations  ;  Part  iv. — Amputations.  With  227  Illustrations. 
By  J.  Ewixg  Mears,  m.d.,  Demonstrator  of  Surgery  in  Jefferson  Medical  Col- 
lege, and  Professor  of  Anatomy  and  Clinical  Surgery  in  the  Pennsylvania  Col- 
lege of  Dental  Surgery.     i2mo.  Price  $2.00 


"  Professor  Mears  has  written  a  convenient  and  use- 
ful book  for  students.  We  can  most  cordially  endorse 
it  as  fulfilling  well  the  promise  made  in  its  modest  pre- 
face."—  Cincinnati  Lancet  and  Clinic. 


"  It  contains  a  great  deal  of  information  upon  the 
subjects  of  which  it  treats,  in  a  convenient  and  con- 
densed form.  Each  division  is  well  illustrated,  thereby 
rendering  the  text  doubly  clear." — New  York  Medical 
Record. 


OLDBERG,  PRESCRIPTION  BOOK. 

Three  Hundred  Prescriptions,  Selected  Chiefly  from  the  Best  Collections  of 
Formulae  used  in  Hospital  and  Out-patient-practice,  with  a  Dose  Table,  and  a 
Complete  Account  of  the  Metric  System.  By  Oscar  Oldberg,  phar.  d.,  Late 
Medical  Purveyor,  United  States  Marine  Hospital  Service ;  Professor  of  Materia 
Medica,  National  College  of  Pharmacy,  Washington,  D.  C. ;  Member  of  the 
American  Pharmaceutical  Association,  and  of  the  Sixth  Decennial  Committee 
of  Revision  and  Publication  of  the  Pharmacopoeia  of  the  United  States. 
i2mo.  Price  51.50 

The  prescriptions  given  in  this  work  are  selected  from  the  Pharmacopoeias  and 
formularies  of  the  great  Hospitals  of  New  York,  Philadelphia,  Boston  and  London, 
or  contributed  from  the  practice  of  medical  officers  of  the  United  States  Service.  The 
Dose  Table  includes  nearly  all  of  the  remedies  that  have  a  place  in  the  current 
Materia  Medica.  * 


3° 


PRESLEY  BLAKISTON'S 


BY   SAME   AUTHOR. 

THE  UNOFFICIAL  PHARMACOPOEIA. 

Comprising  over  700  Popular  and  Useful  Preparations,  not  Official  in  the 
United  States,  of  the  various  Elixirs,  Fluid  Extracts,  Mixtures,  Syrups,  Tinct- 
ures, Ointments,  Wines,  etc,  etc.,  in  constant  demand  throughout  the  country. 
Thick  i2mo.     503  pp.     Half  Morocco.  Price  $3.50 

Sold  by  Subscription. 
ggg'-lT  Will  Prove  a  Useful  Supplement  to  the  Pharmacopoeia  of  the 
United  States  ;  the  aim  has  been  to  make  it  as  complete  as  practicable.  The  form- 
ulae can,  with  a  minimum  of  labor,  be  used  with  any  system  of  weights  and  meas- 
ures. The  virtual  adoption  of  the  metric  system  in  the  forthcoming  Pharmacopoeia 
of  the  United  States  will  account  for  the  preference  given  to  that  system  in  this  vol- 
ume, which,  however,  does  not  prevent  the  ready  use  of  the  book  with  apothecaries' 
weights  and  measures.  An  extended  account  of  the  metric  system  has  been  given, 
accompanied  by  full  tables  of  equivalents.  The  sources  from  which  the  formulae 
have  been  gathered  are  believed  to  be  the  best.  They  include  the  Pharmacopoeias 
of  England,  Germany,  France  and  Sweden.  The  book  is  practically  equivalent  to 
the  possession  of  these  various  Pharmacopoeias,  and  the  formulae  were  selected  with 
reference  to  their  popularity,  usefulness,  and  interesting  character. 

"  This  volume  is  one  of  the  most  practical  and  valuable  contributions  to  Pharmaceutical  work  of  recent  publica- 
tion. It  has  received  high  commendation  from  many  of  our  best  pharmacists." — Lazell,  Marsh  &r>  Gardiner, 
Wholesale  Druggists,  New  York  City. 

OTT,  ACTION  OF  MEDICINES. 

The  Action  of  Medicines.  By  Isaac  Ott,  m.d.,  late  Demonstrator  of  Experi- 
mental Physiology  in  the  University  of  Pennsylvania.  With  22  Illustrations. 
8vo.  Price  $2.00 

"  This  work  is  the  only  one  in  the  English  language  which  can  offer,  with  any  degree  of  completeness,  that  assist- 
ance and  instruction  so  essential  to  the  correct  and  successful  study  of  pharmacology.  Filling,  as  it  does,  this  gap 
in  medical  literature,  we  have  a  work  whicfc  cannot  fail  to  be  of  the  greatest  value  to  students. 

"  From  the  pen  of  a  man  himself  no  novice  in  the  subject  of  which  he  treats,  it  bears  upon  it  the  impress  of  relia- 
bility, due  to  the  author's  own  experience,  a  virtue  too  often  wanting  in  mere  compilations  of  the  works  of  oth- 
ers."— American  Journal  of  Medical  Sciences. 

PAGET,  SURGICAL  PATHOLOGY. 

Lectures  on  Surgical  Pathology,  Delivered  at  the  Royal  College  of  Surgeons. 
By  James  Paget,  f.r.s.  Third  Edition.  Edited  by  William  Turner,  m.d. 
With  Numerous  Illustrations.     8vo.  Price,  Cloth,  $7.00;  Leather,  $8.00 

PARKES,  PRACTICAL  HYGIENE.     Fifth  Edition. 

A  Manual  of  Practical  Hygiene.  By  Edward  A.  Parkes,  m.d.  The  Fifth, 
Revised  and  Enlarged  Edition.     With  Many  Illustrations.     8vo.        Price  56.00 

"  Altogether  it  is  the  most  complete  work  on  Hygiene  which  we  have  seen."— New  York  Medical  Record. 

"  We  find  that  it  never  fails  to  throw  light  on  any  hygienic  question  which  may  be  proposed."— Boston  Medi- 
cal and  Surgical  Journat. 

•'We  commend  the  book  heartily  to  all  needing  instruction  (and  who  does  not),  in  Hygiene  "—Chicago  Midi- 
cal  yournal. 

PIESSE,  THE  MANUFACTURE  OF  PERFUMERY.    Fourth 
Edition. 

The  Art  of  Perfumery ;  or  the  Methods  of  Obtaining  the  Odors  of  Plants,  and 
Instruction  for  the  Manufacture  of  Perfumery,  Dentifrices,  Soap,  Scented  Pow- 
ders, Odorous  Vinegars  and  Salts,  Snuff,  Cosmetics,  etc.,  etc.     By  G.  W.  Septi- 
mus  Piesse.      Fourth   Edition.      Enlarged.     366    Illustrations.     8vo.     Cloth. 
♦  Price  $5.50 


"  An  excellent  book." — Commercial  Advertiser. 
"  It  is  the  best  book  on  Perfumery  yet  published."— 
Scientific  American. 


"  Exceedingly  useful  to  druggists  and  perfumers."— 
Journal  of  Chemistry. 

"  Is  in  the  fullest  sense,  comprehensive." — Medical 
Record. 


PUBLICATIONS.  31 


PENNSYLVANIA  HOSPITAL  REPORTS. 

Edited  by  a  Committee  of  the  Hospital  Staff.  J.  M.  DaCosta,  m.d.,  and 
William  Hunt,  m.d.  Vols.  1  and  2,  containing  Original  Articles  by  former 
and  present  Members  of  the  Staff.  With  Lithographic  and  other  Illustrations. 
8vo.  Price,  per  volume,  $2.00 

These  volumes  consist  of  papers  of  a  practical  character,  based  chiefly  on  obser- 
vations made  at  the  Hospital,  but  containing  the  further  experience  of  the  Members 
of  the  Staff.  In  issuing  the  second  volume  the  Editors  express  their  acknowledg- 
ments for  the  very  favorable  reception  of  the  first  by  the  profession  and  press  of 
this  country  and  Europe. 

PEREIRA,   PRESCRIPTION  BOOK.     Sixteenth  Edition. 

Physician's    Prescription  Book.      Containing  Lists  of  Terms,   Phrases,  Con- 
tractions and  Abbreviations  used  in   Prescriptions,  Explanatory  Notes,  Gram- 
matical Construction  of  Prescriptions,  Rules  for  the  Pronunciation  of  Pharma- 
ceutical   Terms.      By  Jonathan   Pereira,   m.d.,  f.r.s.      Sixteenth    Edition. 
Price,  Cloth,  $1.00;  Leather,  with  tucks  and  pocket,  $1.25 

PIGGOTT,  ON  COPPER. 

Copper  Mining  and  Copper  Ore.  With  a  full  Description  of  the  Principal 
Copper  Mines  of  the  United  States,  the  Art  of  Mining,  etc.  By  A.  Snowden 
Piggott.     i2mo.  •  Price  $1.00 

PRINCE,  ORTHOPEDIC  SURGERY. 

Plastic  and  Orthopedic  Surgery.  By  David  Prince,  m.d.  Containing  a 
Report  on  the  Condition  of,  and  Advance  made  in,  Plastic  and  Orthopedic  Sur- 
gery, etc.,  etc.,  and  Numerous  Illustrations.     8vo.  Price  $4.50 

PHYSICIAN'S  VISITING  LIST,  PUBLISHED  ANNUALLY. 

THIRTY-FIRST  YEAR  OF  ITS  PUBLICATION. 
SIZES   AND   PRICES. 

pencil,       ....    $1.00 

-  1.25 

"  -  1.50 

"  -     ,  -        -        -      2.00 

"  -  2.50 

"  -  3.00 

INTERLEAVED   EDITION. 

For  25  Patients  weekly,  interleaved,  tucks,  pockets,  etc.,         -  1.25 

£       "  "-OI,      {$£{$$  "  :       '-       -       -      Z 

The  Visiting  List  contains  a  New  Table  of  Poisons  and  their  Antidotes.  The 
Metric  or  French  Decimal  System  of  Weights  and  Measures.  Posological  Tables, 
showing  the  relation  of  our  present  system  of  Apothecaries'  Weights  and  Measures 
to  that  of  the  Metric  System,  giving  the  Doses  in  both. 

This  last  is  a  most  valuable  addition,  and  will  materially  aid  the  Physician.  So 
many  writers  now  use  the  metric  system,  especially  in  foreign  books  and  journals, 
that  one  not  familiar  with  it  is  constantly  confused,  and  in  many  cases  unable  to 
understand  the  measurements  or  doses. 

"The  book  is  convenient  in  form,  not  too  bulky,  and 
in  every  respect  the  very  best  Visiting  List  published." 
—  Canada  Medical  and  Surgical  Journal. 

"This  standard  Visiting  List,  for  completeness,  eom- 
pactness,  and  simplicity  of  arrangement,  is  excelled  by 
none  in  the  market." — Nezv  York  Medical  Record. 


For  25 

Patients 

weekly. 

Tucks,  pockets, 

5° 

" 

" 

a           <i 

75 

it 

" 

a           11 

100 

€1 

" 

11            11 

5o 

• 

U 

"  2  vols. 

(Jan.  to  June  ) 
{  July  to  Dec.  } 

100 

II 

"   2  VOls. 

}  Jan.  to  June  ) 
{  July  to  Dec.  j 

"  It  is  certainly  the  most  popular  Visiting  List  ex- 
tant."— New  York  Medical  "Journal. 

"Its  compact  size,  convenience  of  arrangement,  dur- 
ability, and  neatness  of  manufacture  have  everywhere 
obtained  for  it  a  preference." — Canada  Lancet. 


32  PRESLE  Y  BLAKISTON  'S 

POWER,  HOLMES,  ANSTIE  AND  BARNES  (Drs.). 

Reports  on  the  Progress  of  Medicine,  Surgery,  Physiology,  Midwifery,  Dis- 
eases of  Women  and  Children,  Materia  Medica,  Medical  Jurisprudence,  Ophthal- 
mology, etc.,  etc.     Reported  for  the  New  Sydenham  Society.     8vo.     Price  $2.00 

PURCELL,  ON  CANCER. 

Cancer.  Its  Allies  and  other  Tumors,  with  Specia  Reference  to  their  Medi- 
cal and  Surgical  Treatment.  By  F.  Albert  Purcell,  m.d.,  m.r.c.S.  Surgeon 
to  the  Cancer  Hospital,  Brompton,  England.     8vo.  Price  $3.75 

RADCLIFFE,  ON  EPILEPSY. 

On  Epilepsy,  Pain,  Paralysis,  and  other  Disorders  of  the  Nervous  System. 
By  Charles  Bland  Radcliffe,  m.d.     Illustrated.     i2mo.  Price  $1.50 

_  "  To  no  authority  can  the  medical  inquirer  turn  for  an  analysis  of  the  phenomena  of  epilepsy  with  more  satisfac- 
tion than  to  the  admirable  essay  of  Dr.  Radcliffe." — American  Journal  Medical  Sciences. 

ROBERTS,  MANUAL  OF  MIDWIFERY. 

The  Student's  Guide  to  the  Practice  of  Midwifery.  By  D.  Lloyd  P.oberts, 
m.d.,  f.r.c.p.,  Physician  to  St.  Mary's  Hospital,  Manchester,  etc.,  etc.  Second 
Edition.     With  95  Illustrations.     i2mo.  Price  $2.00 

"  As  an  obstetrical  manual,  we  think  that  of  Dr.  Rob- 
erts one  of  the  best  now  offered  to  the  Profession,  as  it 
comes  with  authority,  aSid  he  possesses  the  ability  to 


condense,  and  at  the  same  time  present  a  subject  clear- 
ly."— American  Journal  of  Medical  Science. 

"Concise,   clear,   and    practical." — Mediial  Press 
and  Circular. 


"  The  present  edition  has  been  very  thoroughly  re- 
vised, some  chapters  having  been  entirely  re-written. 
For  its  size,  it  forms  a  remarkably  complete  compendia 
um  of  the  subject,  and  can  hardly  be  surpassed  in  the 
simplicity  and  clearness  of  its  explanations." — Obstet- 
rical Journal  of  Great  Britain  and  Jreland. 


REYNOLDS,   ELECTRICITY. 

Lectures  on  the  Clinical  Uses  of  Electricity.  By  J.  Russell  Reynolds,  m.d., 
f.r.s.     Second  Edition.     i2mo.  Price  $1.00 

"  It  is  thoroughly  reliable  as  a  guide,  very  concise,  and  will  be  found  exceedingly  useful  to  the  general  practi- 
tioner."—  Canada  Lancet. 

RICHARDSON,    MECHANICAL    DENTISTRY.      Third   Edi- 
tion. 

A  Practical  Treatise  on  Mechanical  Dentistry.  By  Joseph  Richardson,  d.d.s. 
Third  Edition.     With  185  Illustrations.    8vo.    Price,  Cloth,  $4.00;  Leather,  $4.75 

"  Taken  as  a  whole,  Professor  Richardson's  work  is  a  valuable  contribution  to  the  dental  art,  and  is  beyond  all 
question  the  best  treatise  extant  upon  the  general  subject  of  Mechanical  Dentistry." — Dental  Cosmos.  9 

RIGBY  AND  MEADOWS,  OBSTETRIC  MEMORANDA. 

Dr.  Rigby's  Obstetric  Memoranda.  Fourth  Edition.  Revised.  By  Alfred 
Meadows,  m.d.     321x10.  Price  .50 

RINDFLEISCH,  PATHOLOGICAL  HISTOLOGY. 

A  Text-Book  of  Pathological  Histology.  By  Dr.  Edward  Rindfleisch. 
Translated  by  Drs.  Wm.  C.  Kolman  and  F.  T.  Miller.  208  Illustrations. 
8vo.  Price,  Cloth,  #5.00;  Leather,  $6.00 

Recommended  as  a  Text-Book  at  the  University  of  Pennsylvania  and  other  Med- 
ical Schools. 

"  To  be  up  with  the  times  our  Pathologists  must  make  themselves  familiar  with  the  thorough,  clear  and  almost 
exhaustive  teachings  of  Professor  Rindfleisch."—  Ohio  Medical  and  Surgical  Reporter. 

"  In  conclusion  wc  cordially  recommend  it  as  the  best  treatise  on  the  subject."—  American  Journal  <f  Medi- 
cal Science. 

RYAN,  ON   MARRIAGE. 

The  Philosophy  of  Marriage.  In  its  Social,  Moral  and  Physical  Relations, 
and  Diseases  of  the  Urinary  Organs.  By  Michael  Ryan,  m.d.  Member  of 
the  Royal  College  of  Physicians,  London.     i2mo.  Price  $1.00 


PUBLICA  TIONS.  33 


ROBERTS'  PRACTICE  OF  MEDICINE. 

A  New  Enlarged  Edition, 

JUST  READY. 

Uniformly  coniniended  by  the  Profession  and  the  Press. 

A  HAND-BOOK  OF  THE  THEORY  AND  PRACTICE  OF  MEDI- 
CINE.    By  Frederick  T.  Roberts,  M.D.,  M.R.C.P.,  Assistant  Pro- 
fessor and  Teacher  of  Clinical  Medicine  in  University  College  Hospital, 
Assistant  Physician  in  Brompton  Consumptive  Hospital,  &c,  &c. 
Third  Edition.     Octavo.     Price,  in  cloth       ....       $5.00 

leather      ....         6.00 
The  Publishers  are  in  receipt  of  numerous  letters  from  Professors  in  the  various  Med- 
ical Schools,  uniformly  commending  this  book ;  whilst  the  following  extracts  from  the 
Medical  Press,  both  English  and  American,  fully  attest  its  superiority  and  great  value 
not  only  to  the  student,  but  also  to  the  busy  practitioner. 

This  is  a  good  book,  yea,  a  very  good  book.  It  is  not  so  full  in  its  Pathology  as  "  Aitken," 
so  charming  in  its  composition  as  "  Watson,"  nor  so  decisive  in  its  treatment  as  "  Tanner; " 
but  it  is  more  compendious  than  any  of  them,  and  therefore  more  useful.  We  know  of  no 
other  work  in  the  English  language,  or  in  any  other,  for  that  matter,  which  competes  with 
this  one.  — Edinburgh  Medical  Journal. 

We  have  .much  pleasure  in  expressing  our  sense  of  the  author's  conscientious  anxiety  to 
make  his  work  a  faithful  representation  of  modern  medical  beliefs  and  practice.  In  this  he 
has  succeeded  in  a  degree  that  will  earn  the  gratitude  of  very  many  students  and  practition- 
ers: it  is  a  remarkable  evidence  of  industry,  experience,  and  research.  —  Practitioner. 

That  Dr.  Roberts's  book  is  admirably  fitted  to  supply  the  want  of  a  good  hand-book  of 
medicine,  so  much  felt  by  every  medical  student,  does  not  admit  of  a  question.  —  Students' 
Journal  and  Hospital  Gazette. 

Dr.  Roberts  has  accomplished  his  task  in  a  satisfactory  manner,  and  has  produced  a  work 
mainly  intended  for  students  that  will  be  cordially  welcomed  by  them  ;  most  of  the  observa- 
tions on  treatment  are  carefully  written  and  worthy  of  attentive  study;  the  arrangement  is 
good,  and  the  style  clear  and  simple.  —  London  Lancet. 

It  contains  a  vast  deal  of  capital  instruction  for  the  student,  much  valuable  matter  in  it  to 

commend,  and  merit  enough  to  insure  for  it  a  rapid  sale. — London  Medical  Times  and  Gazette. 

There  are  great  excellencies  in  this  book,  which  will  make  it  a  favorite  both  with  the 

accurate  student  and  busy  practitioner.    The  author  has  had  ample  experience.— Richmond 

and  Louisville  Journal. 

We  confess  ourselves  most  favorably  impressed  with  this  work.  The  author  has  performed 
his  task  most  creditably,  and  we  cordially  recommend  the  book  to  our  readers.  —  Canada 
Medical  and  Surgical  Journal. 

A  careful  reading  of  the  book  has  led  us  to  believe  that  the  author  has  written  a  work 
more  nearly  up  to  the  times  than  any  that  we  have  seen ;  to  the  student,  it  will  be  a  gift  of 
priceless  value.  — Detroit  Review  of  Medicine. 

Our  opinion  of  it  is  one  of  almost  unqualified  praise.  The  style  is  clear,  and  the  amount  of 
nseful  and,  indeed,  indispensable  information  which  it  contains  is  marvellous.  We  heartily 
recommend  it  to  students,  teachers,  and  practitioners.  —  Boston  Med.  and  Surgical  Journal. 
It  is  of  a  much  higher  order  than  the  usual  compilations  and  abstracts  placed  in  the  hands 
oFstudents.  It  embraces  many  suggestions  and  hints  from  a  carefully  compiled  hospital 
experience ;  the  style  is  clear  and  concise,  and  the  plan  of  the  work  very  judicious.— Medical 
and  Surgical  Reporter. 

It  is  unsurpassed  by  any  work  that  has  fallen  into  our  hands  as  a  compendium  for  gtudents 

preparing  for  examination.    Itis  thoroughly  practical  and  fully  up  to  the  times.—  The  Clinic. 

We  find  it  an  admirable  book.  Indeed,  we  know  of  no  hand-book  on  the  subject  just  now 

to  be  preferred  to  it.     We  particularly  commend  it  to  students  about  to  enter  upon  the 

practice  of  their  profession.  —  St.  Louis  Medical  and  Surgical  Journal. 

If  there  is  a  book  in  the  whole  of  medical  literature  in  which  so  much  is  said  in  so 
few  words,  it  has  never  come  within  our  reach.  So  clear,  terse,  and  pointed  is  the  style ; 
so  accurate  the  diction,  and  so  varied  the  matter  of  this  book,  that  it  is  almost  a  dictionary 
of  practical  medicine.  —  Chicago  Medical  Jorurnok 


34  PRESLEY  BLAKISTON'S 

SANDERSON  AND  FOSTER,  THE    PHYSIOLOGICAL  LA- 
BORATORY. 

A  Hand-book  of  the  Physiological  Laboratory.  Being  Practical  Exercises  for 
Students  in  Physiology  and  Histology.  By  J.  Burdon  Sanderson,  m.d.,  E. 
Klein,  m.d.,  Michael  Foster,  m.d.,  f.r.s.,  and  T.  Lauder  Brunton,  m.d. 
With  over  350  Illustrations  and  Appropriate  Letter-press  Explanations  and  Ref- 
erences. 

Price,  Two  Volumes,  Text  and  Plates,  separate,       -  $7.00 

"      One  "  "  "  bound  together,  Cloth,        6.00 

"         "  "  "  "  "  •'  Leather,    7.00 

Adopted  as  a  Text-book  at  Yale  College,  and  used  at  other  Medical   Schools  in 

America  and  England. 

"  Recognizing  the  fact  that  Physiology  is  emphatic-    I  "We  confidently  recommend  it  to  the  attention  of  all 

ally  an  experimental  science,  it  furnishes  minute  in-  who  are  interested  in  the  wide  and  fertile  field  of  Phy- 

structions    for   performing  a  great  variety   of  exper-  siological  research." — New  York  Medical  Journal. 

iments.  A  student  could  scarcely  desire  a  better  guide."  *  This  is  a  most  superb  bonk,  and  fills  a  hiatus  which 

— Boston  Medical  and  Surgical  Journal.  every  physiological  student  has  lamented." — Chicago 

I  Medical  Journal. 

SANDERSON,  PHYSIOLOGY.     Second  Edition. 

A  Syllabus  of  a  Course  of  Lectures  on  Physiology.  By  J.  Burdon  Sander- 
son, m.d.     For  the  Use  of  Students.     Second  Edition.     8vo.  Price  $1.50 

SANSOM,  PHYSICAL  DIAGNOSIS.     Third  Edition  just  ready. 

The  Physical  Diagnosis  of  Diseases  of  the  Heart.  Including  the  Use  of  the 
Sphygmograph  and  Cardiograph.  By  Arthur  Ernest  Sansom,  m.d.  Third 
Edition.     Revised  and  Enlarged.     With  Illustrations.     i2mo.  Price  $2.00 

"  Dr.  Sansom  is  favorably  known,  and  the  little  work  he  here  presents  reflects  creditably  on  his  skill  in  pre- 
senting with  singular  clearness,  one  of  the  most  difficult  branches  of  diagnosis." — Philadelphia  Medical  and  Sur- 
gical Reporter. 

BY   SAME   AUTHOR. 

ON    CHLOROFORM. 

Chloroform.     Its  Action  and  Administration.     i2mo.  Price  $1.50 

SMITH,  MANUAL  OF  GYNECOLOGY. 

Practical  Gynaecology.  A  Hand-book  of  the  Diseases  of  Women.  By  Hey- 
wood  Smith,  m.d.  Physician  to  the  Hospital  for  Women  and  to  the  British 
Lying-in  Hospital.     With  Engravings.  Price  $1.5 

The  object  of  the  author  has  been  to  present  the  busy  practitioner  with  a  book 
systematically  arranged,  burdened  with  no  discussions  on  vexed  questions  of  pathol- 
ogy, and  giving  at  a  glance  the  salient  points  of  diagnosis  and  treatment  with  clear- 
ness and  brevity. 

Contents.— Chapter  1.  On  the  Means  of  Diagnosis :  On  Touch— immediate  and  intermediate.  On  Sight 
— immediate  and  intermediate.  On  Hearing. — immediate  and  intermediate.  2.  General  Diseases.  3.  Local 
Diseases — Diseases  of  the  Ovary.  4.  Diseases  of  the  Oviduct.  5.  Diseases  of  the  Broad  Ligament.  6.  Diseases 
of  the  Uterus  (unimpregnated).  7.  Diseases  of  the  Vagina.  8.  Diseases  of  the  Vulva.  9.  Diseases  of  the  Mam- 
ma. 10.  Functional  Diseases.  11.  Diseases  connected  with  Pregnancy.  12.  Diseases  connected  with  Parturi- 
tion.    13.  Diseases  consequent  on  Parturition.     Appendix  of  Remedies. 

BY   SAME   AUTHOR. 

DYSMENORRHEA.    Just  Issued. 

Its  Pathology  and  Treatment.     l2mo.  Price  #2.50 

SMITH,  RINGWORM. 

The  Diagnosis  and  Treatment  of  Ringworm.  By  Alder  Smith,  f.r.c.S. 
With  Illustrations.     i2mo.  Price  $1.00 

SMITH,  ON   NURSING. 

The  Efficient  Training  of  Nurses  for  Hospital  and  Private  Practice.  By  Wil- 
liam Robert  Smith.     Illustrated.     i2mo.  Price  $2.00 


PUBLICA  TIONS.  35 


SMITH,  ON  CHILDREN. 

Clinical  Studies  of  Diseases  in   Children.     By  Eustace  Smith,  m.d.     nmo. 

Price  $2.50 

MEDICAL  HERESIES,  HISTORICALLY  CONSIDERED. 

A  Series  of  Critical  Essays  on  the  Origin  and  Evolution  of  Sectarian  Medi- 
cine, embracing  a  Special  Sketch  and  Review  of  Homoeopathy,  Past  and  Pres- 
ent. By  Gonzalvo  C.  Smythe,  a.m.,  m.d.  Professor  of  the  Principles  and 
Practice  of  Medicine,  College  of  Physicians  and  Surgeons,  Indianapolis,  Indi- 
ana.    i2mo.     Cloth.  Price  $1.25 

"  This  book  gives,  in  a  small  compass,  an  excellent 
history  of  medicine,  from  its  earliest  day  to  the  present 
time.'  — Buffalo  Medical  and  Surgical  Journal. 

"Cannot  fail  to  be  of  interest,  not  only  to  the  medi- 
cal profession,  but  to  the  general  reader." — Baltimore 
Gazette. 


"  The  work  is  pleasantly  written,  in  an  easy,  familiar 
style,  and  has  cost  the  writer  much  literary  research." 
— New  York  Medical  Journal. 


"  Students  and  others  interested  in  the  subject  of 
medicine  will  find  a  digest  of  the  entire  controversy 
(between  the  various  schools  of  medicine)  presented  in 
this  volume." — Journal  of  Education. 

"  Professor  Smythe  has  succeeded  in  writing  a  brief, 
clear,  and  interesting  sketch  of  the  evolution  of  medical 
eccentricities,  and  of  modern  homoeopathy,  its  facts  and 
fallacies." — Philadelphia  Medical  Times. 


SAVAGE,  FEMALE  PELVIC  ORGANS.     Author's  Edition. 

The  Surgery,  Surgical  Pathology  and  Surgical  Anatomy  of  the  Female  Pelvic 
Organs.  In  a  Series  of  Colored  Plates  taken  from  Nature,  with  Commentaries, 
Notes  and  Cases.  By  Henry  Savage,  m.d.,  f.r.c.s.  New  Edition.  Issued  by 
arrangement  with  the  Author,  from  the  original  Plates.     Quarto.        [Preparing. 

SAVORY  &  MOORE,  DOMESTIC  MEDICINE. 

A  Condensed  Compend  of  Domestic  Medicine,  and  Companion  to  the  Medi- 
cine Chest.     By  Drs.  Savory  and  Moore.     Illustrated.     i6mo.  Price  .50 

SCHULTZE,  OBSTETRICAL  PLATES. 

Obstetrical  Diagrams.  Life  Size.  By  Prof.  B.  S.  Schultze,  m.d.,  of  Berlin. 
Twenty  in  the  Set.     Colored. 

Price,  in  Sheets,  $15.00  ;  Mounted  on  Rollers  $25.00 

SCANZONI,  DISEASES  OF  WOMEN. 

A  Practical  Treatise  on  the  Diseases  of  the  Sexual  Organs  of  Women.  By 
Dr.  F.  W.  Von  Scanzoni.     Translated  by  A.  K.  Gardiner,  m.d.     8vo. 

Price  $5.00 
SIEVEKING,  LIFE  ASSURANCE. 

The   Medical  Adviser  in  Life  Assurance.     By  E.  H.  Sieveking,  m.d.     i2mo. 

Price  $2.00 

SHEPPARD,  ON  MADNESS. 

Madness,  in  its  Medical,  Social  and  Legal  Aspects.  A  Series  of  Lectures  de- 
livered at  King's  Medical  College,  London.     By  Edgar  Sheppard,  m.d.     8vo. 

Price  $2.25 

STOCKEN,  DENTAL  MATERIA  MEDICA.     Seoond  Edition. 

The  Elements  of  Dental  Materia  Medicaand  Therapeutics  with  Pharmacopoeia. 
By  James  Stocken,  d.d.s.     Second  Edition.     i2mo.  Price  $2.25 

The  first  edition  of  this  book  was  disposed  of  in  a  little  less  than  four  months.  In 
making  this  revision  the  author  has  endeavored  to  make  it  still  more  useful  by  the 
addition  of  considerable  new  matter. 

SUTTON,  VOLUMETRIC  ANALYSIS.     Fourth  Edition. 

A  Systematic  Handbook  of  Volumetric  Analysis,  or  the  Quantitative  Estima- 
tion of  Chemical  Substances  by  Measure,  Applied  to  Liquids,  Solids  and  Gases. 
By  Francis  Sutton,  f.c.s.  Fourth  Edition.  Revised  and  Enlarged,  with  Illus- 
trations.    8vo.  [Preparing. 


PRESLEY  BLAKISTON'S 


"  A  valuable  book  for  the  general  Practitioner  who 
fe  in  want  of  a  practical  manual  relating  especially  to 
diseases  of  the  teeth." — Medical  Brief . 


SEWELL,  DENTAL  ANATOMY  AND  SURGERY. 

A  Manual  of  Dental  Anatomy  and  Surgery,  Including  the  Extraction  of  Teeth. 
By  H.  E.  Sewell,  d.d.s.,  m.d.     With  -jj  Illustrations.     i2mo.  Price  $1.50 

**  It  will  be  found  useful  to  the  general  Practitioner  in 
the  management  of  many  incidental  affections  connected 
with  the  teeth  and  mouth,  which  cannot  always  be 
handed  over  to  the  specialist."— Pacific  Med.  journal. 

STILLE,  ON  MENINGITIS. 

Epidemic  Meningitis,  or  Cerebro-spinal  Meningitis.  By  Alfred  Stille,  m.d., 
Professor  of  Practice  at  the  University  of  Pennsylvania.     8vo.  Price  $2.00 

"  The  name  of  the  author  is  a  sufficient  guarantee  that  this  monograph  is  elegant  in  style,  exhaustive  of  its  sub- 
ject and  rich  with  practical  suggestions."— Philadelphia  Medical  and  Surgical  Reporter. 

STOKES,  DISEASES  OF  THE  HEART. 

The  Diseases  of  the  Heart  and  Aorta.  By  William  Stokes,  m.d.  Thick 
8vo.  Price  $3.00 

SWAIN,  SURGICAL  EMERGENCIES. 

Surgical  Emergencies:  Concise  Descriptions  of  the  Various  Accidents  and 
Emergencies,  with  Directions  for  their  Treatment.  By  Wm.  Paul  Swain,  f.r. 
C.S.     i-ighty-two  Illustrations.     l2mo.  Price  $2.00 

Contents.— Chapter  I.  Injuries  to  the  Head.  II.  Injuries  to  the  Eye.  III.  Injuries  to  the  Mouth, 
Pharynx,  (Esophagus,  and  Larynx.  IV.  The  Chest.  V.  The  Upper  Extremity.  VI.  The  Abdomen.  VII. 
The  Pelvis.  VIII.  The  Lower  Extremity.  IX.  Emergencies  connected  with  Parturition.  X.  Poisoning. 
XI.  Antiseptic  Treatment.     XII.  Apparatus  and  Dressing. 

"  Many  surgeons  will  thank  Dr.  Swain  for  the  trouble  he  has  taken  to  put  them  easily  in  possession  of  this  re- 
fresher of  half  forgotten  knowledge. —  The   Practitioner. 

SWERINGEN,  PHARMACEUTICAL  LEXICON. 

A  Pharmaceutical  Lexicon  or  Dictionary  of  Pharmaceutical  Science.  Contain- 
ing explanations  of  the  various  subjects  and  terms  of  Pharmacy,  with  appropriate 
selections  from  the  Collateral  Sciences.  Formulae  for  Officinal,  Empirical,  and 
Dietetic  Preparations,  etc.,  etc.     By  Hiram.  V.  Sweringen,  m.d.     8vo. 

Price,  Cloth,  $3.00;  Leather,  $4.00 

"  It  is  worthy  of  a  welcome,  and  sure  of  a  ready  recognition  of  its  merits." — London  Pharmaceutical  fourr.al. 
"  It  will  prove  of  great  service  to  the  pharmaceutical  student,  apprentice,  pharmacist,  druggist  and  physician,  as 
a  book  of  ready  reference  and  as  an  aid  to  the  study  of  scientific  works." — American  fournal  of  Pluirmacy. 

THOMPSON,  LITHOTOMY  AND  LITHOTRITY. 

Practical  Lithotomy  and  Lithotrity;  or,  an  Inquiry  into  the  best  Modes  of 
Removing  Stone  from  the  Bladder.  By  Sir  Henry  Thompson,  f.r.c.s.,  Emer- 
itus Professor  of  Clinical  Surgery  in  University  College.  Third  Edition.  8vo. 
With  87  Engravings.  Price  $3.50 

"  The  chapters  of  most  interest  are  those  in  which  Bigclow's  operation  is  discussed,  and  the  final  one,  in 
which  is  a  record  of  500  operations  for  stone  in  cases  of  male  adults  under  the  author's  care.  Such  a  table  has 
never  belore  been  compiled  by  any  surgeon." — Lancet. 

BY   SAME  AUTHOR. 

URINARY  ORGANS. 

Diseases  of  the  Urinary  Organs.  Clinical  Lectures.  Fifth  London  Edition. 
8vo.     With  2  Plates  and  71  Engravings.  Price  ;? 3.50 

ON  THE   PROSTATE. 

Diseases  of  the  Prostate.  Their  Pathology  and  Treatment.  Fourth  London 
Edition.     8vo.     With  numerous  Plates.  Price  £4.00 

CALCULOUS  DISEASES. 

The  Preventive  Treatment  of  Calculous  Disease,  and  the  Use  of  Solvent 
Romrdies.     .Second  Edition.     i6mo.  Price  51.00 

"Catholic  in  his  investigation  of  the  fruit  of  the  labor  of  others,  cautious  in  all  his  deductions,  rejertinj;  all  spe- 
cious  theories  In  the  effort  to  obtain   practically  useful  results,  as  clever  with  his  pen  as  he  is  with  the 
lilhotrite,  one  can  scarcely  wonder  that  he  Is  esteemed  the  muster  that  he  is." — .  \nut .  .'   <j/  Mrdical 

• 


PUBLICA  TIOXS.  37 


TROUSSEAU'S    CLINICAL    MEDICINE. 

COMPLETE. 
In  Two  Large  Eoyal  Octavo  Volumes. 

EMBRACING  ALL  THE  LECTURES  CONTAINED  IN  THE  FIVE 

VOLUME  EDITION  AS  ISSUED  BY   THE 

SYDENHAM  SOCIETY. 

Price,  handsomely  bound  in  cloth $  8.00 

"  "  "  leather         .        .        .         ..  ■      .       10.00 

Lectures  on  Clinical  Medicine. 

Delivered  :it  the  Hotel  Dieu,  Paris,  by  A.  Trousseau,  Professor  of  Clin- 
ical Medicina  to  the  Faculty  of  Medicine,  Paris,  &c,  &c.  Translated 
from  the  Third  Revised  and  Enlarged  Edition  by  P.  Victor  Bazire, 
M.  D.,  London  and  Paris;  and  John  Rose  Cormack,  M.D.,  Edinburgh, 
F.  R.  S.,  &c.     With  a  full  Index,  Table  of  Contents,  &c 

Trousseau's  Lectures  have  attained  a  reputation  both  in  England  and  in  this  country  far 
greater  than  any  work  of  a  similar  character  heretofore  written,  and,  notwithstanding  but  fe-w 
medical  men  could  afford  to  purchase  the  expensive  edition  issued  by  the  Sydenham  Soci- 
ety, it  has  had  an  extensive  sale.  In  order,  however,  to  bring  the  work  within  the  reach  of  all 
the  profession,  the  publishers  now  issue  this  edition,  containing  all  the  lectures  as  contained 
in  the  five-volume  edition,  at  one-half  the  price.  Below  are  a  few  only  of  the  many  favora- 
ble opinions  expressed  of  the  woik  : 

"  It  treats  of  diseases  of  daily  occurrence  and  of  the  most  vital  interest  to  the  practitioner. 
And  we  should  think  any  medical  library  absurdly  incomplete  now  which  did  not  have 
alongside  of  Watson,  Graves,  and  Tanner,  the  'Clinical  Medicine'  of  Trousseau. 

"  The  work  is  full  of  the  results  of  the  richest  natural  observation,  and  is  the  production 
of  one  who  was  enlightened  enough  to  combine  with  new  methods  of  investigation  the  vigor- 
ous and  independent  ideas  of  the  old  physicians  whom  he  so  eloquently  magnifies.  It  is  an 
extremely  rich  and  valuable  addition  to  the  library  of  p  tiysicians  and  practitioners  generally." 

—  London  Lancet. 

"  This  book  furnishes  an  example  of  the  best  kind  cf  elinical  teaching.  It  deserves  to  be 
popularized.  We  scarcely  know  of  any  work  better  fitted  for  presentation  to  a  young  man 
when  entering  upon  the  practical  work  of  his  life.  Tie  delineation  of  the  recorded  cases  i« 
graphic,  and  their  narration  devoid  of  that  prolixity  w.'iich,  desirable  as  it  is  for  purposes  of 
extended  analysis,  is  highly  undesirable  when  the  object  is  to  point  to  a  practical  lesson." — 
London  Medical  Times  and  Gazette. 

"  The  publication  of  Trousseau's  Lectures  furnishes  medical  men  with  one  of  the  best 
practical  treatises  on  disease  as  seen  at  the  bedside.  The  conversational  style  adopted  by 
the  author  lends  animation  to  the  work,  and  the  translator  deserves  credit  for  having  so  well 
preserved  the  easy  and  ready  style  of  the  original." — British  and  Foreign  Medico-Chirur 
gical  Review. 

"  The  great  reputation  of  Prof.  Trousseau  as  a  practitioner  and  teacher  of  Medicine  in  all 
its  branches,  renders  the  present  appearance  of  his  Clinical  Lectures  particularly  welcome." 

—  Medical  Press  and  Circular. 

"  A  clever  translation  of  Prof.  Trousseau's  admirable  and  exhaustive  work,  the  best  book 
of  reference  upon  the  Practice  of  Medicine." — Lndian  Medical  Gazette. 


38  PRESLEY  BLAKISTON'S 

TILT,  THE  CHANGE  OF  LIFE   IN  WOMEN. 

The  Change  of  Life  in  Health  and  Disease.  A  Practical  Treatise  on  the 
Diseases  Incidental  to  Women  at  the  Decline  of  Life.  By  Edward  John  Tilt, 
m.d.     Third  London  Edition.     8vo.  Price  $3.00 

BY  SAME  AUTHOR. 

UTERINE  THERAPEUTICS  AND  DISEASES  OF  WOMEN. 

A  Hand-book  of  Diseases  of  Women  and  Uterine  Therapeutics.  Fourth 
London  Edition,     iamo.  Price  $3.50 

TOMES,  DENTAL  ANATOMY.     New  Edition. 

A  Manual  of  Dental  Anatomy,  Human  and  Comparative.  By  C.  S.  Tomes, 
d.d.s.     With  179  Illustrations.     Second  Edition.     i2mo.  [Preparing.'] 

TOMES,  DENTAL  SURGERY. 

A  System  of  Dental  Surgery.  By  John  Tomes,  f.r.s.  The  Second  Edition, 
Revised  and  Enlarged.     By£.  S.  Tomes,  d.d.s.    With  263  Illustrations.   i2mo. 

Price  $5.00 

"We  rejoice  that  such  books  as  these  (Dr.  Tomes'  Works)  are  demanded  by  the  profession,  and  that  the  men 
to  write  them  are  furnished  by  the  profession." — Dental  Cosmos. 

TAFT,  OPERATIVE  DENTISTRY.     Third  Edition. 

A  Practical  Treatise  on  Operative  Dentistry.  By  Jonathan  Taft,  d.d.s. 
Third  Revised  and  Enlarged  Edition.     Over  100  Illustrations.     8vo. 

Price,  Cloth,  $4.25  ;  Leather,  5.00 

"All  the  important  operations,  in  all  their  modifica-  ]  "It  is  a  thorough  and  complete  treatise  on  the  Art 

tions,  are   clearly  discussed   by  the   author,   and    the  :  of  Practical  Dentistry." — London  Medical  Times  and 

work  is  highly  practical  throughout." — Dental  Regis-  I  Gazette, 
ter. 

TANNER,  INDEX  OF  DISEASES.     Second  Edition. 

An  Index  of  Diseases  and  their  Treatment.  By  Thos.  Hawkes  Tanner,  m.d., 

f.r.c.p.     Sixth  Edition.     Revised  and  Enlarged.     By  W.  H.  Broadbent,  m.d. 

With  Additions.     Appendix  of  Formulae,  etc.     8vo.  Price  $3.00 

By  this  useful  hand-book  the  character  of  any  disease  may  be  determined  in  a 

moment,  and  the  general  outline  of  treatment  pursued  by  the  best  authorities  made 

apparent. 

"  This  work,  like  others  from  the  gifted  author,  has  '  "  Finally,  a  chapter  on  the  climates,  countries,  mine- 
already  won  for  itself  a  reputation."  .  .  .  **  It  is  I  ral  springs,  etc.,  best  adapted  to  the  various  classes  of 
in  truth  what  its  title  indicates." — New  York  Medical  I  invalids,  makes  this  work  the  most  complete  practi- 
Record.  tioner's  manual  that  we  have  yet  seen. — Chicago  Medi- 

I  cal  Times. 

BY   SAME   AUTHOR. 

THE  DISEASES  OF  INFANCY. 

A  Practical  Treatise  on  the  Diseases  of  Infancy  and  Childhood.  Third  Edi- 
tion. Carefully  Revised  and  much  Enlarged.  By  Alfred  Meadows,  m.d. 
8vo.  Price  $3.00 

Recommended  as  a  Text-book  at  Jefferson  Medical  College  and  other  schools  of 
Medicine. 

"One  of  the   most  careful,  ornate,   and   accessible    I       "  We  consider  the  views  of  the  author  on  the  subject 

manuals  on  the  subject." — London  Lancet.  of  therapeutics  as    rational    in   the  highest  degree." — 

I    Boston  Medical  and  Surgical  "Journal. 

MEMORANDA  OF  POISONS. 

A  Memoranda  of  Poisons  and  their  Antidotes  and  Tests.  Fourth  American 
from  the  Last  London  Edition.     Revised  and  Enlarged.  Price  .75 

This  most  complete  Toxicological  Manual  should  be  within  reach  of  all  physi- 
cians and  pharmacists,  and  as  an  addition  to  every  family  library,  would  be  the 
means  of  saving  life  and  allaying  pain  when  the  delay  of  sending  for  a  physician 
would  prove  fatal. 


PUBLICA  TIONS.  39 


TIBBETS,  MEDICAL,  ELECTRICITY. 

A  Hand-book  of  Medical  Electricity.  Giving  full  directions  for  its  Applica- 
tion, etc.     By  Herbert  Tibbets,  m.d.     64  Illustrations.     8vo.  Price  #1.50 

TOLAND,  PRACTICAL  SURGERY. 

Lectures  on  Practical  Surgery.  By  H.  H.  Toland,  m.d.,  Professor  of  Surgery, 
University  of  California.  Second  Edition.  With  Additions  and  Numerous  Illus- 
trations.    8vo.  Price,  Cloth,  $4.50;  Leather,  $5.00 

TRANSACTIONS  OF  THE  COLLEGE  OF  PHYSICIANS. 

The  Transactions  of  the  College  of  Physicians  of  Philadelphia.  New  Series. 
Vols.  1,  11,  in,  iv  and  v.     8vo.  Price,  per  volume,  $2.50 

TYSON,  BRIGHT'S  DISEASE  AND  DIABETES. 

A  Treatise  on  Diabetes  and  Bright's  Disease.  With  Especial  Reference  to 
Pathology  and  Therapeutics.  By  James  Tyson,  m.d.,  Professor  of  Pathology 
and  Morbid  Anatomy  in  the  University  of  Pennsylvania.  With  Colored  Plates 
and  many  Wood  Engravings.     8vo.  Price  $3.50 


"  This  volume  is  the  outcome  of  some  fifteen  years' 
special  study  and  observation,  and  will  be  found  to  be 
a  very  well  prepared  monograph His  direc- 
tions are  clear  and  minute. — Med.  and  Surg.  Reporter. 


"  The  symptoms  are  clearly  defined,  and  the  treat- 
ment Is  exceedingly  well  described,  so  that  every  one 
reading  the  book  must  be  profited." — Cincinnati  Lan- 
cet and.  Clinic. 


BY   SAME   AUTHOR. 

GUIDE  TO  THE  EXAMINATION  OF   URINE. 

A  Practical  Guide  to  the  Examination  of  Urine.  For  the  use  of  Physicians  and 

Students.    With  Colored  Plate,  and  Numerous  Illustrations  Engraved  on  Wood. 

Third  Edition.     i2mo.  Price  #1.50 

Advantage  has  been  taken,  in  bringing  out  a  new  edition  of  this  work,  not  only  to 

correct  the  previous  one,  but  to  make  such  additions  of  new  Facts  and  Processes  as 

would  add  to  its  value  without  materially  increasing  its  size. 

"  Dr.  Tyson  commences  with  a  short  account  of  the  theory  of  renal  secretion,  the  physical  and  chemical  charac- 
ters of  the  urine,  and  the  reagents  and  apparatus  used  in  its  analysisi  Excellent  rules  are  then  given  for  detecting 
the  presence  of  albumen,  sugar,  coloring-matters,  bile,  urea,  uric  acid,  chlorides,  phosphates  and  sulphates  ;  and 
minute  instructions  for  approximative  and  quantitative  determination  of  most  of  those  ingredients  by  volumetric 
analysis  are  supplied." — Philadelphia  Medical  Times. 

"We  have  experienced  both  pleasure  and  profit  ftom  the  perusal  of  this  book.  It  is  agreeably  written,  contains 
much  practical  information,  and  is,  we  believe,  a  reliable  and  satisfactory  guide  to  the  clinical  examination  of 
urine.  We  can  recommend  Dr.  Tyson's  book  as  one  that  amply  supplies  the  clinical  needs  of  the  physician." — 
Dublin  Journal  0/  Medical  Science. 

THE  CELL  DOCTRINE.     Second  Edition. 

The  Cell  Doctrine.  Its  History  and  Present  State.  With  a  Copious  Biblio- 
graphy of  the  subject.  Illustrated  by  a  Colored  Plate  and  Wood  Cuts.  Second 
Edition.     8vo.  Price  $2.00 

TURNBULL,  ARTIFICIAL  ANESTHESIA. 

The  Advantages  and  Accidents  of  Artificial  Anaesthesia ;  Its  Employment  in 
the  Treatment  of  Disease ;  Modes  of  Administration  ;  Considering  their  Rela- 
tive Risks ;  Tests  of  Purity ;  Treatment  of  Asphyxia ;  Spasms  of  the  Glottis ; 
Syncope,  etc.  By  Laurence  Turnbull,  m.d.,  ph.g.,  Aural  Surgeon  to  Jeffer- 
son College  Hospital,  etc.  Second  Edition.  Revised  and  Enlarged.  With  27 
Illustrations  of  Various  Forms  of  Inhalers,  etc.     i2mo.  Price  $1.50 

"  Anaesthesia  is  a  subject  of  great  interest  and  importance  to  physicians  and  dentists,  and  everything  that  will 
aid  them  in  better  understanding  the  subject  is  sought  with  great  avidity.  This  work  we  regard  as  the  best  aid  in 
the  study  of  the  subject,  and  it  presents  the  subject  up  to  the  present  hour." — Dental  Register. 

TEALE,  DANGERS   TO    HEALTH.     Third  Edition. 

A  Pictorial  Guide  to  Domestic  Sanitary  Defects.  By  T.  Pridjin  Teale,  m.d., 
f.r.c.s.     With  Colored  Plates.     8vo.  Price  $3.50 


"  Its  low  price  and  portability  make  it  accessible  and 
convenient  to  every  surgical  registrar  and  practitioner." 
— British  Medical  "Journal. 


40  PRESLE V  BLAKISTON'S 

VACHER,  CHEMISTRY. 

A  Primer  of  Chemistry,     Including  Analysis.     By  Arthur  Vacher.     i8mo. 

Price  .50 

VIRCHOW,  POST-MORTEM  EXAMINATIONS.  Second  Edi- 
tion. 

Post  mortem  Examinations.  A  Description  and  Explanation  of  the  Method 
of  Performing  them  in  the  Dead  House  of  the  Berlin  Charite  Hospital,  with 
especial  reference  to  Medico-legal  Practice.  By  Prof.  Virchow.  Translated 
by  Dr.  T.  P.  Smith.     Second  Edition.     i2mo.     With  4  Plates.  Price  $1.25 

"  A  most  useful  manual  from    the  pen  of  a  master. 

.  .  .  .  For  thorough  and  systematic  method  in 
the  performance  of  post-mortem  examinations,  there  is 
no  guide  like  it." — Lancet. 

WAGSTAFFE,   HUMAN  OSTEOLOGY. 

The  Student's  Guide  to  Human  Osteology.  By  William  Warwick  Wag- 
staffe,  f.r.c.s.  With  23  Lithographic  Plates  of  the  Bones,  Showing  Muscle 
Attachments,  and  60  Wood  Engravings.     i2mo.  Price  $3.00 

WALTON,  DISEASES  OF  THE  EYE.     Third  Edition. 

A  Practical  Treatise  on  Diseases  of  the  Eye.  By  Haynes  Walton,  m.d. 
Third  Edition.  Rewritten  and  Enlarged.  With  five  plain  and  three  colored 
full-page  Plates;  and  many  other  Illustrations,  Test  Types,  etc.  Nearly  1200 
pages.     8vo.  Price  $9.00 

WARNER,  CASE  TAKING. 

The  Student's  Guide  to  Medical  Case  Taking.  By  Francis  Warner,  m.d., 
m.r.c.p.,  etc.     i2mo.     Cloth.  Price  $1.75 

General  Diseases. — Class  1.  Class  2.  Arthritic  Diseases.  Diseases  of  the  Nervous  System.  Of  the  Vas- 
cular System.  Of  the  Respiratory  System.  Of  the  Digestive  System.  Of  the  Liver.  Of  the  Urinary  System. 
Instruction  for  Case  Taking. 

WATERS,  DISEASES  OF  THE  CHEST.     Second  Edition. 

The  Diseases  of  the  Chest.  Their  Clinical  History,  Pathology  and  Treat- 
ment. By  A.  T.  H.  Waters,  m.d.,  Fellow  Royal  College  of  Physicians.  With 
Numerous  Illustrative  Cases  and  Lithographic  Plates.     8vo.  Price  $4.00 

"The  present  edition  contains  new  chapters  on  haemoptysis,  hay  fever,  aortic  regurgitation,  mitral  constriction, 
thoracic  aneurism,  and  the  use  of  chloral  in  certain  diseases  of  the  chest ;  other  chapters  have  received  additions 
of  cases  and  remarks  on  treatment.  Some  characteristic  sphygmographic  tracings  have  also  been  added." — Bos- 
ton Medical  and  Surgical  Journal. 

WEDL,  ATLAS  OF  THE  TEETH. 

An  Atlas  of  the  Pathology  of  the  Teeth.  By  Prof.  Carl  Wedl,  of  Leipsig. 
16  Full-page  Lithographs,  containing  many  figures,  some  colored.     Quarto. 

Price  $10.00 

BY  SAME   AUTHOR. 

DENTAL  PATHOLOGY. 

With  Special  Reference  to  the  Anatomy  and  Physiology  of  the  Teeth.  With 
Notes  by  Thos.  B.  Hitchcock,  m.d.,  of  Harvard  University.  105  Illustra- 
trations.     8vo.  Price,  Cloth,  $3.50;  Leather,  $4.50 

WHITTAKER,  ON  THE  URINE. 

Student's  Primer  on  the  Urine.  By  J.  TRAVIS  Whittaker,  m.d.,  Physician  to 
Anderson's  College  Dispensary.     With  Illustrations  Etched  on  Copper.     161110. 

Trice  $1.50 

Physiological  Study  of  Urine — Sensation  in  Passing.  Quantity.  Color.  Odor.  Specific  Gravity.  History 
and  Behavior.  Sediment  or  Deposits.  Chemical  Study  of  Urine — Reaction.  Albumen.  Chlorides.  Ammonia. 
Urea.  Phosphates.  Blood.  Sugar.  Bile.  Microscopical  Study  of  Urine  and  Urinary  Deposits — Amorphous 
Urates.  Uric  Acid.  Triple  Phosphates.  Phonphate  of  Lime.  Feathery  Phosphates.  Oxalate  of  Lime.  Urate 
of  Soda  and  of  Ammonia.     Cystine.     Tyrosine.     Leucine.    Cholcstcrinc.     Epithelium.      FftJ  GloDTilea.    etc. 

"The  plates  arc  possessed  of  great  vcrsimilitudc,  as  well  as  in  other  respects  admirable." — Mid.   Times. 

"Neat  and  concise,  and  the  illustrations  arc  very  good  testimony  of  the  claim  which  he  makes  of  the  suitability 
of  the  etching  needle  for  delineation  of  microscopical  appearances.  ' — Boston  Med.  and  Surg.  Journal. 


PUBLICA  TIONS.  4I 


WEST,  THE  DISEASES  OF  WOMEN.     Fourth  Edition. 

Lectures  on   the   Diseases   of  Women.     By  Charles  West,  m.d.     Fourth 
London  Edition.     Revised  and  in  part  re-written  by  the  Author.     With  Numer- 
ous Additions  by  J.  Mathews  Duncan,  m.d.,  Obstetric  Physician  to  St.  Bar- 
tholomew's Hospital     Svo.  Price  $5.00 
Drs.  West  and  Duncan   are,  perhaps,  the  most  celebrated    London  physicians 
giving  attention  to  the  Diseases  of  Women,  and   together  have  made  a  most  com- 
plete work,  either  for  the  physician  or  student. 

WILKES,  PATHOLOGICAL  ANATOMY. 

Lectures  on  Pathological  Anatomy.  By  Samuel  Wilkes,  f.r.s.  Second 
Edition.  Revised  and  Enlarged  by  Walter  Moxon,  m.d.,  f.r.s.,  Physician  to 
and  Lecturer  at  Guy's  Hospital,  London.     Svo.  Price  $5.00 

BY   SAME   AUTHOR. 

DISEASES  OF  THE  NERVOUS  SYSTEM. 

Lectures  on  Diseases  of  the  Nervous  System,  Delivered  at  Guy's  Hospital, 
London.     New  Edition,  with  Additions,  Numerous  Illustrative  Cases,  etc.     8vo. 

[Preparing. 

"A  book  of  great  value,  embodying  as  It  does  the  results  of  the  experience  and  observation  of  one  of  the  most 
accomplished  of  the  London  Hospital  Physicians." — American  Journal  of  Medical  Science. 

WRIGHT,  ON  HEADACHES.     Ninth  Thousand. 

Headaches,  their  Causes,  Nature  and  Treatment.  By  Henry  G.  Wright, 
m.d     i2mo.  Price  .50 

WILSON,  ON  DRAINAGE. 

Drainage  for  Health ;  or,  Easy  Lessons  in  Sanitary  Science,  with  Numerous 
Illustrations.  By  Joseph  Wilson,  m.d.,  Medical  Director  United  States  Navy. 
One  Vol.     Octavo.  Price  $1.00 


"  Dr.  Wilson  is  favorably  known  as  one  of  the  lead- 
ing American  writers  on  hygiene  and  public  health. 
The  book  deserves  popularity." — Medical  and  Surgi- 
cal Reporter. 

"  Well  written  and  well  illustrated.  Attention  to  its 
teachings  may  save  much  disease  and  perhaps  many 
lives." — Cincinnati  Gazette. 

"  Interesting  as  well  as  useful." — Philadelphia  Led- 
ger. 


"  Easily  understood,  and  briefly  and  concisely  pre- 
sented."— Providence    "Journal. 

"Will  be  found  of  value." — Boston  Transcript. 

"  Worthy  of  praise  as  a  popular  statement  of  the 
subject." — Boston  Journal  of  Chemistry. 

"  Will  be  sure  to  be  a  harbinger  of  good  in  every  fam- 
ily whose  good  fortune  it  may  be  to  possess  a  copy." — 
Builder  and  Wood  Worker. 


BY   SAME   AUTHOR. 

NAVAL  HYGIENE. 

Naval  Hygiene,  or,  Human  Health  and  Means  for  Preventing  Disease.  With 
Illustrative  Incidents  derived  from  Naval  Experience.  Illustrated.  Second 
Edition.     8vo.  Price  $3.00 

WILSON,  DOMESTIC  HYGIENE. 

Health  and  Healthy  Homes.  A  Guide  to  Personal  and  Domestic  Hygiene. 
By  George  Wilson,  m.d.,  Medical  Officer  of  Health.  Edited  by  Jos.  G. 
Richardson,  m.d.,  Professor  of  Hygiene  at  the  University  of  Pennsylvania. 
314  pages.     i2mo.  Price  $1.00 

Chapter  i. — Introductory,  page  17.  11.  The  Human  Body,  33.  m.  Causes  of  Disease,  66.  iv.  Food  and 
Diet,  119.  v.  Cleanliness  and  Clothing,  169.  VI.  Exercise,  Recreation  and  Training,  187.  vil.  Home  and  Its 
Surroundings,  Drainage,  Warming,  etc.,  221.     vm.   Infectious  Diseases  and  their  Prevention,  269. 

"A  most  useful,  and  in  every  way,  acceptable  book." — New  York  Herald. 

"  Marked  throughout  by  a  sound,  scientific  spirit,  and  an  absence  of  all  hasty  generalizations,  sweeping  asser- 
tions, and  abuse  of  statistics  in  support  of  the  writer's  particular  views.  .  .  .  We  cannot  speak  too  highly  of 
a  work  which  we  have  read  with  entire  satisfaction." — Medical  Times  and  Gazette. 

BY    SAME    AUTHOR. 

A  HAND-BOOK  OF  HYGIENE 

And  Sanitary  Science.  With  Illustrations.  Fourth  Edition.  Revised  and 
Enlarged.     8vo.  Price  $2.75 


42  PRESLEY  B LA KIS TON'S 


WILSON,  HUMAN  ANATOMY.     Tenth  Edition. 

The  Anatomist's  Yade-Mecum.  General  and  Special.  By  Prof.  Erasmus  Wil- 
son. Edited  by  George  Buchanan,  Professor  of  Clinical  Surgery  in  the  Uni- 
versity -of  Glasgow ;  and  Henry  E.  Clark,  Lecturer  on  Anatomy  at  the  Royal 
Infirmary  School  of  Medicine,  Glasgow.  Tenth  Edition.  With  450  Engravings 
(including  26  Colored  Plates] .     Crown  8vo.  Price  $6.00 

Recommended  as  a  Text-book  at  Rush  Medical  College,  Chicago  ;  Bellevue  Hos- 
pital, New  York;  St.  Louis  Medical  College;  Yale  and  Dartmouth  Schools;  and 
many  other  Colleges. 

"The  present  edition  of  the  'Anatomist's  Vade-mecum,'  has  been  prepared  under 
the  same  editorial  control  as  the   Ninth  Edition. 

"  Numerous  additional  wood  cuts  have  been  introduced,  and  full-page  engravings 
of  the  bones,  which  have  been  drawn  and  engraved  with  great  care,  to  secure  ac- 
curacy, and  to  make  them  not  mere  anatomical  diagrams,  but  artistic  pictures." 

BY   SAME   AUTHOR. 

HEALTHY  SKIN.     Eighth  Edition. 

A  Practical  Treatise  on  the  Skin  and  Hair ;  their  Preservation  and  Manage- 
ment.    Eighth  Edition.     i2mo.     Paper.  Price  $1.00 

WILSON,  SEA  VOYAGES  FOR  HEALTH. 

The  Ocean  as  a  Health  Resort.  A  Hand-book  of  Practical  Information  as  to 
Sea  Voyages,  for  the  Use  of  Tourists  and  Invalids.  By  Wm.  S.  Wilson,  l.r.c.p. 
Lond.,  m.r.c.S.e.  With  a  Chart  showing  the  Ocean  Routes,  and  Illustrating  the 
Physical  Geography  of  the  Sea.     Crown  8vo.  Price  $2.50 

Chapter  1.  Curative  Effects  of  the  Ocean  Climate.  2.  The  Various  Health  Voyages.  3.  Time  of  Starting — 
Choosing  a  Ship.  4.  Preliminary  Arrangements.  5.  Life  at  Sea.  6.  Climate  and  Weather.  7.  Management  of 
the  Health  at  Sea.  8.  Occupations  and  Amusements  at  Sea.  9.  Objects  of  Interest  at  Sea.  10.  End  of  the 
Voyage — Future  Plans.  11.  The  Homeward  Voyage.  12.  Australia:  its  Climate,  Cities,  and  Health  Resorts. 
13.  South  Africa  and  its  Climate.     14.  The  Meteorology  of  the  Ocean. 

Appendix  A. — Outfit  Required  for  a  Voyage  to  Australia.  B.  Names  and  Addresses  of  some  of  the  Principal 
Shipping  Firms. 

"All  the  information  is  supplied  by,  or  based  upon,  the  actual  experience  of  the  author;  and  the  book  may  b« 
confidently  recommended  to  all  who  have  to  undertake,  without  previous  experience,  a  sea  voyage  of  any  length. 
Medical  men  may  consult  it  with  advantage,  and  commend  it  to  those  patients  whom  they  may  advise  to  try  the 
effect  of  a  long  voyage  at  sea." — Medical  Times  and  Gazette. 

"  We  have  read  every  page  of  this  book,  and  have  derived  both  instruction  and  amusement." — Lancet. 

WELLS,  OVARIAN  AND  UTERINE  TUMORS. 

The  Diagnosis  and  Surgical  Treatment  of  Ovarian  and  Uterine  Tumors.     By 

T.  Spencer  Wells,  m.d.  [  To  be  issued  shortly. 

So  long  a  time  having  elapsed  since  Dr.  Wells  has  collected  the  results  of  his 

large  experience  in  book  form,  the  present  volume  will  be  eagerly  looked  for  by  all 

interested  in  this  very  important  subject. 

WOLFE,  ON  DISEASES  OF  THE  EYE. 

A  Practical  Treatise  on  Diseases  and  Injuries  of  the  Eye.  Being  a  Course  of 
Systematic  and  Clinical  Lectures  to  Students  and  Medical  Practitioners.  By  M. 
Wolfe,  f.r.cp.e.,  Senior  Surgeon  to  the  Glasgow  Ophthalmic  Institution,  etc. 
With  10  Colored  Plates,  and  numerous  other  Illustrations.  Octavo.       Price  ^7.00 

WALKER,  INTERMARRIAGE. 

Intermarriage,  or.  The  Mode  in  which,  and  the  Causes  why,  Beauty.  Health 
and  Intellect  result  from  certain  Unions ;  and  Deformity,  Disease  and  Insanity 
from  others.     Illustrated.     i2mo.  Price  $1.00 


PUD LIC A  TIONS. 


43 


WOODMAN  and  TIDY,  MEDICAL  JURISPRUDENCE. 

Forensic  Medicine  and  Toxicology.  By  W.  Bathurst  Woodman,  m.d., 
Physician  to  the  London  Hospital,  and  Charles  Meymott  Tidy,  f.c.s.,  Pro- 
fessor of  Chemistry  and  Medical  Jurisprudence  at  the  London  Hospital.  With 
Chromo-Lithographic  Plates,  representing  the  Appearance  of  the  Stomach  in 
Poisoning  by  Arsenic,  Corrosive  Sublimate,  Nitric  Acid,  Oxalic  Acid  ;  the  Spectra 
of  Blood  and  the  Microscopic  Appearance  of  Human  and  other  Hairs;  and 
116  other  Illustrations.     Large  octavo. 

Price,  Cloth,  $7.50;  Medical  Sheep,  $8.50;  Law  Leather,  $8.50 

"  We  have  no  hesitation  in  pronouncing  the  work  to  be  one  of  unusual  merit.  More  readable  than  Taylor, 
more  systematic  in  its  arrangement,  and  more  practical  in  its  instruction,  it  will  prove  to  the  medical  jurist,  not 
less  than  to  the  general  practitioner,  a  storehouse  of  useful  knowledge,  conveyed  in  an  unusually  graphic  style." — 
Dublin  youmal  of  Medical  Science. 

"  The  authors  of  this  truly  great  work  have  largely  supplied  the  want  felt,  sooner  or  later,  by  almost  every 
doctor." — Cincinnati  Lancet  and  Observer. 

"All  the  best  known  works  on  Medical  Jurisprudence  have  been  laid  under  contribution  for  the  production  of 
the  present  volume.  It  contains  almost  everything  that  can  be  found  in  other  works  on  the  subject;  but  it  is  no 
mere  compilation.  Dr.  Woodman  and  Dr.  Tidy  have  both  thought  out  the  subject  for  themselves,  and,  with  rare 
industry  and  acumen,  have  brought  together  a  mass  of  facts  which  is  little  short  of  astounding.  The  book  is 
■worthy  to  take  its  place  alongside  of  any  work  on  the  same  subject,  and  must  prove  of  great  use  to  all  who  prac- 
tice in  criminal  courts,  and  to  all  medical  practitioners.  We  have  no  hesitation  in  recommending  it  to  our  read- 
ers."— Lotidon  Lancet. 

"Altogether  the  work  will  rank  with  the  best  of  its  class  as  a  medico-legal  hand-book,  and  cannot  fail  to  gain 
a  wide  popularity." — Neiv  York  Medical  Record. 

"  It  cannot  be  otherwise  than  a  valuable  contribution  to  the  boundless  subject  of  medical  jurisprudence." — 
Albany  Law  Journal. 

"The  scope  of  this  book  is  very  wide,  and  its  execution  worthy  of  all  commendation." — Philadelphia  Legal 
Intelligencer. 

WYTHE,  ON  THE  MICROSCOPE. 

The  Microscopist.  A  Manual  of  Microscopy  and  Compendium  of  the  Micro- 
scopic Sciences,  Micro-Mineralogy,  Micro-Chemistry,  Biology,  Histology,  and 
Practical  Medicine.  By  Joseph  H.  Wythe,  a.m.,  m.d.  Fourth  Edition.  252 
Illustrations.     8vo.  Price,  Cloth,  $5.00 ;  Leather,  $6.00 

An  Index  and  Glossary  have  been  combined  in  this  edition,  so  as  to  be  a  source 
of  valuable  information.  Notices  of  recent  additions  to  the  microscope,  together 
with  the  genera  of  microscopic  plants,  have  been  given  in  an  Appendix. 


"  From  what  we  knew  of  the  author  of  this  work,  as 
a  skilled  practical  Microscopist,  a  successful  teacher  of 
the  science,  and  a  practitioner  of  medicine  and  surgery 
of  long  and  varied  experience,  we  had  a  right  to  expect 
agoodfbookfrom  his  hands.  Our  expectations  are  fully 
realized  in  the  volume  before  us.  The  style  is  clear 
and  distinct,  and  one  reads  the  book  with  the  utmost 
facility  of  comprehension.  It  is  the  more  valuable  to 
the  physician  and  medical  student  on  account  of  its 
closer  application  of  the  microscope  to  medical  subjects 
than  we  find  elsewhere.  The  numerous  plates,  many 
of  which  are  beautifully  colored,  are  not  to  be  excelled. 
We  feel  proud  of  it  as  an  American  production." — 
Pacific  Medical  and  Surgical  Journal. 


"  This  is  one  of  the  most  valuable  text-books  on  mi- 
croscopy ever  offered  to  students  or  practitioners  of 
medicine.  This  edition  has  been  greatly  enhanced  in 
value  by  the  addition  of  chapters  on  the  use  of  the 
microscope  in  pathology,  diagnosis,  and  etiology,  and 
numerous  new  illustrations,  some  of  which  are  from 
Rindfleisch. 

"  The  author  very  carefully  brings  out  every  neces- 
sary fact  and  principle  relating  to  the  use  of  the  micro- 
scope, and  now  that  this  instrument  has  become  an  es- 
sential part  of  every  practitioner's  armamentarium,  a 
practical  guide  and  reference  book  is  also  a  necessity, 
and  we  are  fully  warranted  in  reiterating  the  statement 
that  this  is  one  of  the  most  valuable  text-books  ever 
offered  to  students  and  practitioners  of  medicine." — 
The  Cincinnati  Lancet  and  Clinic. 


BY   SAME   AUTHOR. 

DOSE  AND  SYMPTOM  BOOK.     Eleventh  Edition. 

The  Physician's  Pocket  Dose  and  Symptom  Book.  Containing  the  Doses  and 
Uses  of  all  the  Principal  Articles  of  the  Materia  Medica,  and  Original  Prepara- 
tions.    Eleventh  Revised  Edition. 

Price,  Cloth,  $1.00;  Leather,  with  Tucks  and  Pocket,  #1.25 

"  The  chapter  on  Dietetic  Preparations  will  be  found  useful  to  all  practicing  physicians,  most  of  whom  have  but 
little  acquaintance  with  the  mode/of  preparing  the  various  articles  of  diet  for  the  sick." — Boston  Medical  and 
Surgical  Journal.  * 

"  Many  a  hard-worked  practitioner  will  find  it  a  useful  little  work  to  have  on  his  study  table." — Canada  Medical 
and  Surgical  Journal. 


44  PRESLE  Y  BLAKISTON'S  PUBLIC  A  TIONS. 

WHEELER,  MEDICAL  CHEMISTRY. 

Medical  Chemistry,  Including  the  Outlines  of  Organic  and  Physiological 
Chemistry.     By  C.  Gilbert  Wheeler,  m.d.     Second  Edition.     i2mo. 

Price  $3.00 
WOAKES,  ON  DEAFNESS  AND  GIDDINESS. 

On  Deafness,  Giddiness  and  Noises  in  the  Head.  By  Edward  Woakes,  m.d., 
London,  Surgeon  to  the  Ear  Department  of  the  Hospital  for  Diseases  of  the 
Throat  and  Chest.  Second  Edition.  Revised  and  Enlarged,  with  additional 
Illustrations.     i2mo.  Price  $2.50 


"  The  early  demand  for  a  fresh  edition  of  Dr. 
Woakes'  volume  is  a  sufficient  criticism  of  its  merits. 
.  .  .  No  brief  summary  of  his  views  could  do  full 
justice  to  the  cogency  and  subtlety  of  his  reasons. 
We  prefer  to  commend  the  whole  work  to  the  thought- 
ful perusal  of  all  intelligent  medical  practitioners  who 
desire  to  rise  above  the  level  of  mere  routine  empiri- 
cism."— Lancet,  August  28th,  1880. 


"This  book,  although  small,  is  evidently  the  result 
of  much  careful  thought  and  observation.  .  .  .  We 
cordially  recommend  the  work  as  original  and  suggest- 
ive, and  as  being  likely  to  prove  very  useful  in  explain- 
ing both  the  causation  of  symptoms  otherwise  puzzling, 
and  their  appropriate  treatment." — Practitioner,  July, 
1879. 


ILLUSTRATED    BOOKS. 

MEDICINAL  PLANTS. 

Being  Descriptions,  with  original  Figures,  of  the  Principal  Plants  employed  in 
Medicine,  and  an  account  of  their  Properties  and  Uses.  By  Robert  Bentley, 
f.l.s.,  Professor  of  Botany  in  the  King's  College,  and  to  the  Pharmaceutical 
Society,  and  Henry  Trimens,  m.b.,  f.l.s.,  late  Lecturer  on  Botany  at  St. 
Mary's  Hospital  Medical  School.  In  42  Parts,  each,  $2.00,  or  in  4  vols.,  large 
8vo,  with   306  Colored  Plates,  bound  in  half  morocco,  gilt  edged.  #90.00 

AN  ATLAS  OF  TOPOGRAPHICAL  ANATOMY. 

After  Plane  Sections  of  Frozen  Bodies.  By  William  Braune,  Professor  of  Anatomy 
in  the  University  of  Leipzig.  Translated  by  Edward  Bellamy,  f.r.c.s.,  Sur- 
geon to  and  Lecturer  on  Anatomy  at  Charing  Cross  Hospital.  With  34  Photo- 
lithographic Plates  and  46  Wood  cuts.     Large  imp.  8vo.  $10.00 

ATLAS  OF  SKIN  DISEASES. 

Consisting  of  a  Series  of  Illustrations,  with  Descriptive  Text  and  Notes  upon 
Treatment.  By  Tilbury  Fox,  m.d.,  f.r.C.p.,  late  Physician  to  the  Department 
for  Skin  Diseases  in  University  College  Hospital.  With  72  Colored  Plates. 
In  18  Parts,  each,  $2.00  or,  1  Vol.,  Royal  4to,  Cloth.  $30.00 

AN  ATLAS  OF  HUMAN  ANATOMY. 

Illustrating  most  of  the  ordinary  Dissections,  and  many  not  usually  practiced  by 
the  Student.  By  Rickman  J.  Godlee,  m.s.,  f.r.c.s.,  Assistant  Surgeon  to 
University  College  Hospital,  and  Senior  Demonstrator  of  Anatomy  in  Universi- 
ty College.  With  48  imp.  4to  Colored  Plates  (112  Figures),  and  a  volume  of  Ex- 
planatory Text.  #30.00 

A  COURSE  OF  OPERATIVE  SURGERY. 

By  Christopher  Heath,  f.r.c.s.,  Home  Professor  of  Clinical  Surgery  in  Uni- 
versity College,  and  Surgeon  to  the  Hospital.  With  20  Plates  drawn  from 
Nature  by  M.  Leveille,  and  colored  by  hand  under  his  direction.     4to.     $14.00 

ILLUSTRATIONS  OF  CLINICAL  SURGERY. 

Consisting  of  Plates,  Photographs,  Wood  cuts,  Diagrams,  etc.,  etc.,  illustrat- 
ing Surgical  Diseases,  Symptoms,  and  Accidents  ;  also  Operative  and  other 
Methods  of  Treatment,  with  Descriptive  Letterpress.  By  Jonathan  Hutchin- 
son, f.r.c.s.,  Senior  Surgeon  to  the  London  Hospital.  Vol.  I,  containing  fas- 
ciculi I  to  X,  bound,  with  Appendix  and  Index.  $25.00 
Fasciculi  XI  to  XIV.     Ready.                                                              Each,  $2.50 


The  Microscopist. 

foitzitb:  edition. 

WITH  TWO  HUNDRED  AND  FIFTY  ILLUSTRATIONS, 

Greatly  Enlarged  by  the  Addition  of  oyer  200  Pages  of  New  Matter. 

By  J.  H.  WYTHE,  A.M.,  M.D., 

Professor  of  Microscopy  and  Histology  in  the  Medical  College  of  the  Pacific, 
San  Francisco,  California. 


This  Manual  of  Microscopy  and  Compendium  of  the  Microscopic  Sciences, 
Micro-Mineralogy,  Micro-Chemistry,  Biology,  Histology,  and  Practical  Med- 
icine, in  which  the  Practice  of  Medicine  receives  the  largest  attention, 
makes  this  work  one  of  the  most  complete  Text-Books  known  on  the  sub- 
ject. Matters  of  mere  curiosity  have  been  but  briefly  referred  to,  while 
every  necessary  fact  or  principle  relating  to  the  microscope  has  been  care- 
fully stated  and  classified. 

The  chapters  on  the  use  of  the  microscope  in  Pathology,  Diagnosis,  and 
Etiology,  which  have  been  added  to  this  edition,  have  been  largely  illus- 
trated with  wood-cuts  from  Rindfleisch. 

The  Index  and  Glossary  have  been  combined  in  this  edition  so  as  to  be  a 
source  of  valuable  information,  and  notices  of  recent  additions  to  the  mi- 
croscope, together  with  the  genera  of  microscopic  plants,  have  been  given 
in  an  Appendix. 

No  pains  have  been  spared  to  render  this  manual  a  useful  companion  to 
the  student  of  Nature,  and  an  aid  to  the  progress  of  real  science.  Cloth, 
$5.00 ;  Sheep,  $6.00. 

"From  what  we  knew  of  the  author  of  this  work,  as  a  skilled  practical  Microscopist, 
a  successful  teacher  of  the  science,  and  a  practitioner  of  medicine  and  surgery  of  long 
and  varied  experience,  we  had  a  right  to  expect  a  good  book  from  his  hands.  Our  ex- 
pectations are  fully  realized  in  the  volume  before  us.  In  a  little  over  400  pages  he  has 
condensed  almost  everything  of  importance  relating  to  the  subject.  The  style,  though 
almost  aphorismal,  is  clear  and  distinct,  and  one  reads  the  book  with  the  utmost  facility 
of  comprehension.  It  is  the  more  valuable  to  the  physician  and  medical  student  on 
account  of  its  closer  application  of  the  microscope  to  medical  subjects  than  we  find  else- 
where. Too  much  praise  cannot  be  bestowed  on  the  mechanical  execution  of  the  volume. 
The  numerous  plates,  many  of  which  are  beautifully  colored,  are  not  to  be  excelled. 
-Added  to  this,  the  large  and  clear  type  and  the  fine  quality  of  paper  make  it  a  most 
comely  book.  We  feel  proud  of  it  as  an  American  production,  dividing  its  authorship 
and  execution  between  the  extreme  west  and  east  territorial  limits  of  the  Kepublic." — 
Pacific  Medical  and  Surgical  Journal. 

"This  is  one  of  the  most  valuable  text-books  on  microscopy  ever  offered  to  students  or 
practitioners  of  medicine.  This  edition  has  been  greatly  enhanced  in  value  by  the  ad- 
dition of  chapters  on  the  use  of  the  microscope  in  pathology,  diagnosis,  and  etiology, 
and  numerous  new  illustrations,  some  of  which  are  from  Rindfleisch. 

"  The  author  very  carefully  brings  out  every  necessary  fact  and  principle  relating  to 
the  use  of  the  microscope,  and  now  that  this  instrument  has  become  an  essential  part  of 
every  practitioner's  armamentarium,  a  practical  guide  and  reference  book  is  also  a  ne- 
cessity, and  we  are  fully  warranted  in  reiterating  the  statement  that  this  is  one  of  the 
most  valuable  text-books  ever  offered  to  students  and  practitioners  of  medicine." — Th« 
Cincinnati  Lancet  and  Clinic. 

P.  BLAKISTON,  SON  &  CO.,  Publishers, 

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